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THE DISPENSATORY

OF THE UNITED STATES
OF AMERICA 25th Edition

OSOL-FARRAR

Synopsis of Arrangement
United States Dispensatory

PART ONE: Drugs recognized by The United States
Pharmacopeia, British Pharmacopoeia, International
Pharmacopoeia, or The National Formulary.

Individual monographs are arranged alphabetically according to the Eng-
lish title, with information for each drug in general following the order:

• Official Tides and Synonyms

• Official Definition

• Unofficial Synonyms, Foreign Language Tides (official

titles appear in bold-face type) , Trade-names and Trade-
marks (name of manufacturer indicated parenthetically)

• Source or Manufacturing Process; History

• Official Description; Tests

• Assay Methods

• Constituents

• Adulterants

• Therapeutic Actions and Uses

• Toxicology

• Dosage

• Storage Requirements

• Official Preparations

• Usual Sizes (for dosage forms)

PART TWO: Drugs not official in The United States

Pharmacopeia, British Pharmacopoeia, International
Pharmacopoeia, or The National Formulary.

Individual monographs are arranged alphabetically, with
information for each drug following the order listed above.

PART THREE : Veterinary Uses and Doses of Drugs

COMPLETE INDEX

Table of Metric Doses
with Approximate Apothecary Equivalents

The approximate dose equivalents in the following table represent the quantities usually prescribed, under
identical conditions, by physicians trained, respectively, in the metric or in the apothecary system of weights
and measures. In labeling dosage forms in both the metric and the apothecary systems, if one is the approxi-
mate equivalent of the other, the approximate figure shall be enclosed in parentheses.

When prepared dosage forms such as tablets, capsules, pills, etc., are prescribed in the metric system, the
pharmacist may dispense the corresponding approximate equivalent in the apothecary system, and vice
versa, as indicated in the following table.

Caution — For the conversion of specific quantities in a prescription which requires compounding, or in
converting a pharmaceutical formula from one system of weights or measures to the other, exact equivalents
must be used.

Liquid Measure

Approximate

Apothecary

Metric

Equivalents

Metric

Equivalents

1000 ml.

1 quart

ml.

minims

750 ml.

1 Vz pints

ml.

minims

500 ml.

1 pint

ml.

minims

250 ml.

8 fluidounces

0.75 ml.

minims

200 ml.

7 fluidounces

0.6

ml.

minims

100 ml.

3V4 fluidounces

0.5

ml.

minims

50 ml.

1% fluidounces

0.3

ml.

minims

30 ml.

1 fluidounce

0.25 ml.

minims

15 ml.

4 fluidrachms

0.2

ml.

minims

10 ml.

254 fluidrachms

0.1

ml.

V/z

minims

8 ml.

2 fluidrachms

0.06 ml.

minim

5 ml.

1 54 fluidrachms

0.05 ml.

minim

4 ml.

1 fluidrachm

0.03 ml.

minim

Weight

Approximate

Apothecary

Metric

Equivalents

Metric

Equivalents

30 Gm.

1 ounce

mg.

grain

15 Gm.

4 drachms

mg.

grain

10 Gm.

2/4 drachms

mg.

grain

7.5 Gm.

2 drachms

mg.

grain

6 Gm.

90 grains

mg.

grain

5 Gm.

75 grains

mg.

grain

4 Gm.

60 grains (1 drachm)

mg.

grain

3 Gm.

45 grains

mg.

grain

2 Gm.

30 grains {Vz drachm)

mg.

VVL

grain

1.5 Gm.

22 grains

mg.

grain

1 Gm.

15 grains

mg.

Y20

grain

750 mg.

12 grains

mg.

grain

600 mg.

10 grains

1.5

mg.

y40

grain

500 mg.

7/4 grains

1.2

mg.

grain

400 mg.

6 grains

mg.

Yeo

grain

300 mg.

5 grains

800

meg.

Yso

grain

250 mg.

4 grains

600

meg.

Yioo

grain

200 mg.

3 grains

500

meg.

Yl20

grain

150 mg.

254 grains

400

meg.

M50 grain

120 mg.

2 grains

300

meg.

Y200

grain

100 mg.

1 Vz grains

250

meg.

%50

grain

75 mg.

1 54 grains

200

meg.

%00

grain

60 mg.

1 grain

150

meg.

■54oo

grain

50 mg.

% grain

120

meg.

Yooo

grain

40 mg.

Vi grain

100

meg.

%00

grain

Note: A cubic centimeter (cc.) is the approximate equivalent of a milliliter (ml.).

The above approximate dose equivalents have been adopted by the latest Pharmacopeia, National Formulary, and
New and Non-official Remedies, and these dose equivalents have the approval of the Federal Food and Drug
Administration.

THE DISPENSATORY

OF THE UNITED STATES
OF AMERICA **

NOV 16198*

THfc CORNER PHARMACY

NOV 16 195f

Contributors

Howard N. Baier, b.s., m.d., m.s.

Associate in Medicine and Physiology, Temple Uni-
versity School of Medicine and Hospital.

Mahlon Z. Bierly, Jr., b.s., m.d.
Assistant Physician, Visiting Staff, Children's Hospi-
tal of Philadelphia; Assistant Pediatrician to OPD,
Bryn Mawr Hospital.

Eleanor E. Buckley, b.s.

Staff Writer, Medical Department Wyeth Laboratories,
Inc.

Peter T. Cassalia, b.s., d.d.s., m.s.

Chief of Oral Surgery, Northeastern Hospital and
Lower Bucks County Hospital.

Dean A. Collins, a.b., a.m., ph.d., m.d.

Professor and Head of the Department of Pharma-
cology, Temple University School of Medicine.

David W. Crjsman, b.s., v.m.d.

Assistant Professor of Microbiology, School of Veteri-
nary Medicine, University of Pennsylvania.

Elmer H. Funk, Jr., b.s., m.d.

Assistant in Aiedicine, Jefferson Medical College:

Assistant Cardiologist to Out-Patients, Pennsylvania

Hospital.

Joan H. Long Gault, b.s., m.d., m.s.

Instructor in Medicine, Temple University School of
Medicine.

Alfonso R. Gennaro, b.s., m.s.

Instructor in Chemistry, Philadelphia College of Phar-
macy and Science.

Elizabeth W. Johnson, b.s., m.s.

Librarian, Philadelphia College of Pharmacy
Science.

Lawrence R. Mallery, Jr.

Medical Writer, Gray & Rogers, Philadelphia

and

John E. Martin, v.m.d.

Assistant Professor of Physiology and Pharmacology,
School of Veterinary Medicine and Graduate School of
Medicine, University of Pennsylvania.

Morton J. Oppenheimer, a.b., m.ed., m.d.

Professor and Head of the Department of Physiology,
Temple University School of Medicine and Hospital.

Edward F. Roberts, a.b., ph.d., m.d.

Director of Clinical Investigation, Wyeth Labora-
tories, Inc.

Bruce S. Roxby, b.s., m.d., m.s.

Instructor in Medicine, Temple University School of
Medicine and Hospital; Director of Health Service,
Temple University.

John B. Roxby, Jr., b.a., m.a., m.d.

Associate in Dermatology, Temple University School
of Medicine and Hospital; Dermatologist, Chestnut
Hill Hospital and Northern Division, Philadelphia
General Hospital.

Joseph Seifter, a.b., ph.d., m.d.

Director, Wyeth Institute for Medical Research; Lec-
turer in Pharmacology, Graduate School of Medicine,
University of Pennsylvania.

Daniel L. Shaw, Jr., b.s., m.d.

Director of Clinical Research, Wyeth Laboratories,
Inc. ; Instructor in Medicine, Jefferson Medical College.

Charles R. Shuman, b.a., m.d., m.s.

Associate in Medicine, Temple University School of
Medicine and Hospital; Consultant in Metabolic Dis-
ease, Philadelphia Veterans Administration Hospital.

Chris J. D. Zarafonetis, b.a., m.d., m.s.

Associate Professor of Medicine, Temple University
School of Medicine and Hospital ; Chief, Hematology
Division, Temple University Hospital.

THE DISPENSATORY

OF THE UNITED STATES
OF AMERICA *•> 25th Edition

ARTHUR OSOL, Ph.G., B.S., M.S., Ph.D.

PROFESSOR OF CHEMISTRY AND DIRECTOR OF THE DEPARTMENT AND SCHOOL OF CHEMISTRY, PHILADELPHIA COLLEGE
OF PHARMACY AND SCIENCE; MEMBER OF THE COMMITTEE OF REVISION OF THE UNITED STATES PHARMACOPEIA

GEORGE E. FARRAR, Jr., B.S., M.D., F.A.C.P.

MEDICAL DIRECTOR, WYETH LABORATORIES, INC.; ASSOCIATE PROFESSOR OF MEDICINE, TEMPLE UNIVERSITY SCHOOL
OF MEDICINE AND HOSPITAL; MEMBER OF THE COMMITTEE OF REVISION OF THE UNITED STATES PHARMACOPEIA

WITH
KARL H. BEYER, Jr., b.s., ph.d., m.d. DAVID K. DETWEILER, v.m.d., m.s.

LECTURER IN PHARMACOLOGY, GRADUATE SCHOOL OF MEDICINE, ASSOCIATE PROFESSOR OF VETERINARY PHARMACOLOGY, SCHOOL

UNIVERSITY OF PENNSYLVANIA, AND TEMPLE UNIVERSITY OF VETERINARY MEDICINE, GRADUATE SCHOOL OF ARTS AND

SCHOOL OF MEDICINE; ASSISTANT DIRECTOR OF RESEARCH, SCIENCES, AND THE GRADUATE SCHOOL OF MEDICINE, UNIVER-
SHARP & DOHME DIVISION, MERCK St CO., INC. SITY OF PENNSYLVANIA

JOHN H. BROWN, v.m.d. ROBERTSON PRATT, a.b., ph.d.

PRODUCTION MANAGER, MARIETTA BIOLOGICAL LABORATORY, PROFESSOR OF PHARMACOGNOSY AND ANTIBIOTICS, UNIVERSITY

WYETH LABORATORIES, INC. OF CALIFORNIA COLLEGE OF PHARMACY

HEBER W. YOUNGKEN, ph.m., ph.d., sc.d.

RESEARCH PROFESSOR OF PHARMACOGNOSY AND BOTANY, MASSA-
CHUSETTS COLLEGE OF PHARMACY; MEMBER OF THE COMMITTEE
OF REVISION OF THE UNITED STATES PHARMACOPEIA.

Editor Emeritus
HORATIO C. WOOD, Jr., M.D., Ph.M.

PROFESSOR EMERITUS OF PHARMACOLOGY, PHILADELPHIA COLLEGE OF PHARMACY AND SCIENCE;
EMERITUS PROFESSOR, GRADUATE SCHOOL OF MEDICINE, UNIVERSITY OF PENNSYLVANIA

Based on the Fifteenth Revision of The United States Pharmacopeia, the Tenth

Edition of The National Formulary, The British Pharmacopoeia, 1953, the First

Edition of the International Pharmacopoeia, Volumes I and 11

Philadelphia ^|[jigg|^ Montreal

J. B. LIPPINCOTT COMPANY

THE DISPENSATORY OF THE UNITED STATES OF AMERICA

\th Edition

25'

Entered, according to Act of Congress, in the year 1877,

By George B. Wood, m.d.,
In the Office of the Librarian of Congress at Washington

, Copyright, 1918, 1926, 1937, 1943, by H. C. Wood, Jr., m.d.

The use in this volume of certain portions of the text of the United States Pharmacopeia, Fifteenth
Revision, official December 15, 1955, is by virtue of permission received from the Board of Trustees of the
United States Pharmacopceial Convention. The said Board of Trustees is not responsible for any inaccuracy
of quotation nor for any errors in the statement of quantities or percentage strengths.

Permission to use for comment parts of the text of the National Formulary, Tenth Edition, in this volume
has been granted by the Committee on Publications by authority of the Council of the American Pharmaceutical
Association.

Distributed in Great Britain by

Pitman Medical Publishing Co., Limited

London

Library of Congress

Catalog Card Number

7-31327

Printed in the United States of America

Historical Title Page

Editors

First Edition (1833) to Eleventh Edition (1858)
GEORGE B. WOOD and FRANKLIN BACHE

Twelfth Edition (1865) and Thirteenth Edition (1870)
GEORGE B. WOOD

Fourteenth Edition (1877)
GEORGE B. WOOD and HORATIO C. WOOD

Fifteenth Edition (1883) to Nineteenth Edition (1907)
HORATIO C WOOD, JOSEPH P. REMINGTON and SAMUEL P. SADTLER

Twentieth Edition (1918)
JOSEPH P. REMINGTON and HORATIO C. WOOD, Jr.

Twenty-first Edition (1926) and Twenty-second Edition (1937)
HORATIO C WOOD, Jr., and CHARLES H. LaWALL

Twenty-third Edition (1943)
HORATIO C WOOD, Jr., and ARTHUR OSOL

Twenty-fourth Edition (1947)
ARTHUR OSOL and GEORGE E. FARRAR, Jr.

The following have also been employed as Associate Editors in the preparation of the
various editions:

WILLIAM PROCTER
ROBERT BRIDGES
HENRY H. RUSBY
HENRY KRAEMER
ALBERT B. LYONS
JOHN F. ANDERSON

LOUIS GERSHENFELD
HEBER W. YOUNGKEN
IVOR GRIFFITH
ARTHUR OSOL
E. EMERSON LEUALLEN
WILLARD F. VERWEY

Publishers

First to Eighth Edition
GRIGG & ELLIOT

Ninth to Eleventh Edition
LIPPINCOTT, GRAMBO & CO.

Twelfth to Fourteenth Edition
J. B. LIPPINCOTT & CO.

Fifteenth to Twenty-fourth Edition
J. B. LIPPINCOTT COMPANY

Preface

This new edition of the UNITED STATES
DISPENSATORY documents the progress of
knowledge concerning medicinal agents in an era
of unprecedented development and expansion in
this field of medical service. In no period of the
long history of this book has so much new infor-
mation been incorporated and so extensive a re-
vision of older information been consummated.
This is in large measure attributable to the fact,
on the one hand, that many medicinal substances
have hardly reached therapeutic maturity before
they are replaced by even safer and more effective
drugs and, on the other, to the finding of new
uses for older drugs as research has disclosed
hitherto unrecognized therapeutic applications or
led to the isolation, in the case of drugs of natural
origin, of potent and therapeutically effective
constituents.

The total of new admissions to the United
States Pharmacopeia, the National Formulary, the
British Pharmacopoeia, and the two volumes of
the International Pharmacopoeia, together with
the new non-official drugs described for the first
time in this edition of the DISPENSATORY,
exceeds 500.

While maintaining the traditional treatment of
drugs according to alphabetic arrangement — which
has many advantages — a feature of this edition
of the DISPENSATORY is the inclusion of many
new general survey articles on pharmacological
classes of drugs. Thus, there appear in Part Two
articles on the following: Adrenergic Blocking
Agents, Anticoagulant Drugs, Antihistamines, Anti-
metabolites, Barbiturates, Curarimimetic Agents
and their Antagonists, Ganglionic Blocking Agents,
Local Anesthetic Agents, Nephrotropic Agents,
Parasympathetic Blocking Agents, Parasympa-
thomimetic Agents and Cholinesterase Inhibitors,
and Skeletal Antispasmodic Compounds. These
articles provide the basis for comparing drugs in
the several categories indicated; also, a correla-
tion between pharmacological action and chemical
structure is thereby often possible, especially since
these general articles are amply illustrated with
structural formulas. Certain other general articles
have been completely rewritten as, for example,
that on Antibiotics, also in Part Two. The estab-
lished uses of radioisotopes in medicine have
naturally necessitated addition of a general
article on this subject, in addition to a specific
article on the official Sodium Radio-iodide (I131)
Solution and innumerable references throughout
the book to specific uses of radioisotopes as tracer
substances.

As in preceding editions of the DISPENSA-
TORY, all articles are amply documented by
original literature references in order to establish
the authority for the information that is provided
and to facilitate further search of the literature
when this is required. In this connection it may
be noted that the new information for this edi-
tion was chosen from more than 25,000 issues of
the approximately 400 medical, pharmaceutical,
biological, and chemical journals which are regu-
larly available to the editors as the basis for re-
vision of the DISPENSATORY.

The very thorough investigations now required
for new drugs before they are released for clinical
use, together with the more extensive clinical
reporting of them, has inevitably resulted in
lengthier monographs concerning individual drugs.
Since oftimes our readers may wish to have only
the most essential information concerning uses of
a drug, we have provided for the lengthier articles
a brief outline of uses at the beginning of the sec-
tion thus designated. Where the articles are of
necessity very long, a summary section has also
been provided, this following the section on uses.
Also, to facilitate quick location of specific in-
formation about drugs having a variety of actions
and uses, the monographs have been conspicuously
and informatively captioned to indicate specific
actions and uses.

Dosage data have been considerably amplified
in this edition. The range of dose, the maximum
single dose, and the maximum total dose in 24
hours are provided for most drugs; variations of
dosage in different diseases are indicated where
such information is required; comparison of dif-
ferent routes of administration is also included
where a choice is available. Toxicological data
have also been expanded and methods of treat-
ment of poisoning are described in sufficient detail
to be of practical utility.

The section on Veterinary Uses and Doses of
Drugs, which was introduced in the 24th Edition
of the Dispensatory and has found wide accept-
ance, has been enlarged by 63 pages both by in-
clusion of new drugs and new data for older ones.

To provide space for the abundance of new
material included, this edition contains over 200
pages more than its predecessor; 102 pages more
were made available by the deletion of general
tests, processes and reagents formerly comprising
Part Three of the DISPENSATORY which, while
important, are of secondary importance to the

viii PREFACE

main purpose of this book in providing practical names are listed opposite the title page; it has

and up-to-the-minute information about drugs. become increasingly apparent in this fruitful

Further savings of space were made by deletion or period of medicinals development that the collabo-

curtailment of information concerning drugs which ration of specialists is essential in order to provide

are no longer or only very rarely used; the editors the thorough and authoritative treatment of the

were not unmindful, however, of the expectation subject required in the DISPENSATORY. Finally,

of users of the DISPENSATORY to find infor- the many contributions of Walter Kahoe, Ph.D.,

mation concerning unusual drugs. A new and Director of the Medical Department of J. B.

somewhat more condensed typography in Part Lippincott Company, toward the culmination of

Two permitted more information to be included the editorial effort in the production of the printed

therein. book are not only acknowledged but greatly

appreciated.
The editors and associate editors acknowledge ARTHUR OSOL,

especially the assistance of the contributors whose Editor-in-Chief

Contents

Page

ABBREVIATIONS xi

PART ONE: Drugs recognized by The United States Pharmacopeia,
British Pharmacopoeia, International Pharmacopoeia, or The Na-
tional Formulary 1

PART TWO: Drugs not official in The United States Pharmacopeia,
British Pharmacopoeia, International Pharmacopoeia, or The Na-
tional Formulary 1523

PART THREE: Veterinary Uses and Doses of Drugs 1935

INDEX 2059

ABBREVIATIONS

A.A.A.S. — The American Association for the Advance-
ment of Science.
A.M.A. — The American Medical Association.
Acta chir. Scandinav .—Acta chirurgica Scandinavica.
Acta dermato-venereol. — Acta dermato-venerologica.
Acta med. Scandinav. — Acta medica Scandinavica.
Advances Enzymol. — Advances in Enzymology and

Related Subjects of Biochemistry.
Allg. med. Centr.-Ztg. — Allegmeine medicinische Cen-

tral-Zeitung.
Am. Drug. — American Druggist.
Am. Fur Breeder — American Fur Breeder.
Am. Heart J. — American Heart Journal.
Am. J. Anat. — American Journal of Anatomy.
Am. J. Bot. — American Journal of Botany.
Am. J. Cancer. — American Journal of Cancer.
Am. J. Clin. Path. — American Journal of Clinical

Pathology.
Am. J. Digest. Dis. — American Journal of Digestive

Diseases and Nutrition.
Am. J. Dis. Child. — American Journal of Diseases of

Children.
Am. J. Hyg. — American Journal of Hygiene.
Am. J. Med. — American Journal of Medicine.
Am. J. Med. Sc. — American Journal of Medical Sci-
ences.
Am. J. Obst. Gyn.— American Journal of Obstetrics

and Gynecology.
Am. J. Ophth. — American Journal of Ophthalmology.
Am. J. Path. — American Journal of Pathology.
Am. J. Pharm. — American Journal of Pharmacy.
Am. J. Physiol. — American Journal of Physiology.
Am. J. Psychiat. — American Journal of Psychiatry.
Am. J. Pub. Health — American Journal of Public

Health and the Nation's Health.
Am. J. Roentgen. — American Journal of Roentgen-
ology and Radium Therapy.
Am. J. Surg. — American Journal of Surgery.
Am. J. Syph. Gonor. Ven. Dis. — American Journal of

Syphilis, Gonorrhea and Venereal Diseases.
Am. J. Syph. Neurol. — American Journal of Syphilis

and Neurology. (Now Am. J. Syph. Gonor. Ven.

Dis.)
Am. J. Trop. Med. — American Journal of Tropical

Medicine.
Am. J. Vet. Res. — American Journal of Veterinary

Research.
Am. Med. — American Medicine.
Am. Perfumer — American Perfumer and Essential Oil

Review.
Am. Pract. Dig. Treat. — American Practitioner and

Digest of Treatment.
Am. Prof. Pharm. — American Professional Pharmacist.
Am. Rev. Soviet Med. — American Review of Soviet

Medicine.
Am. Rev. Tuberc. — American Review of Tuberculosis.
Am. Surg. — The American Surgeon.
Am. Vet. Rev. — American Veterinary Review.
Anais faculdade med. univ. S. Paulo — Anais da facul-

dade de medicina da universidade de Sao Paulo.
Analyst — The Analyst.
Anesth. — Anesthesiology.
Aneth. & Analg. — Current Researches in Anesthesia

and Analgesia.
Angewandte Chem. — Angewandte Chemie.
Ann. Allergy — Annals of Allergy.
Ann. Biochem. Exp. Med. — Annals of Biochemistry

and Experimental Medicine.
Ann. Chem. — Annalen der Chemie, Liebig.

Ann. Chem. Pharm. — Annalen der Chemie und Phar-

macie. (Now Ann. Chem.)
Ann. chim. app. — Annali di chimica applicata.
Ann. Chim. Phys. — Annales de Chimie et de Physique.
Ann. d'igiene — Annali d'igiene.
Ann. dermat. syph. — Annales de dermatologie et de

syphiligraphie.
Ann. Inst. Pasteur — Annales de l'lnstitut Pasteur.
Ann. Int. Med. — Annals of Internal Medicine.
Ann. med.-psychol. — Annales medico-psychologiques.
Ann. N. Y. Acad. Sc. — Annals of the New York Acad-
emy of Science.
Ann. Otol. Rhin. Larytig. — Annals of Otology, Rhi-

nology and Laryngology.
Ann. Rev. Biochem. — Annual Review of Biochemistry.
Ann. Rev. Physiol.— Annual Review of Physiology.
Ann. Surg. — Annals of Surgery.
Ann. Trop. Med. — Annals of Tropical Medicine and

Parasitology.
Ann. West. Med. Surg. — Annals of Western Medicine

and Surgery.
Antibiot. Chemother. — Antibiotics and Chemotherapy.
Apoth.-Ztg. — Apotheker-Zeitung. (See also Deutsche

Apoth.-Ztg.)
Arbeit, pharmakol. Inst. Dorpat — Arbeiten der phar-

makologisches Institut, Dorpat.
Arch. Dermat. Syph. — Archives of Dermatology and

Syphilology.
Arch. Dis. Child. — Archives of Disease in Children.
Arch. exp. Path. Pharm. — Archiv fur experimentelle

Pathologie und Pharmakologie.
Arch, farmacol. sper. — Archivo di farmacologia speri-

mentale e scienze affini.
Arch, farmacol. terap. — Archivio di farmacologia e

terapeutica.
Arch. gen. med. — Archives generates de medecine.
Arch. ges. Physiol. — Archiv fiir die gesamte Physi-
ologic des Menschen und der Tiere.
Arch. Gewerbepath. Gewerbehyg. — Archiv fiir Ge-

werbepathologie und Gewerbehygiene.
Arch. Gyndk. — Archiv fiir Gynakologie.
Arch. Hyg.— Archiv fiir Hygiene und Bakteriologie.
Arch. Int. Med.- — Archives of Internal Medicine.
Arch. Indust. Hyg. — Archives of Industrial Hygiene

and Occupational Medicine.
Arch, internat. pharmacodyn. therap. — Archives in-

ternationales de pharmacodynamic et de therapie.
Arch. mal. du coeur — Archives des maladies du cceur et

des vaisseaux.
Arch. Neurol. Psychiat. — Archives of Neurology and

Psychiatry.
Arch. Ophth. — Archives of Ophthalmology.
Arch. Otolaryng. — Archives of Otolaryngology.
Arch. Path. — Archives of Pathology.
Arch. Path. Lab. Med. — Archives of Pathology and

Laboratory Medicine. (Now Arch. Path.)
Arch. Pediat. — Archives of Pediatrics.
Arch, pediat. Uruguay — Archivos de pediatria del

Uruguay.
Arch. Pharm. — Archiv der Pharmacie.
Arch. Phys. Med. — Archives of Physical Medicine.
Arch. Phys. Ther. — Archives of Physical Therapy.
Arch. Schiffs-Tropen-Hyg. — Archiv fiir Schiffs- und

Tropen-Hygiene.
Arch. Surg. — Archives of Surgery.
Arch. urug. de med. — Archivos uruguayos de medi-
cina, cirugia y especialidades.
Aust. Vet. J. — Australian Veterinary Journal.

XII

ABBREVIATIONS

Australasian J. Pharm. — Australasian Journal of Phar-
macy.

Australia, Council for Sc. & Indust., Res. Bull. — Aus-
tralia, Council for Science and Industry, Research
Bull.

Bact. Rev. — Bacteriological Reviews.

Beitr. Klin. Tuberk. — Beitrage zur Klinik der Tuber-
kulose und spezifischen Tuberkulose-Forschung.

Ber. — Berichte der deutschen chemischen Gesellschaft.

Ber. deutsch. pharm. Ges. — Berichte der deutschen
pharmaceutischen Gesellschaft.

Ber. ges. Physiol. — Berichte iiber die gesamte Physi-
ologic und experimentelle Pharmakologie.

Berl. klin. Wchnschr. — Berliner klinische Wochen-
schrift. (Now Klin. Wchnschr.)

Berl. tierarztl. Wchnschr. — Berliner tierarztliche Wo-
chenschrift.

Biochem. J. — Biochemical Journal.

Biochem. Ztschr. — Biochemische Zeitschrift.

Bol. assoc. brasil. farm. — Boletim da associaqao brasil-
eira de farmaceuticos.

Bol. ministerio agr. — Boletim do ministerio da agri-
cultura (Brazil).

Boll. chim. farm. — Bollettino chimico-farmaceutico.

Boston Med. Surg. J. — Boston Medical and Surgical
Journal. (Now New Eng. J. Med.)

Bot. Abs. — Botanical Abstracts.

Bot. Centralbl. — Botanisches Centralblatt.

Bot. Gaz. — Botanical Gazette.

B.P. — The British Pharmacopoeia.

B.P. Add. — Addendum to the British Pharmacopoeia.

Brasil-med. — Brasil-medico.

Brit. Heart J. — British Heart Journal.

Brit. J. Derm. — British Journal of Dermatology.

Brit. J. Anaesth. — British Journal of Anaesthesia.

Brit. J. Exp. Path. — British Journal of Experimental
Pathology.

Brit. J. Ind. Med. — British Journal of Industrial
Medicine.

Brit. J. Ophth. — British Journal of Ophthalmology.

Brit. J. Pharmacol. Chemother. — British Journal of
Pharmacology and Chemotherapy.

Brit . J. Phys. Med. — British Journal of Physical Medi-
cine and Industrial Hygiene.

Brit. J. Radiol. — British Journal of Radiology.

Brit. J. Surg. — British Journal of Surgery.

Brit. J. Tuberc. — British Journal of Tuberculosis.

Brit. J. Urol. — British Journal of Urology.

Brit. M. J. — British Medical Journal.

Brit. Vet. J. — British Veterinary Journal.

Brodil'naya Prom. — Brodil'naya Promyshlennost.

Bruxelles-med. — Bruxelles-medical.

Bull. A. S. H. P. — Bulletin of the American Society of
Hospital Pharmacists.

Bull. Acad. med. Paris — Bulletin de l'Academie de
medecine.

Bull. Acad. Med. Toronto — Bulletin of the Academy
of Medicine, Toronto.

Bull. Am. Coll. Surgeons — Bulletin of the American
College of Surgeons.

Bull, assoc. chim. — Bulletin de l'association des
chimistes.

Bull. Chem. Soc. Japan — Bulletin of the Chemical
Society of Japan.

Bull. gen. therap. — Bulletin general de therapeutique
medicale, chirurgicale, obstetricale et pharma-
ceutique.

Bull. Health Leag. Nations — Bulletin of the Health
Organization, League of Nations.

Bull. Hist. Med— Bulletin of the Institute of the His-
tory of Medicine.

Bull. Hyg. — Bulletin of Hygiene.

Bull. Johns Hopkins Hosp. — Bulletin of the Johns
Hopkins Hospital.

Bull. med. — Le bulletin medical.

Bull. Nat. Inst. Health— Bulletin of the National In-
stitutes of Health.

Bull. New Eng. Med. Center — Bulletin of the New
England Medical Center.

Bull. N. F. Com. — Bulletin of the National Formulary
Committee.

Bull. N. Y. Acad. Med.— Bulletin of the New York
Academy of Medicine.

Bull. Pharm. — Bulletin of Pharmacy.

Bull. Rheumat. Dis. — Bulletin on Rheumatic Diseases.

Bull. sc. Pharmacol. — Bulletin des sciences pharma-
cologiques.

Bull. Sch. Med. Univ. Maryland — Bulletin of the
School of Medicine, University of Maryland.

Bull. soc. chim. — Bulletin de la societe chimique de
France.

Bull. soc. chim. Belg. — Bulletin de la societes chim-
iques Beiges.

Bidl. soc. chim. biol. — Bulletin de la societe de chimie
biologique.

Bull. soc. franc, dermat. syph. — Bulletin de la societe
franchise de dermatologie et de syphiligraphie.

Bull. soc. med. — Bulletins et memoires de la societe
medicale des hopitaux de Paris.

Bull. soc. path. exot. — Bulletin de la societe de path-
ologie exotique et de ses filiales.

Bull. St. Louis M. Soc. — Bulletin of the St. Louis
Medical Society.

Bidl. Torrey Bot. Club— Bulletin of the Torrey Bo-
tanical Club.

Bull. trav. soc. pharm. Bordeaux — Bulletin des travaux
de la societe de pharmacie de Bordeaux.

Bull. U. S. Army M. Dept— Bulletin of the United
States Army Medical Department.

Bull. War Med. — Bulletin of War Medicine.

Bur. Standards J. Research — Bureau of Standards
Journal of Research.

Calif. & West. Med. — California and Western Medi-
cine.

Calif. Med. — California Medicine.

Can. J. Comp. Med.— Canadian Journal of Compara-
tive Medicine and Veterinary Science.

Can. J. Research — Canadian Journal of Research.

Can. Med. Assoc. J. — Canadian Medical Association
Journal.

Can. Pharm. J. — Canadian Pharmaceutical Journal.

Can. Pub. Health J. — Canadian Public Health Journal.

Can. Vet. Rec. — Canadian Veterinary Record.

Cancer Res. — Cancer Research.

Centralbl. med. Wissensch. — Centralblatt fur die medi-
zinischen Wissenschaften.

Cereal Chem. — Cereal Chemistry.

Chem. Abs. — Chemical Abstracts.

Chem. Centralbl. — Chemisches Centralblatt.

Chem. Drug. — The Chemist and Druggist.

Chem. Eng. News — Chemical and Engineering News.

Chem. Industries — Chemical Industries.

Chem. Met. Eng. — Chemical and Metallurgical Engi-
neering.

Chem. News — Chemical News and Journal of In-
dustrial Science.

Chem. Rev. — Chemical Reviews.

Chem. Trade J. — Chemical Trade Journal and Chem-
ical Engineer.

Ckem.-Ztg. — Chemiker-Zeitung.

Chimica e I'industria Milan — La chimica e l'industria,
Milan.

Chinese J. Physiol. — Chinese Journal of Physiology.

Chinese M. J. — Chinese Medical Journal.

Cincinnati J. Med.— Cincinnati Journal of Medicine.

Cincinnati M. J. — Cincinnati Medical Journal.

Cleveland Clin. Quart. — Cleveland Clinic Quarterly.

Cleveland M. J. — Cleveland Medical Journal.

Clin. J. — Clinical Journal.

Clin. Med. — Clinical Medicine.

Clin. Proc. — Clinical Proceedings.

ABBREVIATIONS

XIII

Clin. Sc. — Clinical Science.

Clinics — Clinics.

Colorado Med. — Colorado Medicine. (Now Rocky

Mountain M. J.)
Compt. rend. acad. sc. — Comptes rendus hebdoma-

daires des seances de l'academie des sciences.
Compt. rend. soc. biol. — Comptes rendus des seances

de la societe de biologic
Confinia Neurol. — Confinia Neurologica.
Connecticut State M. /.—Connecticut State Medical

Journal.
Cornell Vet. — The Cornell Veterinarian.
Dansk Tids. Farm. — Dansk Tidsskrift for Farmaci.
Delaware S. M. J. — Delaware State Medical Journal.
Dental Rec. — Dental Record.
Dental Survey — Dental Survey.
Dentistry — Dentistry, a Digest of Practice.
Derm. Wchnschr. — Dermatologische Wochenschrift.
Derm. Ztschr. — Dermatologische Zeitschrift.
Deutsche Apoth.-Ztg. — Deutsche Apotheker-Zeitung.
Deutsche med. 7.— Deutsches medizinisches Journal.
Deutsche med. Wchnschr. — Deutsche medicinische

Wochenschrift.
Deutsche Mil. — Deutsche Militararzt.
Deutsche tierarztl. Wochenschr. — Deutsche tierarzt-

liche Wochenschrift.
Deutsche zahnarztl. Wchnschr. — Deutsche zahnarzt-

liche Wochenschrift.
Deutsche Ztschr. ges. gerichtl. Med. — Deutsche Zeit-
schrift fur die gesamte gerichtliche Medizin.
Deutsches Arch. klin. Med. — Deutsches Archiv fur

klinische Medizin.
Dis. Nerv. Syst. — Diseases of the Nervous System.
Drug. Circ. — Druggists Circular.
Drug Cosmet. Ind. — Drug and Cosmetic Industry.
East African M. J. — East African Medical Journal.
Edinburgh M. J. — Edinburgh Medical Journal.
Endocrinology — Endocrinology.
Enzymologia — Enzymologia.
Ergebn. Enzymforsch. — Ergebnisse der Enzymfor-

schung.
Exp. Med. & Surg. — Experimental Medicine and

Surgery.
Eye, Ear, Nose & Throat Monthly — Eye, Ear, Nose

and Throat Monthly.
Farm. Revy — Farmacevtisk Revy.
Farmakol. i Toksikol. — Farmakologiia i Toksikologiia.
Fed. Proc. — Federation Proceedings.
Fettchem. Umschau — Fettchemische Umschau. (Now

Fette und Seifen.)
Fette und Seifen — Fette und Seifen.
Folia Medica — Folia Medica, Naples.
Food Res. — Food Research.
Fortschr. Med. — Fortschritte der Medizin.
Fortschr. Ther. — Fortschritte der Therapie.
Fr. — French Codex.
Gastroenterology — Gastroenterology.
Gaz. chim. ital.- — Gazzetta chimica italiana.
Gaz. med. de France — Gazette medicale de France

et des pays de langue franchise.
Gaz. med. Paris — Gazettes medicale, Paris.
Ger. — German Pharmacopoeia.
Geriatrics — Geriatrics.
Guy's Hosp. Rep. — Guy's Hospital Reports.
Heart — Heart.
Heilkunde — Heilkunde.
Helv. Chim. Acta — Helvetica Chimica Acta.
Helv. Physiol. Pharm. Acta — Helvetica Physiologica et

Pharmacologica Acta.
Herbarist — Herbarist.
Human Fert. — Human Fertility.
Hyg. Lab. Bull. — Hygienic Laboratory Bulletin. (Now

Bull. Nat. Inst. Health.)
Illinois M. J. — Illinois Medical Journal.
Ind. Chemist — Industrial Chemist and Chemical

Manufacturer.

Ind. Eng. Chem. — Industrial and Engineering Chem-
istry.

Ind. Eng. Chem., Anal. Ed. — Industrial and Engi-
neering Chemistry, Analytical Edition.

Ind. Med. — Industrial Medicine.

Indian J. Med. Res. — Indian Journal of Medical Re-
search.

Indian J. Pharm. — Indian Journal of Pharmacy.

Indian Med. Gaz. — Indian Medical Gazette.

Indian Vet. J. — The Indian Veterinary Journal.

Indiana State M. A. J. — Indiana State Medical Asso-
ciation Journal.

Internat. Clin. — International Clinics. (Now New
Internat. Clin.)

Internat. J. Med. Surg. — International Journal of
Medicine and Surgery.

Internat. Med. Digest — International Medical Digest.

Internat. Rec. Med. — International Record of Medi-
cine and General Practice Clinics.

It. — Italian Pharmacopoeia.

J.A.CS. — Journal of the American Chemical Society.

/. A. Dent. A. — Journal of the American Dental
Association.

/. A. Dietet. A. — Journal of the American Dietetic
Association.

/. A. Inst. Homeopathy — Journal of the American
Institute of Homeopathy.

J. A.M. A. — Journal of the American Medical Asso-
ciation.

J. A. M. Women's A. — Journal of the American Medi-
cal Women's Association.

J.A.O.A.C. — Journal of the Association of Official
Agricultural Chemists.

/. A. Ph. A. — Journal of the American Pharmaceu-
tical Association.

J. A. Ph. A., Prac. Ed. — Journal of the American
Pharmaceutical Association, Practical Edition.

J.A.V.M.A. — Journal of the American Veterinary
Medical Association.

/. Agric. Food Chem. — Journal of Agricultural and
Food Chemistry.

/. Agric. Res. — Journal of Agricultural Research.

/. Agric. Sc. — The Journal of Agricultural Science.

/. Albert Einstein Med. Center — Journal of the Albert
Einstein Medical Center.

/. Allergy— The Journal of Allergy.

/. Anat. — Journal of Anatomy.

/. Ani. Sc. — Journal of Animal Science.

/. Bad. — Journal of Bacteriology.

J. Biol. Chem. — Journal of Biological Chemistry.

/. Bone Joint Surg. — Journal of Bone and Joint
Surgery.

/. Calif. State Dent. A. — Journal of the California
State Dental Association.

J. Can. Dent. A. — Journal of the Canadian Dental
Association.

/. Chem. Educ. — Journal of Chemical Education.

/. Chem. Ind. — Journal of Chemical Industry (Mos-
cow).

/. Chem. S. — Journal of the Chemical Society.

/. Chemother. — Journal of Chemotherapy.

/. chim. phys. — Journal de chimie physique.

/. Clin. Endocrinol. — Journal of Clinical Endocrinol-
ogy.

/. Clin. Inv. — Journal of Clinical Investigation.

J. Clin. Nutrition — Journal of Clinical Nutrition.

J. Comp. Path. Therap. — The Journal of Comparative
Pathology and Therapeutics.

/. Council Sci. Ind. Res. — Journal of the Council for
Scientific and Industrial Research.

/. Cutan. Dis. — Journal of Cutaneous Diseases includ-
ing Syphilis.

J. Dairy Sc. — Journal of Dairy Science.

/. Dent. Research — Journal of Dental Research.

/. Econ. Entomol. — Journal of Economic Entomology.

/. Endocrinol. — Journal of Endocrinology.

XIV

ABBREVIATIONS

/. Exp. Med. — Journal of Experimental Medicine.

/. Gen. Client. (US.S.R.)— Journal of General Chem-
istry (U.S.S.R.).

J. Gen. Microbiol. — Journal of General Microbiology.

/. Gen. Physiol. — Journal of General Physiology.

J. Geront. — Journal of Gerontology.

J. Hygiene — Journal of Hygiene.

/. Immunol. — Journal of Immunology.

/. Ind. Hyg. Toxicol. — Journal of Industrial Hygiene
and Toxicology.

/. Indian Chem. S. — Journal of the Indian Chemical
Society.

/. Indian Inst. Sc. — Journal of the Indian Institute of
Science.

/. Indian M. A. — Journal of the Indian Medical
Association.

/. Indiana M. A. — Journal of the Indiana State
Medical Association.

/. Inject. Dis. — Journal of Infectious Diseases.

/. Internat. Col. Surg. — Journal of the International
College of Surgeons.

J. Invest. Dermat. — Journal of Investigative Derma-
tology.

/. Iowa M. Soc. — Journal of Iowa State Medical
Society.

/. Lab. Clin. Med. — Journal of Laboratory and Clini-
cal Medicine.

J. -Lancet — Journal-Lancet.

/. Laryng. Otol. — Journal of Laryngology and Otol-
ogy.

J. Linn. Soc. — Journal of the Linnaean Society.

J. M. A. Alabama — Journal of the Medical Associa-
tion of the State of Alabama.

J. M. A. Georgia — Journal of the Medical Association
of Georgia.

/. M. Soc. New Jersey — Journal of the Medical So-
ciety of New Jersey.

/. Maine M. A. — Journal of the Maine Medical Asso-
ciation.

J. mid. chirurg. prat. — Journal de medecine et de
chirurgie pratiques.

/. mid. Lyon — Le journal de medecine de Lyon.

/. mid. Paris — Journal de medecine de Paris.

J. Ment. Sc. — Journal of Mental Science.

J. Michigan M. Soc. — Journal of Michigan State
Medical Society.

/. Missouri M. A. — Journal of Missouri State Medical
Association.

/. Mt. Sinai Hosp. — Journal of the Mount Sinai Hos-
pital, New York.

/. Nat. Cancer Inst. — Journal of the National Cancer
Institute.

J. Nat. M. A. — Journal of the National Medical
Association.

/. Nat. Malaria Soc. — Journal of the National Malaria
Society.

/. Nerv. Ment. Dis. — Journal of Nervous and Mental
Disease.

/. Neurophysiol. — Journal of Neurophysiology.

/. Neurosurg. — Journal of Neurosurgery.

/. Nutrition — The Journal of Nutrition.

/. Obst. Gyn. Br. Emp. — Journal of Obstetrics and
Gynaecology of the British Empire.

/. Oil & Colour Chem. Assoc. — Journal of the Oil
and Colour Chemists' Association.

/. Omaha Mid-West Clin. Soc. — Journal of the Omaha
Mid-West Clinical Society.

/. Oral Surg. — Journal of Oral Surgery.

/. Org. Chem. — Journal of Organic Chemistry.

/. Parasitol. — Journal of Parasitology.

/. Parenteral Therapy — Journal of Parenteral Ther-
apy.

/. Path. Bad. — Journal of Pathology and Bacteriol-
ogy.

/. Pediatr. — Journal of Pediatrics.

J. pharm. Alsace Lorraine — Journal de pharmacie
d'Alsace et de Lorraine.

J. pharm. Belg. — Journal de pharmacie de Belgique.

/. pharm. chim. — Journal de pharmacie et de chimie.

/. Pharm. Pharmacol. — The Journal of Pharmacy and
Pharmacology.

J. Pharm. Soc. Japan — Journal of the Pharmaceutical
Society of Japan.

/. Pharmacol. — Journal of Pharmacology and Experi-
mental Therapeutics.

/. Phys. Chem. — Journal of Physical Chemistry.

/. Physiol. — Journal of Physiology.

/. prakt. Chem. — Journal fvir praktische Chemie.

/. Prevent. Med. — Journal of Preventive Medicine.

J. Proc. Roy. Soc. N. S. Wales — Journal and Proceed-
ings of the Royal Society of New South Wales.

/. Roy. Army Med. Corps — Journal of the Royal
Army Medical Corps.

/. Roy. Soc. W. Australia — Journal of the Royal So-
ciety of Western Australia.

/. Russ. Phys. Chem. S. — Journal of the Russian
Physical-Chemical Society.

/. Soc. Chem. Ind. — Journal of the Society of Chemi-
cal Industry.

/. South African V. M. A. — The Journal of the South
African Veterinary Medical Association.

/. Thoracic Surg.- — Journal of Thoracic Surgery.

/. Trop. Med. Hyg. — Journal of Tropical Medicine
and Hygiene.

/. Urol. — The Journal of Urology.

J. Ven. Dis. Inform. — Journal of Venereal Disease
Information.

Jahresber. Pharm. — Jahresbericht der Pharmazie.

Jap. J. Med. Sc. — Japanese Journal of Medical Sci-
ences.

Kentucky M. J. — Kentucky Medical Journal.

Klin. Monatsbl. Augen. — Klinische Monatsblatter fur
Augenheilkunde.

Klin.-therap. Wchnschr. — Klinisch-therapeutische
Wochenschrift.

Klin. Wchnschr. — Klinische Wochenschrift.

Kunststoffe — Kunststoffe: Zeitschrift fur Erzeugung
und Venvendung veredelter oder chemisch herges-
tellter Stoffe.

Lahey Clin. Bull.- — Lahey Clinic Bulletin.

Lancet — The Lancet.

Laryng. — Laryngoscope.

Laval mid. — Laval medical.

L'Union pharm. — L'Union pharmaceutique.

M. S. C. Vet. — The M. S. C. Veterinarian.

Med. Ann. District Columbia — Medical Annals of the
District of Columbia.

Med. Bl. — Medicinische Blaetter.

Med. Bull. Vet. Admin.— Medical Bulletin of the
Veterans' Administration.

Med. Clin. North America — The Medical Clinics of
North America.

Med. J. Australia — Medical Journal of Australia.

Med. Klin. — Medizinische Khnik.

Med. Press— Medical Press and Circular.

Med. Rec. — Medical Record.

Med. Rund. — Medizinische Rundschau.

Med. Times— Medical Times.

Medecine — La Medecine.

Medicine — Medicine: Analytical Reviews of General
Medicine, Neurology and Pediatrics.

Merck Rep— The Merck Report.

Merck's Jahresber. — Merck's Jahresbericht uber Neu-
erungen auf den Gebieten der Pharmakotherapie
und Pharmazie.

Mfg. Chemist— The Manufacturing Chemist.

Mfg. Perfumer — The Manufacturing Perfumer.
(Merged with Mfg. Chemist.)

Mikrochemie — Mikrochemie.

MU. Surg. — Military Surgeon.

Minn. Med. — Minnesota Medicine.

ABBREVIATIONS

Missouri Agric. Exp. Sta. Res. Bull. — Missouri Agri-
cultural Experiment Station Research Bulletin.
Missouri Med. — Missouri Medicine.
Mitt. med. Akad. Kioto — Mitteilungen aus der medi-

zinischen Akademie zu Kioto.
Monatsh. Chetn. — Monatshefte fur Chemie und ver-

wandte Teile anderer Wissenschaften.
Monatsh. f. Vet.-tned. — Monatshefte fur Veterinar-

medizin.
Monatsh. prakt. Tierheilk. — Monatshefte fiir prak-

tische Tierheilkunde.
Monatsschr. Geburtsh. Gyn'dk. — Monatsschrift fiir

Geburtshiilfe und Gynakologie.
Munch, med. Wchnschr. — Munchener medizinische

Wochenschrift.
N. Carolina M. J. — North Carolina Medical Journal.
N.F. — The National Formulary, Tenth Edition.
N. Y. State J. Med. — New York State Journal of

Medicine.
Nat. Res. Council Bull. — National Research Council

Bulletin.
Nature — Nature.
Nederland. Tijdschr. Pharm. — Nederlandsch Tijd-

schrift voor Pharmacie, Chemie en Toxicologic
New Eng. J. Med. — New England Journal of Medi-
cine.
New Internat. Clin. — New International Clinics.
New Orleans Med. Surg. J. — New Orleans Medical

and Surgical Journal.
North Am. Vet.- — The North American Veterinarian.
Northwest Med. — Northwest Medicine.
Nouv. Rem. — Nouveaux Remedes.
Nutrition Rev. — Nutrition Reviews.
Obst. Gyn. — Obstetrics and Gynecology.
Occup. Med. — Occupational Medicine.
Oesterr. Chem.-Ztg. — Oesterreichische Chemiker-

Zeitung. (Now Wien. Chem.-Ztg.)
Ohio State M. J. — Ohio State Medical Journal.
Oil and Fat Ind. — Oil and Fat Industries. (Now Oil

and Soap.)
Oil and Soap — Oil and Soap.
Oral Surg., Oral Med., Oral Path— Oral Surgery, Oral

Medicine and Oral Pathology.
Orient. J. Dis. Infants — Oriental Journal of Diseases

of Infants.
Pediatr. — Pediatrics.

Pennsylvania M. J. — Pennsylvania Medical Journal.
Perf. Ess. Oil Rec. — Perfumery and Essential Oil

Record.
Pest, med.-chirurg. Presse — Pester medicinisch-chirur-

gische Presse.
Pharm. Acta Helv. — Pharmaceutica Acta Helvetiae.
Pharm. Arch. — Pharmaceutical Archives.
Pharm. Era — Pharmaceutical Era.
Pharm. J. — Pharmaceutical Journal.
Pharm. Monatsh. — Pharmazeutische Monatshefte.
Pharm. Presse — Pharmazeutische Presse.
Pharm. Rev. — Pharmaceutical Review.
Pharm. Rund. — Pharmaceutische Rundschau.
Pharm. Tijdschr. — Pharmaceutisch Tijdschrift voor

Nederlandsch-Indie.
Pharm. Weekblad — Pharmaceutisch Weekblad.
Pharm. Zentr. — Pharmaceutische Zentralhalle fiir

Deutschland.
Pharm. Ztg. — Pharmaceutische Zeitung.
Pharmacol. Rev. — Pharmacological Reviews.
Phila. Med. — Philadelphia Medicine.
Philippine J. Sc. — Philippine Journal of Science.
Physiol. Rev. — Physiological Reviews.
Pittsburgh Med. Bull— Pittsburgh Medical Bulletin.
Plast. Reconstruct. Surg. — Plastic and Reconstructive

Surgery.
Postgrad. Med. — Postgraduate Medicine.
Poultry Sc. — Poultry Science.
Pract . — Practitioner.
Pract. Drug. — Practical Druggist.

Praktika Akad. Athenon — Praktika Akademia
Athen5n.

Prensa med. Argent. — La prensa medica Argentina.

Prensa med. Mexicana — Prensa medica Mexicana.

Presse med. — Presse medicale.

Proc. A. Diabetes A. — Proceedings of the American
Diabetes Association.

Proc. A. Ph. A. — Proceedings of the American Phar-
maceutical Association.

Proc. Centr. Soc. Clin. Res. — Proceedings of the
Central Society for Clinical Research.

Proc. Chem. S. — Proceedings of the Chemical Society.

Proc. Helminthol. Soc. — Proceedings of the Helmin-
thological Society.

Proc. Imp. Acad. Tokyo- — Proceedings of the Im-
perial Academy (Tokyo).

Proc. Indian Acad. Sc. — Proceedings of the Indian
Academy of Sciences.

Proc. Indiana Vet. Med. Assoc. — Proceedings of the
Indiana Veterinary Medical Association.

Proc. Int. Congr. PI. Sc. — Proceedings of the Inter-
national Congress of Plant Science.

Proc. Mayo — Proceedings of the Staff Meetings of
the Mayo Clinic.

Proc. Nat. Acad. Sc. — Proceedings of the National
Academy of Science.

Proc. N. J. Ph. A. — Proceedings of the New Jersey
Pharmaceutical Association.

Proc. Penn. Ph. A. — Proceedings of the Pennsylvania
Pharmaceutical Association.

Proc. Roy. Soc. London — Proceedings of the Royal
Society, London.

Proc. Roy. Soc. Med. — Proceedings of the Royal So-
ciety of Medicine.

Proc. S. Dakota Acad. Sc. — Proceedings of the South
Dakota Academy of Sciences.

Proc. S. Exp. Biol. Med. — Proceedings of the Society
for Experimental Biology and Medicine.

Progres med.- — Le progres medical.

Psych. Quart. — Psychiatric Quarterly.

Psychosom. Med. — Psychosomatic Medicine.

Pub. Health Rep.— Public Health Reports.

Puerto Rico J. Pub. Health — Puerto Rico Journal of
Public Health and Tropical Medicine.

Quart. Bull. Northwest. U. Med. Sch. — Quarterly Bul-
letin of Northwestern University Medical School.

Quart. J. Exp. Physiol. — Quarterly Journal of Ex-
perimental Physiology.

Quart. J. Med.— Quarterly Journal of Medicine.

Quart. J. P. — Quarterly Journal of Pharmacy and
Pharmacology.

Quart. J. Stud. Alcohol — Quarterly Journal of Studies
on Alcohol.

Queensland Agr. J. — Queensland Agricultural Journal.

Radiology — Radiology.

Rec. trav. chim. — Recueil des travaux chimiques des
Pays-Bas.

Rev. assoc. brasil. farm. — Revista da associaqao brasi-
leira de farmaceuticos.

Rev. brasil. med. farm.— Revista brasileira de medi-
cina e farmacia.

Rev . Canad. Biol. — Revue Canadienne de Biologic

Rev. chim. ind. — Revista de chimica industrial (Rio
de Janeiro).

Rev. din. espan. — Revista clinica espanola.

Rev. filipina med. farm. — Revista filipina de medicina
y farmacia.

Rev. flora med. — Revista de flora medicinal (Rio de
Janeiro).

Rev. Gastroenterol. — The Review of Gastroenterology.

Rev. gen. Clin. Therap. — Revue generale de Clinique
et de Therapeutique.

Rev. med. hyg. trop. — Revue de medecine et d'hy-
giene tropicales.

Rev. med. Liege — Revue medicale de Liege.

XVI

ABBREVIATIONS

Rev. med. Suisse Rom. — Revue medicale de la Suisse
Romande.

Rev. neurol. — Revue neurologique.

Rev. quim. pura aplic. — Revista de quimica pura e
aplicada.

Rev. therap. med.-chirurg. — Revue de therapeutique
medico-chirurgicale.

Riechstoff Ind. — Riechstoff Industrie.

Rif. med. — La Riforma medica.

Rocky Mountain M. J. — Rocky Mountain Medical
Journal.

Royal Col. Phys. Rep. Edinburgh — Royal College of
Physicians Laboratory Reports, Edinburgh.

5. Dakota J. M. Pharm.— South Dakota Journal of
Medicine and Pharmacy.

Sang — Le sang.

Sao Paulo med. — Sao Paulo medico.

Schim. Rep. — Schimmel & Co., Annual Report.

Schweiz. Apoth.-Ztg. — Schweizerische Apotheker-
Zeitung.

Schweiz. Arch. Tierheilk. — Schweizerische Archiv fiir
Tierheilkunde.

Schweiz. med. Wchnschr. — Schweizerische medizinische
Wochenschrift.

Schweiz. naturforsch. Gesell. — Schweizerische natur-
forschende Gesellschaft.

Schweiz. Wchnschr. Pharm. — Schweizerische Woch-
enschrift fiir Pharmacie.

Sci. Monthly — Scientific Monthly.

Science — Science.

Scientia Pharm. — Scientia Pharmaceutica.

Seifensieder-Ztg. — Seifensieder-Zeitung.

Semaine med. — Semaine medicale.

Semana medica — La Semana medica.

Skandinav. Arch. Physiol. — Skandinavisches Archiv
fiir Physiologie.

Soap, Perf. & Cos. — Soap, Perfumery and Cosmetics
Trade Journal.

South African J. Med. Sc. — South African Journal
of Medical Sciences.

South. M. J. — Southern Medical Journal.

South. Med. Surg. — Southern Medicine and Surgery.

Sp. — Spanish Pharmacopoeia.

Stanford M. Bull. — Stanford University Medical Bul-
letin.

Siidd. Apoth.-Ztg. — Suddeutsche Apotheker-Zeitung.

Surg. Clinics N. America — Surgical Clinics of North
America.

Surg. Gynec. Obst. — Surgery, Gynecology and Ob-
stetrics with International Abstract of Surgery.

Surgery — Surgery.

Texas Repts. Biol. Med. — Texas Reports on Biology
and Medicine.

Texas State J. Med. — Texas State Journal of Medi-
cine.

Ther. Geg. — Therapie de Gegenwart.

Therap. Gaz. — Therapeutic Gazette.

Therap. Halbmonatsh. — Therapeutische Halbmonat-
shefte.

Therap. Monatsh. — Therapeutische Monatshefte.

Tierdrztl. Rundsch. — Tier'arztliche Rundschau.

Tohoku J. Exp. Med. — Tohoku Journal of Experi-
mental Medicine.

Trade Corres. — Trade Correspondence of the Food
and Drug Administration.

Trans. A. Am. Phys. — Transactions of the Association
of American Physicians.

Trans. Am. Acad. Ophth. — Transactions of the Ameri-
can Academy of Ophthalmology and Oto-
laryngology.

Trans. Am. Inst. Chem. Engrs. — Transactions of the
American Institute of Chemical Engineers.

Trans. Am. Laryng. Rhin. Otol. Soc. — Transactions
of the American Laryngological, Rhinological and
Otological Society.

Trans. Am. Neurol. A. — Transactions of the American
Neurological Association.

Trans. Chem. Soc. — Transactions of the Chemical
Society of London.

Trans. Roy. Soc. Trop. Med. Hyg. — Transactions
of the Royal Society of Tropical Medicine and
Hygiene.

Trans. South. Surg. Gynec. A. — Transactions of the
Southern Surgical and Gynecological Association.

Trans. Stud. Coll. Phys. — Transactions and Studies of
the College of Physicians of Philadelphia.

Trop. Dis. Bull. — Tropical Diseases Bulletin.

U. S. Armed Forces M. J. — United States Armed
Forces Medical Journal.

U. S. Army Vet. Bull. — United States Army Veteri-
nary Bulletin.

U.S.D. — The United States Dispensatory.

U.S.D.A. Farmers' Bull. — United States Department
of Agriculture Farmers' Bulletin.

U.S.D.A. Leaflet. — United States Department of Agri-
culture Leaflet.

US.D.A. Yearbook — United States Department of
Agriculture Yearbook.

U. S. Nav. M. Bull— United States Naval Medical
Bulletin.

U.SJP. — The United States Pharmacopeia, Fifteenth
Revision.

Ugeskr. f. laeger — Ugeskrift for laeger.

Union med. Canada — Union medicale du Canada.

Univ. Hosp. Bull. Ann Arbor — University Hospital
Bulletin (Ann Arbor).

Univ. Mich. M. Bull. — University of Michigan Medical
Bulletin.

Univ. Penn. Bull. Vet. Ext. Quart. — University of
Pennsylvania Bulletin Veterinary Extension Quar-
terly.

Univ. Penn. M. Bull. — University of Pennsylvania
Medical Bulletin.

Upsala lakaref. fdrh. — Upsala lakareforenings for-
handlingar.

Urol. Cutan. Rev. — Urologic and Cutaneous Review.

Ven. Dis. Inform. — Venereal Disease Information.

Vet. Bull. Lederle — Veterinary Bulletin (Lederle).

Vet. J. — Veterinary Journal.

Vet. Med. — Veterinary Medicine.

Vet. Rec. — The Veterinary Record.

Vierteljahrsschr. prakt. Pharm. — Vierteljahrsschrift
fiir praktische Pharmazie. (Merged into Arch.
Pharm.)

Virchows Arch. path. Anat. — Virchows Archiv fiir
pathologische Anatomie und Physiologie und fiir
klinische Medizin.

Virginia Med. Month. — Virginia Medical Monthly.

Vlaam's Diergeneesk. Tijdschr. — Vlaam's Diergenees-
kunde Tijdschrift.

War Med. — War Medicine.

West. J. Surg. Obst. Gyn. — Western Journal of Sur-
gery, Obstetrics and Gynecology.

West Virg. M. J. — West Virginia Medical Journal.

Wien. Chem.-Ztg. — Wiener Chemiker-Zeitung.

Wien. klin. Wchnschr. — Wiener klinische Wochen-
schrift.

Wien. med. Bl. — Wiener medizinische Blatter. (Now
Med. Bl.)

Wien. tierdrztl. Monatsschr. — Wiener tierarztliche
Monatsschrift.

Wisconsin Exp. Sta. Ann. Rep. Bull. — Wisconsin Ex-
periment Station Annual Report Bulletin.

Wisconsin M. J. — Wisconsin Medical Journal.

Yale J. Biol. Med. — Yale Journal of Biology and
Medicine.

Year-book Pharm. — Year-book of Pharmacy and
Transactions of British Pharmaceutical Confer-
ence.

Zentralbl. Bakt. — Zentralblatt fiir Bakteriologie,
Parasitenkunde und Infektionskrankheiten.

ABBREVIATIONS

XVII

Zentralbl. Chir. — Zentralblatt fur Chirurgie.
Zentralbl. Gyntik. — Zentralblatt fur Gynakologie.
Zentralbl. Haut-Geschlechtskrank. — Zentralblatt fur

Haut- und Geschlechtskrankheiten sowie deren

Grenzgebiete.
Zentralbl. inn. Med. — Zentralblatt fiir innere Medizin.
Ztschr. anal. Chem. — Zeitschrift fiir analytische

Chemie.
Ztschr. Biol. — Zeitschrift fiir Biologic
Ztschr. exp. Path. Titer. — Zeitschrift fiir experimen-

telle Pathologie und Therapie.
Ztschr. ges. exp. Med. — Zeitschrift fur die gesamte ex-

perimentelle Medizin.
Ztschr. ges. Neurol. Psych. — Zeitschrift fiir die

gesamte Neurologie und Psychiatric
Ztschr. Hyg. Infektionskr. — Zeitschrift fiir Hygiene

und Infektionskrankheiten.
Ztschr. Immun. exp. Ther. — Zeitschrift fiir Immuni-

tatsforschung und experimentelle Therapie.

Ztschr. Infektionskr. — Zeitschrift fiir Infektionskrank-
heiten, parasitare Krankheiten und Hygiene der
Haustierc

Ztschr. Kinderh. — Zeitschrift fiir Kinderheilkunde.

Ztschr. klin. Med. — Zeitschrift fiir klinische Medizin.

Ztschr. Kreislauf. — Zeitschrift fiir Kreislaufforschung.

Ztschr. Laryng. Rhin. — Zeitschrift fiir Laryngologie,
Rhinologie, Otologie und ihre Grenzgebiete.

Ztschr. Naturforsch. — Zeitschrift fiir Naturforschung.

Ztschr. physiol. Chem. — Zeitschrift fiir physiologische
Chemie.

Ztschr. Untersuch. Nahr. Genussm. — Zeitschrift fiir
Untersuchung der Nahrungs- und Genussmittel,
sowie der Gebrauchsgegenstande. (Now Ztschr.
Untersuch. Lebensm.)

Ztschr. Untersuch. Lebensm. — Zeitschrift fiir Unter-
suchung der Lebensmittel.

Ztschr. Vitaminjorsch. — Zeitschrift fiir Vitaminfor-
schung.

THE DISPENSATORY

THE UNITED STATES

PART ONE: Drugs recognized by The United States

Pharmacopeia, British Pharmacopoeia, International

Pharmacopoeia or The National Formulary

ACACIA. U.S.P., B.P.

Gum Arabic, [Acacia]

"Acacia is the dried gummy exudate from the
stems and branches of Acacia Senegal (Linne)
Willdenow, or of other related African species of
Acacia (Fam. Leguminosa) ." U.S. P. The B.P.
definition is the same except that it does not
specify the geographical origin.

Gum Acacia. Acaciae Gurami; Gummi Africanum; Gummi
Mimosae; Gummi Arabicum. Fr. Gomme arabique; Gomme
de Senegal. Ger. Arabisches Gummi; Akazien Gummi;
Senegalgummi. It. Gomma Arabica; Gomma del Senegal.
Sp. Goma de acacia; Goma Ardbiga; Goma del Senegal.

The name Acacia was employed by the ancient
Greeks to designate the gum tree of Egypt, and
has been appropriately applied to the genus in
which that plant is included. Gum Arabic is re-
corded by Herodotus (5th century B.C.) as being
used by the ancient Egyptians as an adhesive. Its
use in medicine is mentioned in several of the
Egyptian papyri. Hippocrates refers to it in medi-
cal works published between 450-350 B.C.

The genus Acacia includes more than 500 spe-
cies of tropical trees and shrubs, many of which
have been of considerable economic importance
as sources of gums, tannins, timber, dyes and
perfumes. The Ark of the Covenant and the
furniture of the Tabernacle are said to have been
made from timber yielded by Acacia Seyal, the
Shittim wood tree of the Bible. The same wood
was made into coffins for the burial of the
Egyptian kings.

The acacias thrive in the forests of northern
Africa, occupying a zone stretching across the
continent from Abyssinia in the east to Senegal
in the west and chiefly between the 12 th and 13 th
degree of latitude. The most important of the
gum-yielding acacias is the official A. Senegal
(Linne) Willd. This is a small tree rarely exceed-
ing a height of 6 m., with a grayish bark, bipin-
nate leaves, dense spikes of small yellow flowers,
and broad pods containing 5 or 6 seeds. It forms
large forests in western Africa, north of the river
Senegal, and is abundant in eastern Africa, Khor-

dofan, and southern Nubia. It is known by the
natives of Senegambia as Verek and of Khordofan
as Hashab.

Nearly all species of acacia growing in Africa
yield gum. The commercial Somali gum, which is
usually of fair quality, is yielded by A. glauco-
phylla Steud. and A. abyssinica Hochst., shrubs
growing in Abyssinia and the Somali country.
The following species yield a gum having a brown-
ish or reddish color, and hence are less valuable,
viz., African A. arabica Willd. (Amrad gum), A.
stenocarpa Hochst. ex A. Rich., A. Seyal Del. and
A. Ehrenbergiana Hayne. It would appear from
the studies of Rangaswami {Indian J. Pharm.,
1942, 4, 128) that the pale yellow gum from
A. arabica produced in S. India nearly approaches
that of A. Senegal in quality and could be used
as a substitute for it. Inferior gums are yielded
also by the following: A. horrida Willd., which
furnishes the so-called Cape gum, distinguished
by being very brittle and yielding a less adhesive
mucilage. Talca or Sennarr gum is derived from
A. Seyal Delile and A. stenocarpa Hochst. ex A.
Rich. This gum has a greenish tinge and yields
a ropy mucilage. Amritsar gum is obtained from
A. modesta Wall. It occurs in large brown tears
and like A. arabica is used in calico printing.
Mogadore gum, derived from A. gummi f era
Willd., occurs in dark brown tears which are little
fissured. Australian gum has usually a reddish
color, said to be due to the presence of tannin,
although some specimens are light in color and
scarcely distinguishable from acacia. This gum is
also called Wattle gum or Australian gum, and is
derived from the Golden Wattle Acacia (A.
pycnantha Benth.), a shrub growing in southern
Australia. Lutz (/. pharm. chim., 1942, 9:2, 49)
gives Acacia decurrens Willd. var. mollissima
Willd. as the source of Wattle Gum. However,
the term "Wattle" is used for any one of various
species of Acacia of Australia, Tasmania and
S. Africa which are valued for their gum, bark or
wood.

The astringent bark and unripe fruit of the

Acacia

Part I

acacia contain both tannic and gallic acids. The
dried juice of the pod was used by the ancient
Greeks; and an extract is still sold in the bazaars
of India under the name of Akakia.

The gum of the acacias exudes spontaneously
from cracks in the bark, and hardens on exposure;
but in commercial production incisions are usually
made in order to facilitate the exudation. The
gum is said also to be found immediately under
the bark, where it is sometimes collected in
regular cavities. It is formed within the plant by
metamorphosis of the cells of the inner bark.
The tissues involved are chiefly those of the
sieve and the cambium. The formation of the gum
is believed to be a pathological process, as gum-
mosis develops more largely upon the wounding
of the trees and their infection by bacteria and
other parasites. The investigations of Smith tend
to show that all vegetable gums are of bacterial
origin and that the differences in the several gums
are due to the differences in the nature of the
bacteria producing them. (Proc. Linn. Soc. N. S.
Wales, 1904, p. 217.) For further discussion of
the origin of acacia gum see Tschirch, "Hand-
buch der Pharmakognosie," and Greenish, "Mate-
ria Medica," 4th ed.

The trees are not tapped for gum until they
are about six years old. Annual yields from 188
to 2856 Gm. in young trees and from 379 to 6754
Gm. in large trees have been reported. The aver-
age annual yield of gum from young trees is about
900 Gm. and from old trees over 2 kilos.

Commercial History and Varieties. —
There are two principal commercial varieties of
gum arabic: 1. The Kordofan, Gedaref or Arabian
Gum, and 2. the Senegal or West African Gum,
both of these being derived from A. Senegal. The
former of these has the finer commercial qualities,
being nearly white or faint yellowish-white and
yielding a more or less transparent viscid muci-
lage.

Kordofan or Arabian Gum. — This is the
finest variety of gum arabic obtainable. It is
gathered in the Kordofan province of the Sudan.
It was formerly the only kind designated as gum
arabic and entered commerce almost exclusively
through Egypt.

It now occurs in two sub-varieties designated
as "Bleached Kordofan Gum" and "Natural Kor-
dofan Gum." The bleached variety is the most
highly esteemed and occurs in white or weak yel-
low angular fragments or ovoid tears the outer
surfaces of which bear numerous cracks. The
natural variety differs from the former by being
more transparent, owing to fewer cracks, and in
being more deeply yellow or pinkish in color.

During the conquest of the Sudan by Anglo-
Egyptian forces in 1908, a railway was built from
Egypt to Khartoum in the Sudan, and since ex-
tended from Khartoum to El Obeid and Gedaref,
which opened up large areas of acacia country in
which the gum is now collected. The chief Egyp-
tian Sudan market is at El Obeid, the shipping
companies having their main offices at Khartoum
about 500 miles distant. The finest Egyptian gum
consists of large roundish or smaller more or less
irregular fragments, transparent but usually
rendered opaque upon the surface by innumerable

minute fissures. For information concerning
method of collection see U.S.D., 24th ed., p. 2.
Talca or Talha gum, from A. stenocarpa and
A. Seyal, is exceedingly brittle, and usually semi-
pulverulent. It is a mixture of nearly colorless
and brownish gums, is exported at Alexandria, and
is sometimes termed gam savakin or Suakin gum.

Senegal or West African Gum. — This com-
mercial variety ranks second to the Kordofan
gum. It is derived front A. Senegal and other
species of Acacia growing in the Sudan and
Senegal. It yields a good adhesive mucilage and
is valuable for technical purposes. Some of the
best qualities of Senegal gum are also adapted for
certain pharmaceutical uses. It was introduced
into Europe by the Dutch. The French afterwards
planted a colony on the western coast of Africa,
and took possession of the trade. The dry winds,
which prevail after the rainy season, cause the
bark to crack; the juice flows out and hardens in
masses. It is claimed that the exudation is also
largely caused by a parasitic plant, Loranthus
AcacicB Zucc, the gummy exudation freely oozing
out at the point where the parasite penetrates the
bark. Senegal gum is usually in roundish or oval
unbroken tears, or in straight or curled cylindrical
pieces of various sizes, in the finest grades whitish
or colorless, but generally yellowish, reddish, or
brownish-red. The pieces are generally larger than
those of Kordofan gum, less brittle, fissured, and
pulverizable, and break with a more conchoidal
fracture. Vermiform tears are usually present and
aid in diagnosing this variety. It is shipped from
the Senegal river to France and the United States.

The total imports of acacia into this country
during 1952 were over 20 million pounds, mostly
from Sudan, Nigeria, East Africa and India.

Impurities and Adulterations. — As gum
arabic is usually collected in huge piles at Khar-
toum, Gedaref, etc., before being shipped to Port
Sudan the sand and impurities are likely to sift
to the bottom. As a consequence the first orders
will be filled with the cleaner article, while the
latter, containing the siftings, may run as high
as 4 per cent of ash. The inferior grades are often
mixed with, or substituted for, the better kinds,
especially in powder.

The chief adulterant and substitute for acacia
within recent years has been Mesquite gum, from
Prosopis chilensis (Molina) Stuntz (Fam. Legu-
minosce), a plant indigenous to Mexico. It occurs
in brownish to reddish-brown tears of variable
size and differs from acacia in not precipitating
from its aqueous solution when solutions of ferric
chloride, lead subacetate or sodium borate are
added.

Description. — "Unground Acacia occurs in
spheroidal tears up to 32 mm. in diameter or in
angular fragments of white to yellowish white
color. It is translucent or somewhat opaque from
the presence of numerous minute fissures; very
brittle, the fractured surface glassy and occa-
sionally iridescent. It is almost odorless and has a
mucilaginous taste.

"Flake Acacia occurs in white to yellowish
white, thin flakes, appearing under the microscope
as colorless, striated fragments.

"Powdered Acacia is white to yellowish white.

Part I

Acacia

It occurs in angular microscopic fragments with
but slight traces of starch or vegetable tissues
present.

"Granular Acacia is Acacia reduced to fine
granules. It is white to pale yellowish white.
Under the microscope it appears as colorless,
glassy, irregularly angular fragments up to 100 m*
in thickness, some of which exhibit parallel linear
streaks.

"Solubility. — One Gm. of Acacia dissolves in
2 ml. of water; the resulting solution flows
readily and is acid to litmus. It is insoluble in
alcohol." U.S.P.

Acacia is insoluble in ether, and in oils. In 22
per cent alcohol the solubility is 57 Gm. in 100
ml.; in 40 per cent alcohol, 10 Gm. in 100 ml.;
in 50 per cent alcohol, 4 Gm. in 100 ml.

Standards and Tests. — Identification. — A
flocculent, or curdy, white precipitate is produced
immediately when 0.2 ml. of diluted lead subace-
tate T.S. is added to 10 ml. of a 1 in 50, cold,
aqueous solution of acacia. Total ash. — Not over
4 per cent. Acid-insoluble ash. — Not over 0.5 per
cent. Water. — Not over 15 per cent. Optical rota-
tion.— A 1 in 10 solution is only slightly levorota-
tory. Insoluble residue. — A mixture of 5 Gm. of
acacia, 100 ml. distilled water and 10 ml. of
diluted hydrochloric acid boiled gently for 15
minutes yields a residue not exceeding 50 mg.
Starch or dextrin. — Iodine T.S. does not give a
bluish or reddish color with a 1 in 50 aqueous
solution of acacia, previously boiled and cooled.
Tannin-bearing gums. — No blackish coloration or
precipitate is produced when 0.1 ml. of ferric
chloride T.S. is added to 10 ml. of a 1 in 50
aqueous solution of acacia. U.S.P.

The B.P. specifies the following identification
tests for acacia: (1) A flocculent white precipitate
is produced on adding a strong solution of lead
subacetate to a 1 in 50 solution of acacia. (2)
A deep blue color is produced on adding 0.5 ml. of
hydrogen peroxide solution and 0.5 ml. of a 1 in
100 solution of benzidine (in 90 per cent alcohol)
to a solution of 250 mg. of acacia in 5 ml. of
water, the mixture being allowed to stand. (3)
Particles of powdered acacia mounted in solution
of ruthenium red show no red color when ex-
amined microscopically (distinction from agar and
from sterculia). (4) No precipitate is produced on
adding 0.2 ml. of a 1 in 5 solution of lead acetate
to 10 ml. of a 1 in 50 solution of acacia (dis-
tinction from agar and from tragacanth). (5) A
mixture of 100 mg. of powdered acacia and 1 ml.
of 0.02 N iodine does not acquire a crimson or
olive-green color (distinction from agar and from
tragacanth).

Gum arabic undergoes no change on aging, if
kept in a dry place. Its concentrated aqueous
solution remains stable for a considerable time,
but ultimately becomes sour, acid being formed.
The tendency to sour is said to be increased by
using hot water in making the solution.

Constituents. — Acacia consists principally of
the calcium, magnesium and potassium salts of a
polysaccharide known as arabic acid, sometimes
called arabin. On hydrolysis with dilute acid,
arabic acid yields L-arabinose, L-rhamnose,
D-galactose, and an aldobionic acid containing

D-glucuronic acid and D-galactose in glycosidal
combination. An oxidase-type enzyme is present
in acacia, and it is claimed that diastase is also a
constituent.

Incompatibilities. — Bourquelot (/. phartn.
chim., 1904, 19, 473, 474) reported that acacia
contains an oxidase-type enzyme which may
render it unsuitable for use in pharmaceutical
preparations which contain easily oxidized active
constituents. Thus, Kedvessy (Chem. Abs., 1943,
37, 4531) reported that the vitamin A content of
cod liver oil emulsions made with acacia decreased
54 per cent in three weeks. Griffiths et al.
{Analyst, 1933, 58, 65), on the other hand, found
that such emulsions can be kept for at least four
months without serious loss of vitamin A if stored
in well-filled, amber glass bottles and kept in the
dark. Substances stated to be incompatible with
acacia include aminopyrine, pyrogallol, morphine,
vanillin, phenol, thymol, carvol, a- and (5-naphthol,
pyrocatechol, guaiacol, cresols, creosol, eugenol,
acetyleugenol, apomorphine, eserine, epinephrine,
isobarbaloin, caffeotannic acid, gallic acid and
tannin. Kieft (Pharm. Weekblad, 1939, 76, 1133)
recommended heating acacia at 103° to 105° C.
as the best method for destroying its oxidase
enzyme. The oxidizing action of acacia mucilage
may be destroyed by heating at 100° C.

Acacia is also incompatible with strongly alco-
holic liquids, solutions of ferric chloride and lead
subacetate, and strong solutions of sodium borate.

Uses. — Sodium chloride injection is of little
practical value in the treatment of low blood pres-
sure from hemorrhage or surgical shock because
it escapes so rapidly from the blood vessels. This
characteristic is generally attributed to its non-
colloid character and in 1917 Bayliss suggested
the use of a 7 per cent solution of acacia to im-
part the necessary colloid material. Although the
method has received some favorable reports (for
literature see Maytum and Magath, J.A.M.A.,
1932, 99, 2251) the availability of blood plasma
and plasma expanders, such as dextran and
polyvinylpyrrolidone, led to an almost complete
abandonment of the procedure.

In 1933 Hartmann and co-workers recom-
mended intravenous injection of acacia solutions
to relieve the edema of certain types of nephrosis,
on the theory that the edema is due to a dis-
turbance of the cclloid pressure of blood brought
about by a diminution in its protein content.
There has been considerable difference of opinion
as to whether the final results are beneficial or
injurious. Large intravenous doses of acacia in
animals (15 to 47 Gm. per kilogram in dogs)
produce toxic effects, including reduction of eryth-
rocytes, hemoglobin and hematocrit, hastened
sedimentation of erythrocytes, transitory leuko-
penia and reduction of serum proteins, especially
of serum albumin (Hueper, Am. I. Path., 1942,
18, 895). Tissue examination shows enlargement
and thickening of the liver. The parenchymal
cells around the central vein and in the periportal
areas stain lightly, appear distended and contain
a vacuolated cytoplasm (foam cells) which does
not take the special stains used for fat, glycogen,
mucin or amyloid and is probably acacia. Infiltra-
tion with inflammatory cells is minimal. The

Acacia

Part I

foam cells persist for 2 years or more and serum
albumin remains depressed although the level rises
slowly. Similar foam cells are less numerous in
the spleen and the convoluted tubules of the
kidney.

However, in patients who had received as much
as 210 Gm. (3.7 Gm. per kilo) of acacia, as long
as 3 years or as recently as 3 weeks before death
due to other causes, no such histologic changes
were observed. Patients given 60 Gm. of acacia
in the treatment of shock a few days before death
showed no foam cell changes (Smalley, Binger,
Bollman and Power, Arch. Int. Med., 1945, 76,
39). Chemical analyses demonstrate about 20 per
cent of the acacia in the urine during the first
few days; some acacia appears in the feces and
about 20 per cent is stored in the liver; only traces
are found in other tissues. A decrease in serum
albumin concentration associated with an increase
in plasma volume ^ccurs and returns toward
normal after discontinuing the injections (Yuile
and Knutti, /. Exp. Med., 1939, 70, 605). A
variety of tests of liver function reveal no impair-
ment. In edematous patients, the urinary excre-
tion of sodium chloride and water is increased.

Smalley and Binger (J.A.M.A., 1944, 126, 532)
reported on the condition of patients 2 to 7 years
after the intravenous injection of acacia. They
treated 109 patients with the nephrotic syndrome
in the course of chronic glomerulo-nephritis.
These edematous patients with hypoproteinemia
and albuminuria were treated with a low-salt,
high-protein (75-125 Gm. daily) diet, 1 to 1.5
liters of fluid daily and 3 Gm. of potassium nitrate
3 times a day. Edema did not subside in these
cases. Then, 500 ml. of a 6 per cent solution of
pure acacia (30 Gm.) in 0.06 per cent sodium
chloride in distilled water was given intravenously
on alternate days for 3 doses. After the third in-
jection the concentration of acacia in the blood
was about 2 Gm. per 100 ml.; a year later 0.1 Gm.
per 100 ml. remained. After 2 to 7 years, 12 cases
were not traced; 72 cases were alive and 49 were
performing a full day's work, 21 were working
part-time and 2 were bedfast; the remaining 25
cases were dead of uremia, hypertension or cardiac
failure but of these 20 had lost their edema and
12 had lived 2 years and 5 for 4 years after treat-
ment with acacia. No evidence of renal or hepatic
damage was observed in these patients and, in
fact, many cases showed fewer erythrocytes, leu-
kocytes and casts in the urine and decreased al-
buminuria as the edema subsided. In especially
resistant cases, injection of mercurial diuretics on
alternate days, between the acacia injections, was
found to be effective and safe. Most patients
received 90 Gm. of acacia but, if necessary, as
much as 200 Gm. appears to be safe. Larger doses
produce the deleterious effects already described
(Falkenstein and Jackson, /. Pediatr., 1940, 16,
700).

Reactions during injection of acacia occurred
in 12 of the 109 cases consisting of cold extremi-
ties, flushing of the face, chill, nausea, vomiting,
dyspnea and urticaria. Epinephrine effectively
controlled or prevented these reactions.

Industrial exposure to acacia, especially as an
"offset spray" in printing, may cause asthmatic

seizures. Acacia contains sufficient protein nitro-
gen to serve as an antigen (Bohner, Sheldon and
Trenis, /. Allergy, 1941, 12, 290).

In plastic surgery, a 50 per cent acacia "glue"
has been employed successfully in grafting de-
stroyed peripheral nerves (Klemme, Woolsey and
deRezende, J.A.M.A., 1943, 123, 393).

In irritations of the mouth or fauces, a small
lump or lozenge of acacia may be allowed to dis-
solve slowly in the mouth for its demulcent effect.
The hygroscopic property of acacia has not proved
sufficiently marked in the intestine to serve as a
hydrophilic laxative (Gray and Tainter, Am. J.
Digest. Dis., 1941,8, 130).

In pharmacy, acacia is extensively used in the
preparation of emulsions (see Emulsions, Part II),
for the suspension of insoluble substances in mix-
tures, and as a binding agent in tablets, pills and
troches. For the preparation of emulsions by the
Continental method, in which acacia is required
to be mixed with the oil, preference is usually
given to the finely powdered form; granulated
acacia, possibly because of its greater content of
water, dissolves more readily in water with less
tendency to form lumps and is preferable for the
preparation of aqueous solutions. As a general
rule, one part of acacia is sufficient for the emulsi-
fication of four parts of fixed oil or two parts of
volatile oil. S

Off. Prep.— Acacia Mucilage U.S.P., B.P.;
Cod Liver Oil Emulsion; Liquid Petrolatum
Emulsion, N.F., B.P.; Compound Chalk Powder;
Phenolphthalein in Liquid Petrolatum Emulsion,
N.F.; Compound Powder of Tragacanth, B.P.

ACACIA MUCILAGE. U.S.P. (B.P.)

[Mucilago Acaciae]

B.P. Mucilage of Acacia. Mucilago Gumrai Arabici.

Fr. Mucilage de gomrae arabique. Gcr. Gummischleim.

It. Mucillaggine di gomma arabica. Sp. Mucilago de
goma Arabiga.

Place 350 Gm. of acacia, in small fragments,
in a graduated bottle having a wide mouth and a
capacity not much more than 1000 ml. Wash the
drug with cold purified water, allow it to drain,
and add enough warm purified water, in which 2
Gm. of benzoic acid has been dissolved, to make
the product measure 1000 ml. Stopper the bottle,
lay it on its side, rotate it occasionally, and when
solution has been effected strain the mucilage.
Acacia mucilage may also be prepared by adding
400 ml. of purified water, in which the benzoic
acid has been dissolved with the aid of heat, to
350 Gm. of powdered or granular acacia and
triturating until the acacia is dissolved; sufficient
purified water is added to make the product meas-
ure 1000 ml. U.S.P.

"Caution. — Acacia Mucilage must be free from
mold or any other indication of decomposition."
U.S.P.

The B.P. mucilage is prepared by dissolving
400 Gm. of acacia, previously washed with water,
in 600 ml. of chloroform water.

Acacia mucilage does not keep very well.
Though many suggestions have been offered for
preserving it, none appears to be entirely satis-
factory. Generally, addition of a preservative in-
troduces potential incompatibilities; the use of

Part I

Acetanilid

chloroform water, as directed by the B.P., may be
objectionable because of the taste it gives to the
preparation.

Acacia mucilage is employed as an aid in sus-
pending insoluble substances in liquids, as an
emulsifier, and as a pill and tablet excipient. Occa-
sionally it is employed for its demulcent effect,
the average dose being 15 ml. (approximately
4 fluidrachms).

Storage. — Preserve "in tight containers."
U.S.P.

ACACIA SYRUP. U.S.P.

[Syrupus Acaciae]

Syrupus Gummi (Gummosus); Sirupus Gummi Arabici.
Fr. Sirop de gomme. Ger. Gummisirup. It. Sciroppo di
gomma arabica. Sp. Jarabe de goma.

Mix 100 Gm. of granulated or powdered acacia,
1 Gm. of sodium benzoate, and 800 Gm. of
sucrose; add 425 ml. of purified water, mix, and
heat the mixture on a water bath until solution
is effected. Cool, remove the scum, add 5 ml. of
vanilla tincture and sufficient purified water to
make the product measure 1000 ml. Strain if
necessary. U.S.P.

This demulcent syrup is often effective in mask-
ing the bitter or acid taste of medicaments, per-
haps in part functioning by a protective colloid
action. A dose of 4 to 15 ml. (approximately 1 to
4 fluidrachms) is used.

Storage. — Preserve "in tight containers, and
avoid excessive heat." U.S.P.

ACETANILID.

[Acetanilidum]

N.F.

NHC0CH3

Antifebrin; Phenylacetamide; Acetylamidobenzene; Mono-
acetylaniline. Fr. Acetanilide. Ger. Azetanilid; Acet-
phenylamid. Sp. Acetanilida ; Acetilfenilamina.

Acetanilid, introduced into medicine in 1886 as
antifebrin, may be prepared by the action of
acetic anhydride, acetyl chloride, or glacial acetic
acid on aniline. A commercial process involves
heating glacial acetic acid and aniline for several
hours until tests show the absence of unreacted
aniline. The crude product is purified by re-
crystallization from hot water.

Description. — "Acetanilid occurs as white,
shiny crystals, usually in scales, or as a white,
crystalline powder. It is odorless, and is stable in
air. Its saturated solution is neutral to litmus
paper. One Gm. of Acetanilid dissolves in 190 ml.
of water, in 3.5 ml. of alcohol, in 4 ml. of chloro-
form, and in about 17 ml. of ether. One Gm.
dissolves in 20 ml. of boiling water, and in about
0.6 ml. of boiling alcohol. It is soluble in glycerin.
Acetanilid melts between 114° and 116°." N.F.

Standards and Tests. — Identification. — (1)
100 mg. of acetanilid boiled with 5 ml. of sodium
hydroxide T.S. evolves vapors of aniline; addition
of several drops of chloroform and further heat-
ing produces phenyl isocyanide, a poisonous com-
pound recognized by its disagreeable odor. (2) A
white, crystalline precipitate of ^-bromoacet-
anilid forms on adding a few drops of bromine

T.S. to 10 ml. of saturated solution of acetanilid.
Loss on drying. — Not over 0.5 per cent on drying
over sulfuric acid for 2 hours. Residue on igni-
tion.— Not over 0.05 per cent. Readily carboniz-
able substances. — A solution of 500 mg. of acet-
anilid in 5 ml. of sulfuric acid has no more color
than matching fluid A. N.F.

Incompatibilities. — Acetanilid is incompat-
ible with alkalies (which liberate aniline) and
when it is triturated with phenol, resorcinol,
chloral hydrate, acetylsalicylic acid, antipyrine,
and many other organic drugs it forms a mixture
which liquefies. With ethyl nitrite spirit, amyl
nitrite, or with acid solutions of nitrites a yellow
solution is produced which turns to red upon
standing. In acid solutions acetanilid is slowly
hydrolyzed. Bromides and iodides form with acet-
anilid a precipitate. Ferric salts produce with it a
red color.

Uses. — Acetanilid possesses analgesic and
antipyretic properties, and is today used in medi-
cine especially for the former, and to a lesser
extent for the latter, effect. As with acetophenet-
idin, it yields in the system principally N-acetyl-
/»-aminophenol, to which the therapeutic utility
of the compounds is apparently attributable.
From 70 to 90 per cent of acetanilid administered
to humans appears in the urine as conjugation
derivatives, with sulfuric acid and glucuronic acid,
of />-aminophenol and its N-acetyl derivative
(Greenberg and Lester, /. Pharmacol., 1946, 88,
87). A minor fraction of acetanilid deacetylates
to aniline (ibid., 1948, 94, 29).

The most striking actions of acetanilid are upon
the heat-regulating mechanism and upon pain
perception. The maintenance of body tempera-
ture is the result of a delicate balance between
the amount of heat generated in the system by
oxidation and that which is utilized or dissipated.
Antipyretics, including acetanilid, have little if
any effect on production of heat; their action
appears to be that of increasing dissipation of heat
by dilatation of cutaneous blood vessels and by
increasing the degree of sweating. There is differ-
ence of opinion as to the advisability of using
antipyretic drugs to lower body temperature when
it is elevated. At times these drugs produce such
a sudden or excessive change as to lead to
collapse. The need for antipyretic drugs has
diminished as effective chemotherapeutic agents
have become available.

The most important use of acetanilid at the
present time is for the relief of pain, especially
that of neuralgia, whether of the head or other
portions of the body. While it will usually relieve
even severe neuralgic pains, it is comparatively
feeble in traumatic conditions. It is believed that
the analgesic effect is the result of depression of
the pain-perceiving mechanism. Hale and Grab-
field (/. Pharmacol., 1923, 21, 77), in experi-
ments upon men, found that the threshold of
perception of faradic irritation of the skin was
raised about 30 per cent. Wolff, Hardy and
Goodell (/. Clin. Inv., 1941, 20, 62) reported a
similar degree of reduction in the perception of
pain caused by radiant heat. The analgesic effect
appeared about an hour after oral administration,
and persisted for 2 to 3 hours. Doses larger than

Acetanilid

Part I

300 mg. did not increase or prolong the analgesic
effect. In the presence of pain induced by a
tourniquet on the arm which obstructed arterial
flow for 30 minutes, acetanilid induced the same
decrease in the sensitivity to the discomfort
caused by radiant heat on the forehead as it did
in the absence of pain in the arm. In contrast
morphine, which raised the threshold about 70
per cent without pain in the arm, elevated the
threshold (to heat on the forehead) only about
30 to 40 per cent when ischemic pain was present
in the arm. Acetanilid allayed restlessness and
anxiety more effectively than did 300 mg. of
acetylsalicylic acid. Combinations with other
analgesic drugs did not enhance the action above
that of the most effective component. Mullin and
Luckhardt (Arch, internal, pharmacodyn. therap.,
1937, 55, 112), on the other hand, did not find
acetanilid to produce in men any diminution in
the perception of pressure pain.

Locally acetanilid is mildly antiseptic and to
some degree anesthetic. It has been used as a
dusting powder in various types of ulcers, but its
use is not free from danger and it does not appear
to have any great advantage over a number of
other safer remedies for this purpose. H

Toxicology. — The freedom with which acet-
anilid and allied drugs are used by the laity
makes the subject of their potential danger a
matter of considerable economic as well as hy-
gienic importance. Unfortunately, much that has
been written on the subject has been in the spirit
of trying to establish a preconceived opinion
rather than to discover the truth. From the welter
of polemics, certain deductions are scientifically
justified.

In ordinary doses acetanilid has no demonstra-
ble action on respiration or circulation in lower
animals, although in very large quantities it acts
as a depressant to the heart (Higgins and
McGuigan, /. Pharmacol, 1933, 49, 466). It
appears also to be feebly depressant to the motor
centers in the cord.

Acute poisoning (cyanosis, prostration and col-
lapse) is rare. The acute lethal dose of acetanilid
for the lower animals (see Clark, /. Pharmacol.,
1940, 69, 280), and ordinarily for men, is so large
that one would hardly class it as a poison. On the
other hand, there have been several deaths from
acute acetanilid poisoning, one from as little as
18 grains. Several of these deaths occurred dur-
ing its use in fever and it is well known that a
sudden reduction in body temperature may pro-
duce circulatory collapse. The common custom
of adding caffeine to acetanilid mixtures to guard
against cardiac depression has been shown by
several investigators to be futile; indeed it seems
well established that caffeine increases the toxicity
of acetanilid (see Smith and Hambourger. /.
Pharmacol, 1935. 55, 200 and 1936, 57, 34). The
number of deaths from acetanilid which can be
ascribed to idiosyncrasies, compared to the mil-
lions of doses which have been ingested appears
singularly small.

Acute poisoning in children is manifested by
vomiting, abdominal pain, diarrhea, cyanosis,
fatigue, vertigo, somnolence, palpitation, muscu-
lar spasms, delirium and coma. Urticaria is seen.

Treatment consists of gastric lavage, cathartics,
an enema, oxygen inhalation and nikethamide,
pentylenetetrazole, etc. Venesection and replace-
ment of blood capable of carrying oxygen may be
necessary.

It seems definitely established that the con-
tinued use of acetanilid in large doses (1.5 Gm.
daily) leads to anemia and degenerative changes
in the heart and other organs. Chronic poisoning
is manifested by cyanosis, anorexia, cachexia,
anemia, varied psychic and neurologic disorders,
lassitude, insomnia and headache (Lundsteen,
Meulengracht and Rischel, Acta med. Scandinav.,
1938, 96, 462). Since headache may be the
symptom for which the drug was taken, a vicious
cycle is established. Splenomegaly is often asso-
ciated with the hemolytic anemia. Tolerance to
large doses may develop and withdrawal symp-
toms, such as acute mania, have been reported
(Austin, J.A.M.A., 1942, 120, 911; Mcintosh,
N. Carolina M. J., 1940, 1, 143; Payne, /.
Pharmacol, 1935, 53, 401).

The repeated use of acetanilid in large doses
leads to a change in the color of the blood.
Although Young and Wilson (/. Pharmacol, 1926,
27, 1334) believed that the new pigment is due to
decomposition products of />ara-aminophenol, the
observations of Harrop and Waterfield (J. A.M. A.,
1930, 95, 647), of Smith (/. Pharmacol, 1940,
70, 171) and many others seem to leave no room
for doubt that there is a formation of either
methemoglobin, sulfhemoglobin, or both. Bran-
denburg and Smith (Am. Heart J., 1951, 42, 582)
reported 62 clinical cases of sulfhemoglobinemia,
44 of which followed the prolonged ingestion of
acetanilid alone or in combination with potassium
bromide and caffeine. Reynolds and. Ware
(J.A.M.A., 1952, 149, 1538), in reporting 6 cases
of sulfhemoglobinemia following the prolonged
use of acetanilid, emphasize that this pigment
occurs more commonly than methemoglobin. Ac-
companying the change in hemoglobin there is a
diminution in the oxygen-carrying power of the
blood. Methemoglobin is rapidly reversed to
normal hemoglobin by the enzyme systems in the
red blood cells as soon as the offending agent is
removed, but sulfhemoglobin is not reversible to
hemoglobin and, once formed, it persists for the
life of the red cell. The two pigments may be
differentiated by spectroscopic examination of
the blood.

Whether acetanilid is to be classed as a habit-
forming drug depends largely on what one means
by the term "habit-forming" (whether psychic or
physical dependence). Undoubtedly, there are
hundreds of persons who use acetanilid daily,
just as there are millions who are addicted to caf-
feine beverages, but we do not believe it is justi-
fiable to speak of it as a habit-forming drug in the
sense that opium or alcohol is. despite the report
of Stewart (J. A.M. A., 1905. 44, 1724). Just how
much of the drug is needed to bring about these
noxious effects it is impossible to say. Acetanilid
is relatively safe as a therapeutic agent but its
habitual use by the laity is not to be encouraged
(see also Hanzlik, /. Am. Dent. A., Sept., Oct.
and Nov., 1940).

Dose. — The usual dose of acetanilid is 200 mg.

Part I

Acetarsone

(approximately 3 grains), with a range of 200 to
500 mg. ; not more than 1 Gm. should be taken in
24 hours.

Storage. — Preserve "in well-closed con-
tainers." N.F.

ACETANILID TABLETS. N.F.

[Tabellae Acetanilidi]

"Acetanilid Tablets contain not less than 94
per cent and not more than 106 per cent of the
labeled amount of CsHgNO." N.F.

Assay. — A representative sample of tablets,
equivalent to about 300 mg. of acetanilid, is
digested with petroleum benzin to remove lubri-
cants, after which the acetanilid is extracted with
chloroform, the solvent evaporated, and the resi-
due of acetanilid dried at about 80° for 2 hours,
and finally weighed as CsHgNO. N.F.

Storage. — Preserve "in well-closed con-
tainers." N.F.

Usual Sizes. — 3 and 5 grains (approximately
200 and 300 mg.).

ACETARSONE. N.F. (B.P.) LP.

3-Acetamido-4-hydroxybenzenearsonic
Acid, [Acetarsonum]

As0(0H)o

NHC0CH-,

"Acetarsone, dried at 105° for 1 hour, yields
not less than 98.8 per cent and not more than
101.4 per cent of CsHioAsNOs." N.F. The B.P.
defines acetarsol as 3-acetamido-4-hydroxyphenyl-
arsonic acid, and requires it to contain not less
than 27.1 per cent and not more than 2 7.5 per
cent of As, calculated with reference to the sub-
stance dried to constant weight at 105°. The LP.
limits are 26.8 to 27.5 per cent of As, with refer-
ence to the substance dried at 100° for 4 hours.

B.P. Acetarsol. I. P. Acetarsolum. N-acetyl-4-hydroxy-m-
arsanilic acid. Stovarsol (Merck), Kharophen, Orarsan,
Spirocid.

The intermediate from which acetarsone, as
well as arsphenamine and most other arsenicals,
may be prepared is 3-nitro-4-hydroxyphenyl-
arsonic acid (for method of obtaining it see under
Arsphenamine) . By reducing only the nitro group
— not the arsenic — in this intermediate and
acetylating the resulting amino group acetarsone
is produced.

Description. — "Acetarsone occurs as a white
or slightly yellow, odorless powder. It is stable at
ordinary temperatures. Acetarsone dissolves in
solutions of alkali hydroxides or carbonates. It is
slightly soluble in water and insoluble in alcohol.
Its saturated aqueous solution is acid to litmus
paper." N.F. The B.P. gives the melting point as
about 240°, with decomposition.

Standards and Tests. — Identification. — (1)
A yellow precipitate is produced on adding 2 Gm.
of sodium hydrosulfite to a solution of 1 Gm. of
acetarsone in 10 ml. of sodium hydroxide T.S.

diluted with 10 ml. of water, the mixture being
heated in a water bath for 20 minutes; after de-
canting the supernatant liquid the precipitate dis-
solves in an excess of sodium hydroxide T.S. (2)
A yellow precipitate, soluble in ammonium carbo-
nate T.S., is produced when hydrogen sulfide is
passed into the solution resulting from the assay
for arsenic. (3) A solution of 100 mg. of acetar-
sone in 5 ml. of sodium hydroxide T.S. is evapo-
rated to about 3 ml., cooled, 2 or 3 drops of
alcohol and 2 ml. of sulfuric acid added and the
mixture heated gently : an odor of ethyl acetate is
apparent. Loss on drying. — Not over 2 per cent,
when dried at 105° for 1 hour. Residue on igni-
tion.— Not over 0.2 per cent. Solubility in sodium
carbonate. — A practically clear solution, not
darker than a pale yellow, is obtained from 1 Gm.
of acetarsone and 10 ml. of sodium carbonate
T.S. Aminohydroxyphenylarsonic acid. — No red
or brown color is produced on adding 2 drops of a
1 in 30 potassium dichromate solution to the fil-
trate obtained by shaking 1 Gm. of acetarsone
with 10 ml. of a mixture of equal volumes of di-
luted hydrochloric acid and water and then filter-
ing. Inorganic arsenates. — No precipitate is pro-
duced on adding a slight excess of ammonia T.S.
and 2 ml. of magnesia mixture T.S. to a solution
of 500 mg. of acetarsone in 10 ml. of water; on
heating the solution for 10 or 15 minutes a pre-
cipitate will form. N.F.

As the test for aminohydroxyphenylarsonic
acid the B.P. specifies that the color produced
when a solution of unhydrolyzed acetarsone is
diazotized and coupled with betanaphthol shall
not be deeper than that obtained when about
%ooth of the amount of acetarsone is hydrolyzed
by acid and similarly diazotized and coupled.
Loss on drying to constant weight at 105° is
limited to 0.5 per cent. A limit test for chloride
is also provided by the B.P.

Assay. — In the N.F. assay about 200 mg. of
dried acetarsone is decomposed with potassium
permanganate and sulfuric acid. Hydrogen per-
oxide is added to reduce the excess permanganate
and the pentavalent arsenic is reduced to the
trivalent state by iodide; the liberated iodine is
titrated with 0.1 iV sodium thiosulfate. Each ml.
of 0.1 N sodium thiosulfate represents 13.75 mg.
of CsHioAsNOs. The B.P. assay provides for
oxidation of the acetarsone with fuming nitric
acid and sulfuric acid. The nitric acid is subse-
quently decomposed with the aid of ammonium
sulfate, the arsenic reduced by iodide and, finally,
in the presence of sodium bicarbonate, the tri-
valent arsenic is oxidized to the pentavalent state
by titration with 0.1 iV iodine. The LP. assay is
practically the same as that of the B.P.

Uses. — This pentavalent arsenical was among
those which Ehrlich tested but rejected because
it produced severe nerve disorders in mice. In
1921 Fourneau introduced it as a preventive and
curative remedy for syphilis. Its value in this
condition was studied by Raiziss {Arch. Dermat.
Syph., 1935, 25, 799) who found that it appar-
ently penetrates into the spinal canal more easily
than trivalent arsenicals. While it is apparently
less efficient than arsphenamine as an antisyphi-
litic, it is effective when given by mouth. How-

Acetarsone

Pari I

ever, doses which are effective for adult syphilis
produce toxic effects in from 7 to 20 per cent of
patients. Because of its toxicity it is generally not
recommended for the treatment of congenital lues
in infants (Vem. Dis. Inform., 1942, Suppl. 18,
1-92). Considering the availability of other and
safer methods of treating syphilis the risk of
toxicity from such use of acetarsone is not justi-
fied. Both acetarsone and its bismuth salt have
been employed as an adjuvant to the malarial
therapy of neurosvphilitic insanitv (Parkenham-
Walsh. J. Meat. Sc, 1942. 88, 344).

Yaws has been successfully and cheaply treated
with oral doses of 250 mg. daily in 3 courses of
20 days each, separated by 14-day intervals with-
out medication (Pardo-Costello, Arch. Dermat.
Syph., 1939. 40, 762).

Vincent's angina responds favorably to 250 mg.
of acetarsone in a paste made with glycerin or
water and locally applied (Maxwell. Pract., 1936.
2, 660). In a jelly vehicle it has given prompt
relief in fusospirochetal balanitis (Thompson.
Brit. M. J., 1943. 2, 485). Meigs (New Eng. J.
Med., 1942. 226, 562) and others have used
acetarsone with success in trichomonas vaginitis;
100 mg. may be applied as a powder or in aqueous
solution in the office, and a tablet or impregnated
tampon containing acetarsone, with glucose, lactic
and boric acids, starch, sodium bicarbonate and
tartaric acid prescribed for insertion at bedtime.
A powder containing 12.5 per cent of acetarsone
with kaolin and sodium bicarbonate is used by
some physicians for insufflation every second or
third day until three or four treatments have been
given.

In amebic dysentery Faust. D'Antoni and
Sawitz {Clin. Med., 1943. 50, 261) found acet-
arsone highly effective; they administered 260
mg. twice a day for two days, then three times
daily for three days. Balantidiasis also responds
to this drug (McCarey. Brit. M. J., 1952, 1, 629).
Acetarsone is reported to be valuable in the
treatment of pemphigus (Oppenheim and Cohen,
Arch. Dermat. Syph., 1950. 61, 500); and of
diphtheria carriers, being administered by nasal
instillation (Brit. M. J., 1937. 1, 2).

Acetarsone is completely absorbed, after oral
administration, and rapidly excreted in the urine,
with only small amounts stored in the fiver and
other tissues (Dimter and Allin. Ztschr. Ki?idcrh.,
1943. 63, 760). It should be remembered that
although acetarsone is generally given by mouth
it is capable of giving rise to the same group of
toxic manifestations that follow arsphenamine.
The effective dose nearly equals the toxic dose.
Toxic effects are infrequent if rest periods of
three to five days are prescribed between each
three to five days of administration. Deaths have
been due to nephritis, neuritis, encephalitis, ex-
foliative and bullous dermatitis, hepatitis, aplastic
anemia and indefinite causes. Less severe reac-
tions include erythema, diarrhea, vomiting, fever,
albuminuria, paresthesias and vertigo. Acetarsone
is contraindicated in patients with disease of the
cardiovascular system, impaired liver or kidney
function, optic neuritis, fever or recent hemor-
rhage (Ven. Dis. Inform., 1942, Suppl. 18, 1-92). ®

Dose. — The range is from 60 to 250 mg. (ap-
proximately 1 to 4 grains), two or three times a
day. It should not be continued for more than a
week or 10 days; treatment may be resumed after
a rest period.

Derivatives. — A water-soluble sodium deriva-
tive of acetarsone. suitable for the preparation of
injections, is sold abroad. Other derivatives are
the bismuth compound, generally injected as an
oil suspension, and the water-soluble diethyla-
mine acetarsol, known as Acetylarsan (Merck),
used intramuscularly or subcutaneously.

Storage. — Preserve "in well-closed contain-

ers." X.F.

ACETARSONE TABLETS.

[Tabellae Acetarsoni]

X.F.

'Acetarsone Tablets contain not less than 92.5
per cent and not more than 107.5 per cent of the
labeled amount of CvHu.AsXO-,." X.F.

Usual Sizes.— 10, 50, 100, and 250 mg. (ap-
proximately %, H, 1%, and 4 grains).

ACETIC ACID. U.S.P., B.P.

[Acidum Aceticum]

"Acetic Acid is a solution containing not less
than 36 per cent and not more than 37 per cent,
by weight, of C2H4O2." U.S.P. The B.P. requires
33.0 per cent w/w of C2H4O2 (limits, 32.5 to

OO.J).

Ethanoic Acid. Acetum Concentratum : Acidum Aceticum
Dilutum (.Get., Sp.) Ger. Verdiinnte Essigsaure. Sp. Acido
acetico diluido.

Formerly the chief commercial source of acetic
acid was the destructive distillation of wood.
When carbonized out of contact with air. wood
yields many volatile products, among which are
an acid liquor called pyroligneons acid, an empy-
reumatic oil. and tar containing creosote and some
other proximate principles (see Pine Tar). When
the carbonization is performed in closed vessels.
these products may be collected, and, at the same
time, a large amount of charcoal be obtained. In
the case of resinous woods, wood oil and turpen-
tine oil are obtained before the charring tempera-
ture is reached.

Crude pyroligneous acid, sometimes called
pyroligneons vinegar, or wood vinegar, is a dark
brown liquid, having a strong smoky odor, and
consisting of acetic acid, methanol, acetone, water
and more or less tar. At one time the crude
pyroligneous acid was converted to calcium ace-
tate by treatment with lime, and the acetic acid
obtained by subsequent distillation with sulfuric
acid. This method of recovering acetic acid from
pyroligneous acid is no longer economically prac-
ticable; at present, the acetic acid is separated
by processes invoking solvent extraction, as with
isopropyl ether, and removal of water by azeo-
tropic distillation, using a water-entraining liquid
(see Glacial Acetic Acid). The product can readily
be concentrated, if desired, to contain over 99 per
cent of CH3COOH.

During the first World War the facilities of
the wood distillation industry were found to be

Part I

Acetic Acid

entirely inadequate to supply the demand for
acetic acid and it was made from molasses which
had been fermented into alcohol. In this process
conversion of the molasses alcohol into acetic acid
was accomplished by the quick fermentation proc-
ess in which weak alcohol was passed through
percolators filled with beech wood shavings which
had been inoculated with Mycoderma aceti. An-
other method for the rapid production of acetic
acid, introduced during the same war, depends on
the conversion of acetylene to acetaldehyde which
is then readily oxidized to acetic acid by means
of air; catalysts are employed in both reactions.

Still another process for the manufacture of
acetic acid is the oxidation of alcohol vapor by
air in the presence of suitable catalysts. Acetic
acid may also be produced by heating a mixture
of carbon monoxide and methyl alcohol in the
presence of catalysts.

Description. — "Acetic Acid is a clear, color-
less liquid, having a strong, characteristic odor,
and a sharply acid taste. Acetic Acid is miscible
with water, with alcohol, and with glycerin. The
specific gravity of acetic acid is about 1.045."
U.S.P.

The specific gravity of acetic acid increases
with concentration to a maximum of 1.0681 at
25° C. (76-79 per cent HC2H3O2), after which it
decreases until it reaches 1.0471 at 25° C, the
specific gravity of the 100 per cent acid. The
specific gravities of the glacial (100 per cent) and
the 39 per cent acid are practically the same, and
this applies also to the 74 and 81 per cent acids.

Standards and Tests. — Identification. —
Acetic acid responds to tests for acetate. Non-
volatile residue. — Not over 1 mg. of residue re-
mains when 20 ml. of acetic acid is evaporated on
a water bath and dried at 105° for 1 hour.
Chloride. — No opalescence is produced when silver
nitrate T.S. is added to a 1 in 10 aqueous solution
of acetic acid. Sulfate. — No turbidity is produced
when barium chloride T.S. is added to a 1 in 10
aqueous solution of acetic acid. Heavy metals. —
The limit is 10 parts per million. Readily oxidiz-
able substances. — The color of 4 ml. of acetic
acid, 20 ml. of distilled water, and 0.3 ml. of
0.1 N potassium permanganate does not change
to brown at once nor does it lose its pink tint en-
tirely in less than 30 seconds. U.S.P.

The B.P. specifies a test for limit of formic
acid and of oxidizable impurities in which the
acid is mixed with 0.1 N potassium dichromate
and sulfuric acid and, after standing for a minute,
with a solution of potassium iodide; a yellow or
brown color should be produced immediately, in-
dicating the presence of less than the limit of
impurity. An arsenic limit of 2 parts per million
and a lead limit of 1 part per million are stipu-
lated. Other tests are similar to corresponding
tests in the U.S.P.

Assay. — A sample of about 6 ml. is weighed,
diluted with water, and titrated with 1 N sodium
hydroxide, using phenolphthalein indicator. Each
ml. of I N sodium hydroxide represents 60.05 mg.
of C2H4O2. U.S.P.

Uses. — Acetic acid has an active astringent ac-
tion and is occasionally used for this purpose in

skin diseases; it is also employed as a styptic.
Along with copious amounts of water, a 3 per
cent or less concentrated solution of acetic acid
may be used to neutralize alkali burns of the skin;
the heat produced in the neutralization of residual
alkali may aggravate the injury if the acid is con-
centrated. A 0.5 per cent solution is used as a
cleansing agent or for moistening compresses on
infected burns or other wounds of the skin; this
concentration is bacteriostatic for most common
bacteria. Nielson (J. A.M. A., 1934, 102, 1179)
recommended 18 per cent acetic acid as a local
application, every third or fourth day, in the
treatment of various forms of ringworm of the
skin, such as tinea capitis and athlete's foot. A
1 per cent solution is an effective surgical dress-
ing for pyocyaneus infections. Boiled household
vinegar, equivalent to 5 per cent acetic acid, was
instilled into the external auditory canal in cases
with purulent drainage from chronic otitis media
by Ochs (Arch. Otolaryng., 1950, 52, 935); when
the canal was thoroughly cleansed, a tampon of
cotton was inserted against the drum, moistened
with the vinegar and left for 2 days. Infection
cleared after 1 to 3 treatments in 36 ears and
relapsed in only 5. In chronic pulmonary suppura-
tion due in part at least to Pseudomonas aeru-
ginosa, Currence (Am. J. Dis. Child., 1952, 83,
637) used 1 ml. of a 1 : 1000 solution as an aerosol
three times daily; symptoms were relieved al-
though the bacteria persisted. Steam inhalations
from 30 ml. of vinegar in a liter of water were
also used. For urinary infections with cystitis an
0.5 to 1 per cent solution is used as a bladder
irrigation, especially for ammonia-forming bac-
teria. As an acid (pH 5) vaginal douche, 1 to 2
per cent acetic acid (%. to x/z cup of white vine-
gar to 2 quarts of warm water) is commonly
used (Hirst, Am. J. Obst. Gynec, 1952, 64), in
the treatment of Trichomonas vaginalis and other
types of vaginitis. For contraceptic purposes, 1
per cent acetic acid has been incorporated in a
mucilaginous vehicle containing tragacanth, acacia,
agar, etc.

Internally, acetic acid is occasionally employed
as a refrigerant drink, but it is less palatable than
citric acid solution. Because it is completely
oxidized in the body acetic acid does not affect
the acidity of the general system. As an emer-
gency remedy in hemorrhage from the stomach,
diluted acetic acid, mixed with an equal volume
of water — so that the solution contains about
3 per cent of HC2H3O2 — has been used in table-
spoonful doses every few minutes as required. Be-
cause of its volatility and pungency, the vapor of
acetic acid is used for inhalation in the treatment
of faintness and sick headache, in the same man-
ner as smelling salts. This action, like that of
ammonia, is due to reflexes from irritation of the
mucous membrane of the nose. The N.F.V. recog-
nized, under the name Acetum Aromaticum, a
mixture containing several volatile oils, with
acetic acid, for this particular use.

Acetic acid possesses extraordinary solvent
power for many organic substances, and enhances
the miscibility of many, otherwise immiscible,
liquids with water. Charles F. Squibb and J. P.

Acetic Acid

Part I

Remington called attention to the solubilizing
effect of acetic acid when used in the menstrua
for extracting certain drugs, and proposed a class
of preparations, called acetracts, as substitutes for
the conventionally prepared solid extracts. |v]

Dose, 0.3 to 0.6 ml. (approximately 5 to 10
minims), diluted with water; topically, 0.5 to 20
per cent solutions are used.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep.— Diluted Acetic Acid, N.F., B.P.;
Aluminum Subacetate Solution, U.S. P.; Lobelia
Tincture, N.F.

GLACIAL ACETIC ACID. U.S.P., B.P.

[Acidum Aceticum Glaciate]
CH3.COOH

"Glacial Acetic Acid contains not less than 99.4
per cent, by weight, of C2H4O2." U.S.P. The B.P.
rubric is not less than 99.0 per cent C2EUO2.

Crystallizable Acetic Acid. Acidum Aceticum Concen-
tratum; Acidum Aceticum {Fr., Ger., It., Sp.). Fr. Acide
acetique; Acide acetique cristallisable; Acide acetique pur.
Ger. Essigsaure; Eisessig. It. Acido acetico. Sp. Acido
acetico; Acido Acetico Glacial; Acido etanoico.

Formerly glacial acetic acid was prepared by
distilling a mixture of anhydrous sodium acetate
and sulfuric acid, but it is now prepared by con-
centrating weaker solutions of acetic acid. Com-
mercial processes depend upon the separation of
water by fractional distillation, by formation of
compounds with anhydrous salts, by refrigeration,
by entrainment with an organic solvent or by
other chemical reactions. Thus, acetic acid may
be rendered anhydrous by rectification with dieth-
ylcarbonate which lowers the boiling point of
the water. By this means 50 per cent acetic acid
may be distilled to produce an acetic acid of 99.8
to 100 per cent purity. In another process acetic
acid is dehydrated by treating it with a water-
entraining liquid such as ethylene or propylene
chloride which, together with the entrained water,
is subsequently separated from the acetic acid by
distillation.

Description. — "Glacial Acetic Acid is a color-
less, clear liquid, having a pungent, characteristic
odor, and, when well diluted with water, an acid
taste. It boils at about 118° and has a specific
gravity of about 1.049. Glacial Acetic Acid is
miscible with water, with alcohol, and with glyc-
erin. Glacial Acetic Acid congeals at a tempera-
ture not lower than 15.6°." U.S.P. The B.P. states
that glacial acetic acid crystallizes at about 10°
and does not completely remelt until warmed to
about 15°. The freezing point is given as not lower
than 14.8°.

Standards and Tests. — Identification. — Tests
for acetate are given by a mixture of 1 volume of
glacial acetic acid and 2 volumes of water. Non-
volatile residue. — Not over 1 mg. of residue re-
mains when 20 ml. of glacial acetic acid is evapo-
rated in a tared porcelain dish and dried at 105°
for 1 hour. Chloride. — Silver nitrate T.S. pro-
duces no opalescence when added to a 1 in 20
aqueous solution of glacial acetic acid. Sulfate. —
Barium chloride T.S. produces no turbidity when

added to a 1 in 10 aqueous solution of glacial
acetic acid. Heavy metals. — The limit is 10 parts
per million. Readily oxidizable substances. — The
pink color of a mixture of 2 ml. of glacial acetic
acid, 10 ml. of water, and 0.1 ml. of 0.1 N potas-
sium permanganate is not changed to brown within
2 hours. U.S.P.

The tests described in the B.P. are similar to
those described under Acetic Acid, exceptions
being the arsenic limit of 6 parts per million and
the lead limit of 3 parts per million.

Assay. — A sample of about 2 ml. of acid is
weighed in a glass-stoppered flask, diluted with
distilled water, and titrated with 1 N sodium hy-
droxide, using phenolphthalein T.S. as indicator.
Each ml. of 1 N sodium hydroxide is equivalent
to 60.05 mg. of C2H4O2. U.S.P.

Uses. — Glacial acetic acid is comparatively
little employed as a therapeutic agent; it is official
chiefly because it is an ingredient of other official
preparations. It was formerly used to some extent
as a caustic for the removal of warts and corns,
but has been largely replaced by the more efficient
trichloroacetic acid or the high-frequency electric
current. When properly diluted, it may, of course,
be employed for the various purposes described
under Acetic Acid, (v]

Glacial acetic acid possesses the property of
dissolving a number of substances, such as volatile
and fixed oils, camphor, resins, gelatin, etc. It
also promotes the mutual solubility of partially
miscible liquids. As it attracts moisture from the
atmosphere, it should be preserved in well-stop-
pered bottles.

Toxicology. — The ingestion of glacial acetic
acid is followed by severe pain in the mouth,
throat and abdomen. White plaques and ulcers
are seen on the mucous membranes. Vomiting and
hematemesis occur and diarrhea may follow.
Hoarseness, rapid and shallow respiration, and
circulatory collapse appear. Body temperature is
subnormal. Albuminuria, oliguria and uremia may
develop.

Morphine injection is indicated for pain. Gas-
tric lavage or bicarbonate salts are contraindicated
since they may rupture the eroded stomach. A
suspension of 60 Gm. of calcium or magnesium
hydroxide in 500 ml. of water should be ingested
if possible. Milk, egg white and other demulcent
substances are indicated. Parenteral fluids and
supportive measures are important.

Chronic poisoning causes pallor, cachexia, ero-
sion of the teeth, halitosis, bronchitis and gastro-
intestinal disturbances. Industrial exposure to the
vapors results in conjunctivitis and blepharitis.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Aluminum Acetate Solution,
U.S. P.; Cantharides Tincture, N.F.; Strong Solu-
tion of Ammonium Acetate, B.P.

DILUTED ACETIC ACID. N.F. (B.P.)

[Acidum Aceticum Dilutum]

"Diluted Acetic Acid is a solution containing,
in each 100 ml., not less than 5.7 Gm. and not
more than 6.3 Gm. of C2H4O2." N.F.

Part I

Acetone

Diluted acetic acid may be prepared by mixing
158 ml. of acetic acid with sufficient purified
water to make 1000 ml. N.F.

The B.P. formula yields a preparation of the
same strength.

B.P. Dilute Acetic Acid. Fr. Acide acetique dilue ;
Solution aqueuse, au dixieme, d'acide acetique.

Description. — "Diluted Acetic Acid is a clear,
colorless liquid having a characteristic odor, and
a sharply acid taste. Diluted Acetic Acid is
miscible with water, with alcohol and with glyc-
erin. Its specific gravity is about 1.008." N.F.

For therapeutic uses of this substance, see under
Acetic Acid.

Storage. — Preserve "in tight containers." N.F.

Off. Prep. — Ammonium Acetate Solution;
Iron and Ammonium Acetate Solution; Squill
Vinegar, N.F.; Tincture of Ipecac, B.P.

ACETOMENAPHTHONE.

Acetomenaphthonum

B.P.

The B.P. defines Acetomenaphthone as 1 :4-
diacetoxy-2-methylnaphthalene and requires not
less than 98.0 per cent of C15H14O4, referred to
the substance dried to constant weight at 80°.

Menadiol Diacetate. 2-Methyl-l,4-naphthohydroquinone
Diacetate.

The B.P. states that acetomenaphthone may be
prepared by reducing 2-methyl-l,4-naphthoquinone
(menadione) with zinc and acetic acid in the pres-
ence of acetic anhydride. The compound thus
represents menadione which has been reduced to
its corresponding hydroquinone and the two
hydroxyl groups of the latter acetylated. In the
B.P. synthesis nascent hydrogen produced by the
interaction of zinc and acetic acid effects the re-
duction, while the acetic anhydride accomplishes
the acetylation. The synthesis of acetomenaph-
thone has also been described by Anderson and
Newman (/. Biol. Chem., 1933, 103, 405), who
prepared it as an intermediate in the synthesis of
the tubercle bacillus pigment phthiocol, which is
2-methyl-3-hydroxy- 1 ,4-naphthoquinone.

Description and Standards. — Acetomenaph-
thone is a white, crystalline powder, odorless or
with a slight odor of acetic acid. It is almost in-
soluble in water, slightly soluble in cold alcohol,
soluble in 3.3 parts of boiling alcohol.

It may be identified by a test in which the
compound is hydrolyzed with sodium hydroxide,
and the resulting hydroquinone oxidized with
hydrogen peroxide to menadione; tests are then
applied for both acetate and menadione.

The melting point of acetomenaphthone is be-
tween 112° and 115°. The absorbancy of a 0.003
per cent w/v solution in dehydrated alcohol, at
285 m\i, is between 0.69 and 0.78. One Gm. con-
tains no more zinc than corresponds to 0.2 mg. of
zinc sulfate. When dried to constant weight at 80°
the loss in weight is not over 1.0 per cent. The
limit of sulfated ash is 0.1 per cent.

Assay. — A sample of about 200 mg. of aceto-
menaphthone is boiled with a mixture of 15 ml.
of glacial acetic acid and 15 ml. of diluted hydro-
chloric acid, under a reflux condenser, for 15
minutes to remove the acetate groups by hydrol-

ysis; the resulting hydroquinone is quantitatively
oxidized to quinone by titration with 0.05 N eerie
ammonium sulfate, using o-phenanthroline-ferrous
complex as indicator. A second titration is per-
formed in the same manner, except that the
sample is omitted and that the solution is not
heated; this corrects for any reducing substances
in the reagents. Each ml. of the difference in the
volumes of eerie ammonium sulfate solution re-
quired represents 6.457 mg. of C15H14O4; this
equivalent is based on two eerie ions being re-
quired to oxidize the hydroquinone derived from
acetomenaphthone. B.P.

Uses. — Acetomenaphthone is intended for oral
administration in the treatment or prevention of
vitamin K deficiency and the hypoprothrombinemia
resulting therefrom. Its relationship to menadione
has been referred to above; it differs from
menadiol sodium diphosphate (q.v.) in being a
diacetate of menadiol instead of the tetrasodium
salt of the diphosphate of menadiol.

Ansbacher and colleagues (J.A.C.S., 1939, 61,
1924; 1940, 62, 155) observed that several de-
rivatives of 2 -methyl- 1,4-naphthohydroquinone
(referred to as menadiol) exert, in lower animals,
the typical effect of the K vitamers in restoring
coagulability of the blood in animals suffering
from vitamin K deficiency. They found that
menadiol diacetate (acetomenaphthone) had to
be given in about twice the dose of menadione to
produce the same degree of therapeutic effect.
Fieser et al. (J. Biol. Chem., 1941, 137, 680)
estimated the antihemorrhagic potency of aceto-
menaphthone to be about one-third that of
menadione. Since the toxic dose of acetomenaph-
thone is more than three times as large as that
of menadione (Ansbacher et al., J. Pharmacol.,
1942, 75, 111), the ratio of efficacy to toxicity
is better for acetomenaphthone than for mena-
dione. Ewing et al. (J. Biol. Chem., 1939, 131,
345) called attention to a further advantage of
acetomenaphthone in not being adversely affected
by light, as is the case with menadione.

Fantl et al. (Australian J. Exp. Bio. Med. Sc,
1951, 29, 433) found that the presence of bile in
the intestine is not essential for enteric absorption
of acetomenaphthone; they proposed a test of
vitamin K deficiency based on urinary excretion
of the drug following an oral dose of 50 to 60 mg.,
the excretion in the normal individual exceeding
15 per cent of the ingested dose in 24 hours.
Douglas and Brown (Brit. M. J., 1952, 1, 412)
found acetomenaphthone to be less effective than
vitamin Ki (phytonadione) in correcting the
hypoprothrombinemia induced by Tromexan.

The dose of acetomenaphthone is 2 to 10 mg.
(approximately 1/30 to 1/6 grain) by mouth daily.

The B.P. recognizes Tablets of Acetomenaph-
thone, requiring not less than 92.5 per cent and
not more than 107.5 per cent of the labeled
amount of C15H14O4.

ACETONE. N.F.

Dimethyl Ketone, [Acetonum]
CH3.CO.CH3

"Acetone contains not less than 99 per cent of
CaHeO." N.F.

Acetone

Part I

Dimethylketone; Diraethylketal; Propanone; Pyroacetic
Ether. Fr. Acetone. Ger. Azeton ; Essiggeist; Mesitalkohol.
Sp. Acetona.

Acetone is found in small amount in normal
urine, in blood, etc., and in larger amount in cer-
tain pathological conditions. It is a product of the
dry distillation of sugar, gum, cellulose, etc.

Acetone may be made in commercial quan-
tities by the dry distillation of calcium acetate at
a temperature not exceeding 300°. The crude
acetone thus obtained may be purified by digestion
with quicklime and again distilled from sodium
hydroxide. During the first World War the large
demand for acetone led to the development of a
process in which corn starch was fermented by
Clostridium acetobutylicum Weizmann. yielding
butyl alcohol, acetone, and ethyl alcohol. Later a
process was developed in which the Bacillus aceto-
ethylicitm was employed; this resulted in the
formation of acetone and ethyl alcohol. Today
both processes, in many different modifications,
are in use; the raw materials include a wide
variety of carbohydrates, especially molasses, but
including also potatoes, Jerusalem artichokes and
plant wastes rich in pentosans (corn stalks, wheat
and rye bran, etc.) ; for a review of the recent
production status see hid. Eng. Cliem., 1952, 44,
1677. Acetone has also been produced commer-
cially starting with propylene made from petro-
leum, and it can be prepared catalytically from
ethanol.

Description. — "Acetone is a transparent,
colorless, mobile, volatile liquid, having a char-
acteristic odor. A solution of Acetone (1 in 2) is
neutral to litmus. Acetone is miscible with water,
with alcohol, with ether, with chloroform, and
with most volatile oils. The specific gravity of
Acetone is not more than 0.789, indicating not
less than 99 per cent of C3H6O. Acetone distils
between 55.5° and 57°."

Standards and Tests. — Identification. — (1)
A yellow precipitate of iodoform is obtained on
adding a few ml. of iodine T.S. to a warm mixture
of 1 ml. of sodium hydroxide T.S. and 1 ml. of a
1 in 200 aqueous solution of acetone. (2) A deep
red color is produced when 1 ml. of a 1 in 200
aqueous solution of acetone is mixed with 5 drops
of sodium nitroprusside T.S. and 2 ml. of sodium
hydroxide T.S., then acidified slightly with acetic
acid; on diluting the mixture with several volumes
of distilled water a violet tint develops. Non-
volatile residue. — Not over 2 mg. from 50 ml. of
acetone, evaporated in a tared porcelain dish on a
water bath and dried at 105° for 1 hour. Readily
oxidizable substances. — A mixture of 20 ml. of
acetone and 0.1 ml. of 0.1 N potassium per-
manganate is not decolorized within 15 minutes.
N.F.

Distilled with water and chlorinated lime, ace-
tone yields nearly twice its weight of chloroform,
and hence is largely used to produce the latter.

Uses. — Acetone is used chiefly as a solvent,
especially for fats, resins, camphors, and pyroxy-
lin; it was employed as a menstruum for ex-
tracting oleoresins in U.S. P. VIII. It is sometimes
included in the formulation of topically applied
antiseptic solutions to facilitate penetration and

intimate contact with the skin, and to hasten
evaporation of the solvent following application
of the solution. Some physicians use it in prefer-
ence to ethyl alcohol for cleansing the skin in
preparation for smallpox vaccination. Prolonged
or repeated contact of acetone with the skin causes
erythema and dryness. Acetone is used as the de-
naturing ingredient in some formulas for denatured
alcohol.

In a general way, the physiological effects of
acetone seem to resemble those of alcohol. The
metabolism of acetone was reported by Price and
Rittenberg (/. Biol. Chem., 1950. 185, 449 j; the
fate of acetone labeled with the radioactive isotope
C14 was reported by Sakami and Lafaye {ibid.,
1951, 193, 199). Koehler et al. (ibid., 1941, 140,
811) gave intravenous injections of acetone at
the rate of 5 Gm. per hour to human subjects
without any symptomatic effects other than slight
drowsiness. The rate of acetone breakdown as
judged from blood levels and urinary excretion
was extremely slow. Data on respiratory excretion
of acetone were reported by Henderson et al.
(Diabetes, 1952, 1, 188).

A liver function test employing an intravenous
injection of 40 ml. of a 5 per cent solution of
acetone containing 1 Gm. of sodium bicarbonate,
followed by a determination of the blood acetone
level after 12 hours, was described by Schumann
and Klotzbucher (Klin. Wcknschr., 1940, 19,
1101).

The industrial hazard to health from exposure
to acetone has been studied by Haggard et al.
(J. Indust. Hyg. Toxicol., 1944, 26, 133). In-
halation of vapors of acetone will cause headache,
excitement, and fatigue; at high concentrations
unconsciousness and narcosis mav result (Chatter-
ton and Elliot. J. A.M. A., 1946, 'l30, 1222). The
patient should have access to fresh air, and oxygen
inhalation and stimulants should be employed if
required. Albertoni found that doses of 15 to 20
Gm. of acetone produced no symptoms in man
beyond slight narcosis.

Storage. — Preserve "in tight containers, re-
mote from fire." N.F.

Off. Prep. — Surgical Merbromin Solution;
Xitromersol Tincture; Thimerosal Tincture, N.F.

ACETOPHENETIDIN. U.S.P. (B.P., LP.)

Acetphenetidin, Phenacetin, [Acetophenetidinum]

C2H50

NH-C0-CH3

The B.P. defines Phenacetin as aceto-/>-phenet-
idide, while the LP. defines it as aceto-4-phenet-
idine.

B.P., LP. Phenacetin, Phenacetinum. Para-acetphenet-
idine; Para-acetaminophenetol. Acetphenetidinum ; Ethoxy-
para-acetanilidum; Acethylphenetidina; Acethylphenet-
idinum. Fr. Ethoxypara-acetanilide ; Phenedine; Phenine.
Ger. Phenazetin. It. Acetilfenetidina. Sp. Acetilfeneti-
dina ; Acetofenetidina; Fenedina; Fenina; Fenacetina.

Acetophenetidin may be manufactured by any
one of several processes, the choice of the method
depending on the availability of the respective
starting materials and the economy of their utili-

Part I

Acetophenetidin Tablets 13

zation. In one process phenol is converted to a
mixture of ortho- and />ara-nitrophenol ; the
former, which is not utilizable, is removed by dis-
tillation with steam. The sodium derivative of
the />ara-nitrophenol is treated with ethyl chloride
or ethyl bromide, producing ethyl />-nitrophenol
or p-nitrophenetol, C6H4(N02jOC2H5. This is
reduced with sodium sulfide or with iron filings
and hydrochloric acid to p-phenetidin, CeHU-
(NH2)OC2Ho. Glacial acetic acid or any other
acetylating agent is used to introduce the acetyl
group, producing />-acetophenetidin. Monochloro-
benzene, normally less costly than phenol, may
also be employed as the starting point for the
synthesis of acetophenetidin; by nitration £-chlo-
ronitrobenzene is obtained and this, by treatment
with alkali, is converted to p-nitrophenol which is
treated as described above. Acetophenetidin may
also be prepared from />-acetaminophenol by
ethylation. In still another method acetophenet-
idin is obtained by the action of the gas ketene,
CH2=CO, on />-phenetidin dissolved in acetone
or other inert solvent.

Description. — "Acetophenetidin occurs as
white, glistening crystals, usually in scales, or as
a fine, white, crystalline powder. It is odorless,
has a slightly bitter taste, and is stable in air. Its
saturated solution is neutral to litmus. One Gm.
of Acetophenetidin dissolves in about 1300 ml. of
water, in 15 ml. of alcohol, in 15 ml. of chloro-
form, and in about 130 ml. of ether. One Gm. of
Acetophenetidin dissolves in 85 ml. of boiling
water, and in about 3 ml. of boiling alcohol.
Acetophenetidin melts between 134° and 136°."
U.S.P.

Standards and Tests. — Identification. — A
ruby red color slowly develops when 200 mg.
acetophenetidin is boiled for 1 minute with 1 ml.
of hydrochloric acid, diluted with 10 ml. of water,
cooled, filtered, and 1 drop of potassium dichro-
mate T.S. added to the filtrate. Loss on drying. —
Not over 0.5 per cent on drying at 60° for 1 hour.
Residue on ignition. — Not over 0.05 per cent.
Readily carbonizable substances. — A solution of
500 mg. of acetophenetidin in 5 ml. of sulfuric
acid has no more color than matching fluid T.
Acetanilid. — Neither turbidity nor precipitation
results when bromine T.S. is added, dropwise, to
the filtrate from a mixture of 500 mg. of aceto-
phenetidin and 10 ml. of water which has been
boiled for 1 minute, then cooled and filtered.
U.S.P.

Incompatibilities. — Acetophenetidin is slowly
decomposed by strong acids and alkalies; oxidiz-
ing agents usually produce a red color; ethyl ni-
trite spirit causes the slow development of a yel-
low color which deepens to reddish brown. It
forms a wet mass when triturated with chloral
hydrate, acetylsalicylic acid, aminopyrine, and
many other substances. An insoluble derivative is
formed with iodine.

Uses. — Acetophenetidin is useful as an anti-
pyretic and analgesic in the same group of cases
in which acetanilid is of service. It is commonly
prescribed in combination with other drugs such
as acetylsalicylic acid or acetanilid, caffeine or
citrated caffeine, and codeine sulfate, etc. Aceto-

phenetidin, like acetanilid, yields in the body
N-acetyl-p-aminophenol and its physiological ac-
tion and therapeutic effects are essentially the
same as those of acetanilid (q. v.) Its action,
however, is more gradual and more prolonged and
it is less likely to give rise to undesirable symp-
toms. Only 7 of the 62 cases of sulfhemoglob-
inemia reported by Brandenburg and Smith (see
under Acetanilid) were associated with prolonged
use of acetophenetidin, as compared to the 44
cases reported from the prolonged use of ace-
tanilid. The same increase in the threshold to the
pain produced by radiant heat was observed by
Wolff, Hardy and Goodell with an oral dose of
300 mg. of acetophenetidin as was produced by
300 mg. of acetanilid. The Food and Drug Ad-
ministration believes that acetophenetidin may be
a dangerous drug if the daily dose exceeds 1 Gm.
and has expressed the following opinion: "It is
well established that frequent or continued use of
acetophenetidin-containing preparations may be
dangerous, causing serious blood disturbances.
This fact should be borne in mind in devising la-
bels for this preparation to conform with the re-
quirement of section 502 (f)(2) of the Act that
the labeling of drugs bear adequate warnings."
{Drug & Cosmetic Ind., 1941, 48, 163.) S

The usual dose of acetophenetidin is 300 mg.
(approximately 5 grains), with a range of 300 mg.
to 1 Gm. A total dose in 24 hours up to 3 Gm. has
been reported (but see above).

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

ACETOPHENETIDIN TABLETS.
U.S.P. (B.P., LP.)

[Tabellae Acetophenetidini]

"Acetophenetidin Tablets contain not less than

94 per cent and not more than 106 per cent of
the labeled amount of C10H13O2N." U.S.P. The
B.P. requires that Tablets of Phenacetin contain
not less than 95.0 per cent, and not more than
105.0 per cent, of the stated amount of phe-
nacetin. The tablets may be prepared by moist
granulation and compression. The LP. limits are
94.0 and 106.0 per cent, respectively.

B.P. Tablets of Phenacetin; Tabellae Phenacetini. LP.
Compressi Phenacetini. Sp. Tabletas de Acetofenetidina.

Assay. — A representative sample of tablets,
equivalent to about 300 mg. of acetophenetidin,
is extracted with petroleum benzin to remove
lubricants, then with chloroform to dissolve aceto-
phenetidin. The chloroform is evaporated and the
residue of acetophenetidin is dried at 60° and
weighed. U.S.P.

In the B.P. assay the phenacetin is extracted
from a sample of powdered tablets with hot

95 per cent alcohol, the solution is evaporated
and the residue washed with successive 5-ml. por-
tions of water, previously saturated with phenace-
tin. The washed residue is redissolved in hot 95
per cent alcohol, the solution evaporated and the
residue dried to constant weight at 105°.

Usual Sizes. — 1, 2, 3, and 5 grains (approxi-
mately 60, 120, 200, and 300 mg.).

14 Acetophenetidin and Phenyl Salicylate Tablets

Part I

ACETOPHENETIDIN AND PHENYL
SALICYLATE TABLETS. N.F.

Phenacetin and Salol Tablets
[Tabellae Acetophenetidini et Phenylis Salicylates]

"Acetophenetidin and Phenyl Salicylate Tablets
contain not less than 90 per cent and not more
than 110 per cent of the labeled amounts of
acetophenetidin and of phenyl salicylate." N.F.

Tests. — Identification. — (1) The tablets re-
spond to the identification tests under Phenyl
Salicylate Tablets. (2) A purplish color is pro-
duced when powdered tablets equivalent to about
100 mg. of acetophenetidin is boiled for 1 minute
with 1 ml. of hydrochloric acid, diluted with 10
ml. of water, cooled, filtered, and 1 drop of po-
tassium dichromate T.S. added to the filtrate.
N.F.

Assay. — For acetophenetidin. — A representa-
tive portion of tablets, equivalent to not more
than 80 mg. of phenyl salicylate, is extracted with
chloroform to dissolve both the acetophenetidin
and the phenyl salicylate. The chloroform is
evaporated and the residue is heated for 15 min-
utes with 2.5 per cent sodium hydroxide solution
which hydrolyzes phenyl salicylate to sodium
phenolate and sodium salicylate, but does not
affect acetophenetidin. The latter is extracted
with chloroform and, after washing each of the
chloroform portions with water, the solvent is
evaporated and the acetophenetidin dried at 60°
for 1 hour and weighed. For phenyl salicylate. —
The alkaline solution and aqueous washings re-
maining after the extraction of acetophenetidin
is analyzed as directed under the assay for Phenyl
Salicylate Tablets. N.F.

Storage. — Preserve "in tight containers at a
temperature not above 35°." N.F.

Usual Size. — These tablets usually contain
2^2 grains (approximately 150 mg.) of each in-
gredient.

ACETRIZOIC ACID. U.S.P.

3-Acetamido-2,4,6-triiodobenzoic Acid

NH-CO-CH3

"Acetrizoic Acid contains not less than 99 per
cent of C9H6I3NO3. and not less than 67 per
cent and not more than 68.5 per cent of iodine
(I), calculated on the dried basis." U.S.P.

Acetrizoic acid is the active component of so-
dium acetrizoate injection (Urokon, Mallinck-
rodt), a radiopaque medium described in a
separate monograph. The acid is prepared by re-
ducing ra-nitrobenzoic acid to w-aminobenzoic
acid, treating with iodine monochloride to pro-
duce 2,4,6-triiodobenzoic acid, and finally acetyl-
ating with acetic anhydride (Wallingford,
J.A.Ph.A., 1953, 42, 721). For detailed informa-
tion see U. S. Patent 2,611,786 (1952).

Description. — "Acetrizoic Acid occurs as a
white powder. It is odorless. Acetrizoic Acid is

slightly soluble in water. It is soluble in alcohol,
slightly soluble in ether, very slightly soluble in
chloroform, and practically insoluble in benzene.
It is soluble in solutions of alkali hydroxides.
Acetrizoic Acid melts with decomposition between
278° and 283°." U.S.P.

Standards and Tests. — Identification. — (1)
On heating acetrizoic acid the substance melts to
a dark brown liquid and liberates iodine vapors.
(2) After preliminary hydrolysis of acetrizoic
acid with alkali, followed by diazotization and
coupling with betanaphthol, a white precipitate,
which becomes purple within 5 minutes, is pro-
duced. Loss on drying. — Not over 0.1 per cent,
when dried at 105° for 18 hours. Heavy metals. —
The limit is 20 parts per million. U.S.P.

Assay. — For acetrizoic acid. — An alcohol solu-
tion of 1 Gm. of acetrizoic acid is titrated with
0.1 N sodium hydroxide, using phenolphthalein
as indicator. Each ml. of 0.1 N sodium hydroxide
represents 55.69 mg. of C9H6I3NO3. For iodine.
— The assay for iodine specified for Iodophthalein
Sodium is employed. U.S.P.

For information concerning the ultimate use of
this agent, in the form of its sodium salt, see
under Sodium Acetrizoate Injection.

Storage. — Preserve "in well-closed containers."
U.S.P.

ACETYLCHOLINE CHLORIDE. LP.

Acetylcholine Chloridum

CH3.COOCH2.CH2.N(CH3)3Cl

Acetylcholine chloride is 2-acetoxyethyltri-
methylammonium chloride; it contains not less
than 98.0 per cent, and not more than the equiva-
lent of 102.0 per cent, of C7H16O2NCI, calculated
with reference to the substance dried to constant
weight at 110°. LP.

Acecoline (Anglo-French Laboratories)

Acetylcholine occurs naturally in many tissues
(see below) but for pharmacological experimenta-
tion and therapeutic use it is prepared syntheti-
cally, as the chloride salt. In the method most
commonly used trimethylammonium chloride is
interacted with ethylene oxide to form choline
chloride, which is treated with acetic anhydride
to form acetylcholine chloride.

Description. — Acetylcholine chloride occurs
as white, odorless, very hygroscopic crystals. It
is very soluble in water, in alcohol, in chloroform,
and in acetic acid; it is insoluble in ether and in
benzene. Acetylcholine chloride, after drying at
110°, melts between 149° and 152°.

Standards and Tests.— Identification. — (1)
Trimethylamine, recognizable by its odor, is
evolved when acetylcholine chloride is heated with
sodium hydroxide T.S. (2) An aqueous solution
of acetylcholine chloride yields a precipitate with
phosphotungstic acid T.S., with trinitrophenol
T.S., and with iodine T.S. (3) It responds to tests
for chloride and, after alkaline hydrolysis, to tests
for acetate. Reaction. — A 10 per cent w/v solu-
tion in water is neutral to litmus T.S. Arsenic. —
The limit is 2 parts per million. Heavy metals —
The limit is 10 parts per million. Lead. — The limit
is 10 parts per million. Free acid. — Not more than

Part I

Acetylsalicylic Acid 15

0.2 ml. of 0.01 N sodium hydroxide produces a
red color in a solution of 100 mg. of acetylcholine
chloride in 10 ml. of recently boiled and cooled
water to which 1 drop of phenolphthalein T.S. has
been added. Trimethylamine. — No odor of that
substance is apparent on boiling a solution of
100 mg. of acetylcholine chloride in 10 ml. of
saturated solution of sodium carbonate. Loss on
drying. — Not over 0.75 per cent when dried to
constant weight at 110°. Residue on ignition. —
Not over 0.1 per cent. LP.

Assay. — About 100 mg. of acetylcholine chlo-
ride, dissolved in boiled and cooled distilled water,
is boiled under reflux for 15 minutes with 10 ml.
of 0.1 N carbonate-free sodium hydroxide, which
releases acetic acid by hydrolysis. The excess of
alkali is titrated with 0.1 N sulfuric acid, using
phenolphthalein T.S. as indicator. Each ml. of
0.1 N sodium hydroxide represents 18.17 mg. of
C7H16O2NCI. LP.

Action of Acetylcholine. — Acetylcholine,
CH3.COOCH2.CH2N(CH3)30H, is now gener-
ally considered to be the chemical mediator of
the parasympathetic postganglionic, the auto-
nomic (sympathetic and parasympathetic) pre-
ganglionic and motor nerve impulses. When one
of these nerves, as for example the vagus, is
stimulated, there is formed at the peripheral ter-
minations a substance which appears to be acetyl-
choline, and which is generally believed to act
upon the parenchyma of the organ under consid-
eration (see under Parasympathomimetic Agents
and Cholinesterase Inhibitors). After excitation
of the nerve ceases there is a rapid breakdown of
the compound, effected by the presence of the
enzyme cholinesterase (see Koppanyi and associ-
ates, /. Pharmacol, 1953, 107, 482, 501). As a
result of this enzyme-catalyzed hydrolytic action,
the acetyl radical is split off, leaving choline,
which is comparatively inert.

If acetylcholine is injected into the circulation
it will cause all the characteristic effects of elec-
trical stimulation of all the parasympathetic
nerves, such as slowing of the pulse, vasodilata-
tion, fall in blood pressure, bronchospasm, in-
creased bronchial secretion, hyperpnea, increased
gastric secretion, increased tone and peristaltic
contractions of the gastrointestinal tract, increased
secretion of sweat, tears and saliva, contraction
of pupils, etc. (Koppanyi, Bull. Johns Hopkins
Hosp., 1948, 83, 532). In larger doses, acetyl-
choline excites the sympathetic ganglia, producing
a very definite group of reactions which resemble
those of nicotine. Large doses of acetylcholine
also cause reactions of the voluntary muscles.
This contraction of skeletal muscle has led to the
basic concept of cholinergic (acetylcholine) me-
diation of motor impulses to skeletal muscles (see
under Curarimimetic Agents) ; for further infor-
mation see Feldberg, Physiol. Rev., 1945, 25,
596, also Lorente de No, Bull. Johns Hopkins
Hosp., 1948, 83, 497). Welsh {ibid., 568) con-
cluded that acetylcholine acts on all cells of the
body to alter the excitability of the cell through
change of membrane polarity and permeability.
Acetylcholine is also important in the transmission
of the nerve impulse along the axone (Nachman-
sohn, ibid., 1948, 83, 463).

Uses. — Acetylcholine has been employed to
some extent as a therapeutic remedy in various
acute conditions in which stimulation of the au-
tonomic nervous system is desirable. It has been
used for tobacco amblyopia (Duggan, J.A.M.A.,
1937, 109, 1354), paroxysmal auricular tachy-
cardia (Abbott, ibid., 1939, 113, 1243), acropares-
thesia (Ekbom, Acta psychiat. neurol., 1939, 14,
311), and paralytic ileus (Abel, Lancet, 1933, 2,
1252). The extreme evanescence of its action and
the marked stimulation of the autonomic ganglia
from overdoses have greatly restricted its value.
Methacholine chloride and carbachol are gener-
ally preferred. Drugs which inhibit cholinesterase,
such as neostigmine and physostigmine, are more
widely used. S

The dose of acetylcholine chloride is 50 mg.
initially, then 100 mg. daily, subcutaneously or
intramuscularly. At the most, 200 mg. (approxi-
mately 3 grains) is given. It should not be
administered intravenously because less than
one-tenth these quantities will cause marked
physiological reactions. When using the drug it
is advisable to have a solution of atropine ready
for immediate administration if it is necessary to
counteract the effects of acetylcholine.

Acetylcholine chloride, because of its pro-
nounced hygroscopicity and the instability of its
aqueous solutions, is supplied in ampuls contain-
ing 100 mg. of the crystals, from which a solution
may be prepared as required. Under the name
Acecoline a propylene glycol solution containing
in 1 ml. 20 mg., 50 mg., 100 mg., or 200 mg., with
saligenin, is also marketed.

Storage. — Acetylcholine chloride should be
kept in a tightly-closed container. LP.

ACETYLSALICYLIC ACID.
U.S.P., B.P., LP.

Aspirin, [Acidum Acetylsalicylicum]

C00H

O-CO-CH3

"Acetylsalicylic Acid, dried over sulfuric acid
for 5 hours, contains not less than 99.5 per cent of
CoHsOi." U.S.P. The B.P. assay rubric is the
same, but the chemical is not required to be dried.
The LP., which defines the compound as 2-acet-
oxybenzoic acid, likewise requires not less than
99.5 per cent purity, the substance not being
dried.

Fr. Acide acetylsalicylique ; Aspirine. Ger. Acetylsali-
zylsaure. It. Acido acetilsalicilico. Sp. Acido acetil-

salicilico; Acido salicilacetico; Aspirina.

Acetylsalicylic acid had been synthesized some
years before it was introduced into medicine, in
1899, by Dreser. The name aspirin, by which this
substance is popularly known, is not purely fanci-
ful nor arbitrary. It is derived from the fact that
salicylic acid, as originally obtained from Spiraa
ulmaria, was at first known as acidum spiricum.
Acetylsalicylic acid may be prepared by acetyliz-
ing salicylic acid by means of acetic anhydride or
acetyl chloride, the former being the more fre-
quently used because of its greater economy. An

16 Acetylsalicylic Acid

Part I

excess of acetic anhydride is heated with salicylic
acid at a temperature of about 150° for three
hours; the excess of the anhydride, as well as
acetic acid formed in the reaction, is removed by
distillation, and the residue of acetylsalicylic acid
is purified by recrystallization from a non-aqueous
solvent. Acetylsalicylic acid cannot be purified
by crystallization from water or solvents contain-
ing it because of its tendency to undergo hydrol-
ysis. It may be crystallized from benzene, methyl
acetate, chloroform, or strong ethyl or methyl
alcohol.

Patents have been granted in this country and
in Great Britain for a process whereby salicylic
acid is dissolved in an inert solvent, such as dry
ethyl ether, through which ketene. a gas having the
chemical formula CH2:CO, is passed until the
solution is saturated. Upon evaporating the ether,
needle-like crystals of acetylsalicylic acid are ob-
tained. The chemical reaction takes place accord-
ing to the following equation:

CeEUOH.COOH + CH2:CO -*

C6H4.0(CH3CO).COOH

Description. — "Acetylsalicylic Acid occurs as
white crystals, commonly tabular or needle-like,
or as a white, crystalline powder. It is odorless or
has a faint odor. It is stable in dry air; in moist
air it gradually hydrolyzes to salicylic and acetic
acids. One Gm. of Acetylsalicylic Acid dissolves
in about 300 ml. of water, in 5 ml. of alcohol, in
17 ml. of chloroform, and in from 10 to 15 ml. of
ether. It is less soluble in absolute ether. Acetyl-
salicylic Acid dissolves with decomposition in
solutions of alkali hvdroxides and carbonates."
U.S.P.

The B.P. gives the melting point as from 135°
to 138° C. Considerable variation exists in the
reported values of the melting point of aspirin,
some investigators claiming it to be 131° to
132° C.. while others claim 134° to 135° C. Beal
and Szalkowski (/. A. Ph. A., 1933, 22, 36) be-
lieve that these differences are due to the fact that
some decomposition occurs during the process of
heating the acid to the melting temperature, and
also that excessive trituration to produce a fine
powder results in partial decomposition. Both
effects are evidenced by a lowered melting point.
The composition of the glass used for the melting
point tube may influence the melting point of
acetylsalicylic acid; Pyrex glass appears to be
without effect.

Standards and Tests. — Identification. — (1)
A violet red color is produced when acetylsalicylic
acid is heated with water for several minutes,
cooled, and a drop or two of ferric chloride T.S.
added. (2) When 500 mg. of acetylsalicylic acid
is hydrolyzed by boiling with 10 ml. of sodium
hydroxide T.S., the solution cooled and acidified
with 10 ml. of diluted sulfuric acid a white pre-
cipitate of salicylic acid is obtained, and the odor
of acetic acid is developed. If the mixture is
filtered, and 3 ml. of alcohol and 3 ml. of sulfuric
acid are added to the filtrate an odor of ethyl
acetate develops on warming the mixture. Loss on
drying. — Acetylsalicylic acid loses not more than
0.5 per cent of its weight on drying over sulfuric

acid for 5 hours. Residue on ignition. — Not over
0.05 per cent. Readily carbonizable substances. —
A solution of 500 mg. of acetylsalicylic acid in
5 ml. of sulfuric acid has no more color than
matching fluid Q. Chloride. — The limit is 140
parts per million. Sulfate. — The limit is 400 parts
per million. Free salicylic acid. — The limit is 0.1
per cent. Heavy metals. — The limit is 10 parts per
million. Substances insoluble in sodium carbonate
T.S. — A portion of 500 mg. of acetylsalicylic acid
should form a clear solution with 10 ml. of warm
sodium carbonate T.S. U.S.P.

The B.P. tests differ from corresponding de-
scriptions and tests of the U.S.P. only in minor
details, except that the former permits but half
the amount of salicylic acid allowed by the U.S.P.
An arsenic limit of 2 parts per million and a limit
of lead of 10 parts per million are provided.

Assay. — The U.S.P. directs that about 1.5 Gm.
of acetylsalicylic acid, previously dried over sul-
furic acid for 5 hours, be boiled for 10 minutes
with 50 ml. of 0.5 N sodium hydroxide and the
excess base determined by titration with 0.5 N
sulfuric acid using phenolphthalein as indicator.
In this assay the acetylsalicylic acid is hydrolyzed
to form the sodium salts of acetic and salicylic
acids; the reliability of the assay is dependent on
having a sample which has not decomposed beyond
the permitted limit. A residual blank titration is
performed. Each ml. of 0.5 N sodium hydroxide
represents 45.04 mg. of C9HSO4. U.S.P.

The B.P. assay is the same as that of the U.S.P.
except that phenol red is employed as indicator.
The LP. assay is also the same, phenolphthalein
indicator being used.

Incompatibilities. — Acetylsalicylic acid read-
ily undergoes hydrolysis with aqueous solvents
with liberation of salicylic and acetic acids. In
pure water complete decomposition takes place
in 100 days. Acids hasten the rapidity of such
change. Alkalies and solutions of alkaline acetates
and citrates dissolve acetylsalicylic acid, but the
resulting solutions hydrolyze rapidly to form salts
of acetic and salicylic acids. The decomposition
may be retarded somewhat by glycerin and sugar.
Liquefaction occurs when acetylsalicylic acid is
triturated with phenyl salicylate, acetanilid, aceto-
phenetidin. aminopyrine., antipyrine and many
other organic products. Partial hydrolysis occurs
in mixtures of acetylsalicylic acid with hygro-
scopic substances or salts containing water of
hydration. Hydriodic acid is slowly produced from
iodides and subsequent oxidation by the air liber-
ates iodine.

The statement that quinine and acetylsalicylic
acid react upon each other to form the poisonous
quinotoxin has been contradicted by the experi-
ments of Sollmann. Ruddiman and Lanwermeyer
(/. A. Ph. A., 1924, 13, 1009) experimented with
mixtures of acetylsalicylic acid with basic quinine
and also the sulfate, bisulfate. hydrochloride and
other cinchona alkaloids. They found that the
mixture with quinine alkaloid, after several
months, changed to a brownish red viscid mass if
exposed to the light, but when kept in the dark
the change was less rapid; this mixture tested on
frogs was not more poisonous than the freshly

Part I

Acetyl salicylic Acid 17

made mixture nor than the equivalent dose of ace-
tylsalicylic acid.

It has been reported that morphine and codeine
form poisonous compounds with this drug.

Uses (see also Salicylic Acid and Sodium
Salicylate). — The antipyretic effect of willow bark
was known to the ancients and, early in the 19th
century, salicylic acid was prepared from salicin,
a glycoside from this bark. Acetylsalicylic acid
was introduced into medicine in 1899.

Metabolism. — Acetylsalicylic acid is absorbed
as such from the gastrointestinal tract (Bradley
et al., Am. J. Digest. Dis., 1936, 3, 415) and
transported throughout the tissues as the sodium
salt, appearing in the joints, the pleura, etc. Fol-
lowing doses of 10 Gm. daily, the salicylate con-
centration in the blood ranges from 30 to 50 mg.
per 100 ml. {J. A.M. A., 1945, 128, 1195). The
simultaneous administration of sodium bicar-
bonate in equivalent dosage decreases the blood
concentration almost one-half (Smull et al.,
J.A.M.A., 1944, 125, 1173; but see Lester et al,
J. Pharmacol, 1946, 87, 329). About £0 per cent
of the drug is excreted in the urine, making its
appearance within 10 to 15 minutes after ingestion
(/. Pharmacol, 1919, 14, 25). Excretion is almost
complete within a few hours although traces ap-
pear in the urine during several days. In febrile
patients only 60 to 70 per cent is excreted. From
10 to 35 per cent of the ingested acetylsalicylic
acid appears in the urine unchanged or as the
sodium salt; some is present as a glucuronate.
Such urine reduces Benedict's solution and gives
a violet color with ferric chloride.

Therapeutic Actions. — Acetylsalicylic acid is
used medicinally for several purposes.

Antipyretic. — The antipyretic effect of acetyl-
salicylic acid arises from its action on the central
nervous system. Barbour {Arch. Int. Med., 1919,
24, 617 and 624; Physiol. Rev., 1921, 1, 295)
showed that it facilitates dissipation of heat
through increased peripheral blood flow, hydration
of the blood, and sweating. Although sponges with
tepid water or alcohol are effective for the reduc-
tion of temperature, acetylsalicylic acid is com-
monly used and is simpler when the discomfort
arising from fever is great, as in influenza, or when
prolonged high fever may be deleterious to the
general welfare of the patient. Weakness may be
aggravated by sweating and the water and salt so
lost should be replaced. Therapeutic doses have
no effect on the cardiovascular system.

Analgesic. — Acetylsalicylic acid alleviates pain
by a depressant action on the central nervous sys-
tem, probably on the thalamus; Lester et al.
(J. Pharmacol, 1946. 87, 329) believe its action
to be exercised mainly by the unhydrolyzed frac-
tion in the plasma. Integumental pain such as
myalgia, arthralgia, headache, etc., responds better
than does pain of visceral origin. Although it has
little local anesthetic action, acetylsalicylic acid is
sometimes employed as a gargle or a chewing gum
with symptomatic relief of sore throat. It is prob-
ably the most commonly used analgesic, being
prescribed alone or in combination with aceto-
phenetidin, codeine, caffeine, amphetamine and
other drugs.

The threshold for cutaneous pain through heat
is increased about 35 per cent within 50 to 100
minutes after oral doses of 65 to 300 mg., the
effect lasting for about 2 hours. In comparison,
15 mg. of morphine sulfate injected intramuscu-
larly increases the threshold about 70 per cent
(Wolff, Hardy and Goodell, /. Clin. Inv., 1941,
20, 63). Unfortunately, evaluation of analgesic
drugs according to their ability to depress the
threshold of pain perception caused by radiant
heat applied to the skin of normal subjects or
animals has not been proved to be an accurate
prediction of their efficacy in patients with pain
due to injury or disease. Beecher (Science, 1952,
116, 157) and his associates have struggled with
the evaluation of the subjective phenomenon of
pain in sick patients. In attempting to establish
criteria for effectiveness of an analgesic agent he
denied the validity of measuring sensory percep-
tion of pain produced by heat in normal subjects.
Letters to the editor by Hardy, Wolff and Goodell
(Science, 1953, 117, 164) and Beecher (ibid.,
166) have debated the issue to little, if any, prac-
tical conclusion. Ravich (ibid., 118, 144) com-
ments that "physiological" pain produced by heat
on normal tissue is a normal sensory response
whereas "pathological" pain caused by disease is
an abnormal phenomenon with many more un-
known features. Beecher comments that so-called
"common sense" in hundreds of years of clinical
practice has arrived at an average effective dose
of morphine (15 mg.) which is twice as large as
the one (8 mg.) which gives essentially maximum
pain relief in his complicated, controlled studies
of hospital patients. It can only be concluded that
adequate methods of evaluating analgesic drugs
remain to be developed. Furthermore, the physi-
cian is desirous of relieving pain in his patient
rather than using a dose which will relieve pain in
nearly all patients in the statistical sense but
which might fail in his particular patient.

Acetylsalicylic acid relieves the aching and the
fever of "grippe" although it does not shorten the
course of the illness.

Antirheumatic. — Acetylsalicylic acid (see also
Sodium Salicylate) is the drug most generally
employed in the treatment of acute rheumatic
fever. Larger doses are administered than in most
other conditions, from 1 to 1.3 Gm. (approxi-
mately 15 to 20 grains) being given hourly until
the acute joint symptoms are relieved. About 10
doses are usually required. If toxic symptoms ap-
pear the drug is discontinued for 12 hours, then
given in doses of 1 Gm. every 4 hours, six times
daily, until evidence of active rheumatic fever
has been absent for 1 week (McEwen, Bull N. Y.
Acad. Med., 1943, 19, 679). The mechanism of
the almost specific action of salicylates in acute
rheumatic fever is unknown; morphine, for ex-
ample, relieves the pain but not the swelling,
redness and increased heat of the joints. How-
ever, salicylates do not shorten the course of the
disease or prevent cardiac and other complica-
tions. There are general similarities between the
effects of salicylates and cortisone. Both relieve
pain, produce a fall in temperature, reduce the
erythrocyte sedimentation rate and prevent re-

18 Acetylsalicylic Acid

Part I

lapse of the rheumatic state as long as adminis-
tration is continued. Pfeiffer (/. Pharmacol., 1950.
98, 26) demonstrated an increase in eosinophil
count after administration of acetylsalicylic acid.
An increase in urinary excretion of reducing ster-
oids following the use of acetylsalicylic acid has
been reported by Van Cauwenberge (Lancet,
1951, 260, 771; Acta M. Scand., 1952, 141, 265).
Mild Cushing's syndrome is reported to have
followed acetylsalicylic acid therapy in acute
rheumatic fever (Cochran, Brit. M. J., 1950, 2,
1411). Pelloja (Lancet, 1952, 262, 233) found
salicylates capable of inhibiting the action of
hyaluronidase in a manner similar to cortisone.
Whether these effects are primary or are medi-
ated through cortisone release awaits further
elucidation. Actually, in a large cooperative study
of the effect of corticotropin, cortisone and acetyl-
salicylic acid (Houser et al., Am. J. Med., 1954.
16, 168). the results failed to demonstrate supe-
rior efficacy for, any of the 3 drugs both as to
controlling the acute symptoms and the duration
of the active disease. In other forms of poly-
arthritis (gonorrheal, streptococcal, meningococ-
cal, etc.) salicvlate therapy induces less dramatic
relief (Cecil, JAMA., 1940. 114, 1443). In acute
rheumatic fever Coburn (Bull. Johns Hopkins
Hosp., 1943, 73, 435) reported excellent results
from doses of salicylates sufficient to maintain a
blood concentration of 30 to 50 mg. per 100 ml.
but Wegria and Smull (J. AM. A., 1945, 129, 485)
and others failed to confirm the shorter course of
the disease and the decreased incidence of endo-
cardial damage. With doses of 10 Gm. or more
daily, the danger of salicylism requires careful
observation of the patient. Salicylates increase
excretion of ascorbic acid (Samuels et al., J. Phar-
macol, 1940, 68, 465), but correction of the de-
ficiency permits continuation of therapy.

Acute intraocular inflammation such as uveitis
responds well to large doses of salicylates
(JAMA., 1920, 75, 725; 1939, 113, 928"). In
lumbago, pleurodynia and other myalgias, in cer-
tain inflammations of nerves such as sciatica, in
some instances of rheumatoid arthritis and osteo-
arthritis, and in the host of similar conditions
which, for want of better diagnostic acumen, we
are wont to call rheumatism, acetylsalicylic acid
is a valuable palliative drug.

Action on the Kidney. — A single dose of acetyl-
salicylic acid increases the renal excretion of uric
acid by 30 to 50 per cent and often decreases the
concentration of uric acid in the blood, an effect
probably due to a decrease in tubular resorption
of uric acid. This action persists on repeated ad-
ministration if the diet contains sufficient purines.
Hanzlik and Scott (Arch. Int. Med.. 1917, 20,
329) found albumin, with or without casts, and
red and white cells in the urine after doses of
more than 3 Gm. In salicylism. water retention
by the kidney, manifested by increase in body
weight but not by actual pitting edema, was also
described. In current experience, albuminuria and
other evidences of renal damage are extremely
rare even with doses of 6 to 10 Gm. dailv
(J.A.M.A., 1945, 128, 1195). In gout, acetyl'-
salicylic acid in large doses relieves the acute
attacks but is less effective than colchicum. It is

also less effective than cinchophen or probenecid
in the prevention of recurrent attacks in the course
of the disease (Hench, Proc. Mayo, 1937, 12,
262).®

Toxicology. Acetylsalicylic acid is not highly
toxic. Hopkins (Lancet, 1945, 1, 145) records 50
deaths in England in 5 years, a figure not unduly
large in view of the wide use of the drug and the
large doses sometimes employed (see also Green-
berg, New Eng. J. Med., 1952, 243, 124;. It is
frequently taken in very large doses with suicidal
intent but usually without success (J.A.M.A.,
1936, 107, 276; Ruttan, Can. Med. Assoc. J.,
1952. 67, 151). A single dose of 10 to 30 Gm. is
likely to be fatal although survivals after larger
doses and deaths from smaller ones have been
reported. Impaired renal function enhances the
toxicity. A total of 12 Gm. during 24 hours usu-
ally produces symptoms of salicylism such as
tinnitus, vertigo, impaired hearing and headache.
More severe manifestations include hyperpnea.
fever and acidosis and, less regularly, dimness of
vision, sweating, thirst, nausea, vomiting, diarrhea,
skin rashes, tachycardia, restlessness, delirium
and hallucinations. Salicylism may resemble dia-
betic or renal acidosis. In the worst cases, depres-
sion, stupor, coma, cardiovascular collapse, con-
vulsions and respiratory failure follow. Fatal cases
show diffuse endothelial damage with petechial
hemorrhage and congestion throughout the vis-
cera (Troll and Menton, Am. J. Dis. Child., 1945,
69,37).

Treatment. — Treatment of acute poisoning in-
volves the prompt removal of the unabsorbed
drug by gastric lavage and the administration of
30 Gm. of magnesium sulfate. Water and sodium
chloride are replaced parenterally and intravenous
glucose, one-sixth molar sodium r-lactate. and
vitamin K given as required. High fever should
be controlled with tepid sponges. Sedation may
be required for some patients; for others caffeine
or ephedrine are needed to overcome depression.

Complications. — Although most tests of liver
function show no abnormality, large doses of
salicylates may depress the prothrombin activity
of the blood (Smith, Lancet, 1951. 261, 569;
Field, Am. J. Physiol, 1949, 159, 40; Schaeffer.
/. Maine M. A., 1951, 42, 262). Hemorrhagic
tendencies following the use of acetylsalicylic acid
in post-tonsillectomv cases have been reported
(Jones, South. M. J ., 1949. 42, 124). Decreased
prothrombin activity may also be responsible in
part for the hemorrhagic manifestations of sali-
cylism and it may aggravate the hemorrhagic
tendencv of the rheumatic state (Clever-Howard.
Proc. S. Exp. Biol. Med., 1943. 53, 234). Hypo-
pro thrombinemia is prevented by simultaneous
administration of 1 mg. of menadione for each
1 Gm. of salicvlate (Shapiro. JAMA., 1944,
125, 546: Emerson. JAMA., 1952. 149, 348).

Large doses of acetylsalicylic acid frequently
lead to gastric distress. Sodium bicarbonate may
be used to alleviate this distress but it should be
pointed out that its use may decrease the blood
concentration of acetylsalicylic acid. Various
other buffering systems are used to alleviate this
distress, including aluminum dihydroxyamino-
acetate and magnesium carbonate, which is also

Part I

Acetylsalicylic Acid, Acetophenetidin and Caffeine Capsules 19

said to increase salicylate absorption from the
gastrointestinal tract (Paul, J. A. Ph. A., 1950,
39, 21; Tebrock, Ind. Med., 1951, 20, 480).

Allergy. — Idiosyncrasy to acetylsalicylic acid
is rare {Am. J. Med. Sc, 1940, 200, 390; and is
most frequently observed in asthmatics and espe-
cially in those with nasal polyps (J.A.M.A., 1937,
108, 445; Ann. Int. Med., 1947, 26, 734; Can.
Med. Assoc. J., 1951, 64, 187). The manifesta-
tions are urticaria, erythema, desquamative or
bullous or purpuric skin lesions, angioneurotic
edema, laryngeal stridor, asthma and peripheral
vascular collapse. These reactions are often seri-
ous and frequently fatal. Hypodermic or intra-
venous epinephrine is usually an effective treat-
ment. In milder cases antihistaminic drugs may
be useful. As a test for sensitivity, Duke advised
placing one-eighth of a tablet in the mouth; in
hypersensitive persons symptoms appear in one
minute and the rest of the tablet can be rinsed
from the mouth with water.

Dose. — The usual dose is 600 mg. (approxi-
mately 10 grains) by mouth every 4 hours, as
necessary, with a range of 300 to 900 mg. Ordi-
narily the maximum safe dose is 1 Gm. and it is
seldom that a total dose of more than 10 Gm. in
24 hours is employed. In acute rheumatic fever,
300 mg. to 1.3 Gm. (approximately 5 to 20 grains)
may be given every hour until a daily total of
about 10 Gm. has been given. Children tolerate
proportionately larger doses. Sodium bicarbonate
is often administered in equal amount with each
dose to lessen gastric irritation.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

ACETYLSALICYLIC ACID
CAPSULES. N.F.

Aspirin Capsules

"Acetylsalicylic Acid Capsules contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of C9H8O4." N.F.

Usual Size. — 5 gr. (approximately 300 mg.).

ACETYLSALICYLIC ACID TABLETS

U.S.P. (B.P., LP.)

Aspirin Tablets [Tabellae Acidi Acetylsalicylici]

"Acetylsalicylic Acid Tablets contain not less
than 95 per cent and not more than 105 per cent
of the labeled amount of C9H804." U.S.P. The
corresponding B.P. limits are 94.5 per cent and
105.0 per cent; the LP. limits are the same as
those of the U.S.P.

B.P. Tablets of Acetylsalicylic Acid. LP. Compressi
Acidi Acetylsalicylici. Sp. Tabletas de Acido Acetilsalicilico.

Assay. — A representative sample of tablets,
equivalent to about 500 mg. of acetylsalicylic
acid, is mixed with neutralized alcohol, cooled to
from 15° to 20°, and titrated with 0.1 N sodium
hydroxide T.S., using phenolphthalein T.S. as in-
dicator. In this titration the carboxyl group of
acetylsalicylic acid is neutralized, as well as any
acetic and salicylic acids that may be present. To
the mixture is added a volume of 0.1 N sodium
hydroxide equal to that used in the titration, plus
15 ml. more; the mixture is heated in a boiling

water bath for 15 minutes to convert the sodium
acetylsalicylate to sodium acetate and sodium
salicylate. After cooling the mixture to room tem-
perature the excess of alkali is titrated with 0.1 iV
sulfuric acid, using phenolphthalein T.S. as in-
dicator. A volume of 0.1 N sodium hydroxide
equal to that added the second time is then mixed
with the same volume of alcohol as used in the
test, diluted with water to the same volume and
heated for the same period of time, then titrated
with 0.1 N sulfuric acid. Each ml. difference in
the two titration figures corresponds to 18.02 mg.
of C9H.8O4, U.S.P.

The B.P. assay is essentially the same as the
B.P. employs for acetylsalicylic acid. The validity
of the assay is established by providing a limiting
test for salicylic acid.

Usual Sizes. — 1, 2% and 5 grains (approxi-
mately 60, 150 and 300 mg.).

ACETYLSALICYLIC ACID, ACETO-
PHENETIDIN AND CAFFEINE
CAPSULES. N.F.

Aspirin, Phenacetin, and Caffeine Capsules;
APC Capsules

"Acetylsalicylic Acid, Acetophenetidin and Caf-
feine Capsules contain not less than 90 per cent
and not more than 110 per cent of the labeled
amounts of acetylsalicylic acid (C9H8O4), aceto-
phenetidin (C10H13NO2), and caffeine (CsHio-
N4O2." N.F.

Assay. — For acetylsalicylic acid. — A chloro-
form solution containing all three active ingredi-
ents is shaken with a sodium bicarbonate solution,
which removes the acetylsalicylic acid. Sodium
hydroxide is added to the aqueous solution, which
is heated to hydrolyze the acetylsalicylic acid; the
resulting salicylate is determined by reaction with
a measured excess of 0.1 N bromine, in the pres-
ence of acid, which forms tribromophenol and
carbon dioxide. Excess bromine is estimated by
its releasing an equivalent amount of iodine, which
is titrated with 0.1 N sodium thiosulfate. The
equivalent weight of acetylsalicylic acid in this
reaction is one-sixth its molecular weight. For
acetophenetidin and caffeine. — The chloroform
solution remaining after extraction of acetylsali-
cylic acid is evaporated to dryness and the residue
of acetophenetidin and caffeine thus obtained is
weighed. The residue is dissolved in a small vol-
ume of alcohol, and a measured volume of water
is added to precipitate acetophenetidin, which is
removed by filtration. To a portion of the filtrate
a measured excess of 0.1 N iodine is added to
precipitate the caffeine; this precipitate is filtered
off and the excess iodine in a portion of the fil-
trate is titrated with 0.05 N sodium thiosulfate.
The equivalent weight of caffeine is one-fourth
its molecular weight, based on the formation of
C8H10N4O2.HI.I4. The weight of acetopheneti-
din is calculated by subtracting the weight of
caffeine found from the combined weight of
acetophenetidin and caffeine. N.F.

Uses. — Combinations of acetylsalicylic acid,
acetophenetidin and caffeine find wide usage as
analgetics. It would appear that inclusion of caf-
feine enhances the overall analgetic effect in clini-
cal usage, though it is difficult to evaluate the

20 Acetylsalicylic Acid, Acetophenetidin and Caffeine Capsules

Part I

effect quantitatively and it is not apparent what
the mechanism may be. Some clinicians do not
believe that caffeine contributes to the efficacy
of the preparation. For a discussion of the actions
and uses of the component drugs see the respec-
tive monographs for each.

Storage. — Preserve "in well-closed containers."
N.F.

ACETYLSALICYLIC ACID, ACETO-
PHENETIDIN AND CAFFEINE
TABLETS. N.F.

Aspirin, Phenacetin, and Caffeine Tablets; APC Tablets

"Acetylsalicylic Acid, Acetophenetidin and Caf-
feine Tablets contain not less than 90 per cent
and not more than 110 per cent of the labeled
amounts of acetylsalicylic acid (CoHsO.*), aceto-
phenetidin (C10H13NO2), and caffeine (CsHio-
N4O2)." N.F.

For assay and uses see the preceding mono-
graph.

Storage. — Preserve "in well-closed containers."
N.F.

Usual Size. — Tablets containing 180 mg. (ZYi
grains) of acetylsalicylic acid, ISO mg. (2y2
grains) of acetophenetidin, and 30 mg. (V2 grain)
of caffeine.

TABLETS OF ACETYLSALICYLIC
ACID AND PHENACETIN. B.P.

Tablets of Aspirin and Phenacetin, Tabellae Acidi
Acetylsalicylici et Phenacetini

The B.P. provides a formula from which tab-
lets, each containing 226.8 mg. (3j^ grains) of
acetylsalicylic acid and 162 mg. {2Yi grains) of
phenacetin, may be prepared. The content of
acetylsalicylic acid is required to be within the
limits of 94.5 to 105.0 per cent and that of phe-
nacetin within the limits of 95.0 to 105.0 per cent
of the amounts specified, respectively, by the
formula.

Tests and Assay. — The presence of acetyl-
salicylic acid is confirmed by chemical identifica-
tion tests, while that of phenacetin is established
by specifying that the melting point of the residue
obtained in the assay for phenacetin shall be
about 134°.

In the assay for acetylsalicylic acid a repre-
sentative sample of tablets is alkalinized with
sodium hydroxide solution and the phenacetin is
extracted with chloroform, which solution is set
aside. The acetylsalicylic acid in the aqueous
solution is completely hydrolyzed by heating the
alkaline solution and the resulting salicylic acid
determined by adding an excess of 0.1 N bromine,
which forms tribromophenol and carbon dioxide;
the excess of bromine is measured through release
of an equivalent amount of iodine, which is
titrated with 0.1 TV sodium thiosulfate. The
equivalent weight of acetylsalicylic acid in this
assay is one-sixth of its molecular weight, since
three molecules of bromine react with a molecule
of salicylic acid. To assay for phenacetin the
chloroform solution set aside in the preceding
assay is evaporated to dryness and the residue
of acetophenetidin weighed after drying at 105°.
B.P.

This is a popular analgesic combination for
which the B.P. gives the dose as 1 or 2 tablets.

TABLETS OF ACETYLSALICYLIC

ACID WITH IPECACUANHA

AND OPIUM. B.P.

Tablets of Aspirin and Dover's Powder, Tabellae Acidi
Acetylsalicylici cum Ipecacuanha et Opio

The B.P. provides a formula from which tab-
lets, each containing 162 mg. {2]/2 grains) of
acetylsalicylic acid and 162 mg. (2y2 grains) of
Powder of Ipecacuanha and Opium, may be
prepared. The content of acetylsalicylic acid is
required to be within the limits of 94.5 to 105.0
per cent of the amount of that substance speci-
fied, and that of anhydrous morphine, C17H19-
NO3, within the limits of 0.90 to 1.10 per cent
of the amount of powder of ipecacuanha and
opium specified by the formula.

Tests and Assay. — Identification tests for
the several constituents are provided. In the
assay for acetylsalicylic acid a representative
portion of the powdered tablets is heated with
dilute sulfuric acid, which effects hydrolysis of
the aspirin to acetic and salicylic acids. The latter
is extracted with ether, which is then extracted
with a sodium hydroxide solution, and the sali-
cylic acid finally determined as explained in the
assay for Tablets of Acetylsalicylic Acid and
Phenacetin. An assay for morphine is performed
by the method employed in the assay for Powder
of Ipecacuanha and Opium. B.P.

This combination is employed as an anti-
pyretic in the treatment of acute febrile condi-
tions; the dose is 1 or 2 tablets.

ACONITE. N.F. (LP.)

Aconite Root, Monkshood, Aconiti tuber, [Aconitum]

"Aconite is the dried tuberous root of Acotiitum
Napellus Linne (Fam. Ranunadacece) . The po-
tency of Aconite is such that 100 mg. possesses
an activity equivalent to not less than 150 meg.
of Reference Aconitine." N.F. The LP. requires
Aconite Root to contain not less than 0.6 per cent
of the alkaloids of aconite, of which not less than
30 per cent consists of aconitine.

LP. Aconiti Tuber; Aconite Root. Wolfsbane; Friar's
Cap; Blue Rocket. Aconiti Tuber; Tubera Aconiti; Radix
Aconiti. Fr. Aconit napel ; Coqueluchon. Ger. Eisenhut-
knollen; Aconitknollen; Fuchswurz; Monchswurz; Wolfs-
wurzel. It. Aconito. Sp. Tuberculo de aconito; Raiz de
aconito.

The name Aconite is derived, according to
Pliny, from the ancient Black Sea port, Aconis.
Some species of aconite was used by the ancient
Chinese as well as by the hill tribes of India.
While the physicians of Myddvai indicated the
importance of aconite as a remedy during the 13th
century, it was introduced into modern medicine
by Storck, of Vienna, in 1763. The drug was ad-
mitted into the London Pharmacopoeia in 1788
and into the first U.S. P. The genus Aconitum is
a relatively large one. there being some sixty well-
defined species, nearly half of which have been
used in medicine. The species which is official and
recognized by nearly all the pharmacopoeias is
Aconitum Napellus. It is indigenous to the moun-
tainous regions of Middle Europe and is found

Part I

Aconite

growing in the Alps, Pyrenees and mountainous
districts of Germany, Austria, Denmark, Sweden
and Siberia, its range extending eastward to the
Himalayas. It is not found in India, according to
Dutt, the nearest approach to it there being
A. soongariciim Stapf. The pure species occurs
wild in North America as an escape from cultiva-
tion. The most nearly related American plant is
the variety delphinifolium Ser. which occurs from
Alaska to British Columbia. Varieties and sub-
species of A. Napellus are extensviely cultivated
in temperate climates for their foliage and flowers.
There are about twenty species of Aconitum
which are indigenous to the mountainous regions
of the United States, three of which occur in the
eastern section, the remainder being distributed in
the west, chiefly in the Rocky Mountains.

Aconitum Napellus is a perennial herb attain-
ing a height of 0.7 to 1.5 meters, with a fusiform
to conical tuberous root, seldom exceeding 10 cm.
in length and 2 cm. in thickness near the summit,
brownish externally, whitish and fleshy within,
and sending forth numerous long, thick, fleshy
rootlets. When the plant is in full growth, there
are usually two or three roots joined together by
short shoots from axillary buds at the base of the
stem, of which the oldest is dark brown, fusi-
form, wrinkled, and supports the stem, while the
youngest is of a light yellowish-brown color and
conical shape and is destined to furnish the stem
of the following year, the old root decaying. The
stem is erect, round, smooth and leafy. The
leaves are alternate, petiolate, with suborbicular,
subcordate to broadly ovate, palmately 5- to 7-
parted to divided blades, from two to four inches
in diameter, deep green upon their upper surface,
light green beneath, somewhat rigid, and more or
less smooth and shining on both sides. Those on
the lower part of the stem have long petioles and
five or seven divisions; the upper, short petioles
and three or five divisions. The divisions are
wedge-form, with two or three lobes, which ex-
tend nearly or quite to the middle. The lobes are
cleft or toothed, and the lacinice or teeth are
linear or linear-lanceolate and pointed. The flowers
are of a dark violet-blue color, large and beauti-
ful, and are borne at the summit of the stem
upon a thick, simple, straight, erect, spike-like
raceme, beneath which, in the cultivated plant,
several smaller racemes arise from the axils of
the upper leaves. There are 2 lanceolate bracts
beneath each pediceled flower. The sepals are five,
the upper helmet-shaped and beaked, nearly hemi-
spherical, open or closed, the two lateral roundish
and internally hairy, the two lower oblong-oval.
They enclose 2 distinct, hammer-like, nectarif-
erous petals which are covered by the hood of
the posterior sepal. The stamens are numerous
and hypogynous. The carpels are 3 to 4 with
bilobed stigma.

The fruit consists of 3 to 4 beaked follicles.
The seeds are angular, wrinkled and very acrid.
They rapidly lose their germinating power upon
drying and storing and are for the greater part
non-viable after a year.

A number of subspecies, varieties and hybrids
of A. Napellus are abundant in the alpine mead-
ows and mountain forests of France, Switzerland,

and Germany. Many of these are cultivated in
the gardens of Europe, and have been introduced
into this country as ornamental plants. All parts
of the plants are acrid and poisonous. The leaves
and flowering tops (Aconiti Folia) were formerly
used but only the root is now official. The fresh
leaves have a faint narcotic odor, most sensible
when they are rubbed. Their taste is at first bitter
and herbaceous, afterward burning and acrid,
with a feeling of numbness and tingling, on the
inside of the lips, tongue, and fauces, which is
very durable, lasting sometimes many hours. The
root is much more active than the leaves; an
extract from the latter is said to have only one-
twentieth of the strength of one made from the
former. It should be gathered in autumn or winter
after the leaves have fallen, and is not perfect
until the second year. It has been mistakenly sub-
stituted for horseradish root, as a condiment,
with fatal effects. The studies of P. W. Squire
seem to show that in the autumn the root is the
most active. But the practical difficulty is that the
root of A. paniculatum Lam. cannot be distin-
guished by the ordinary collector from that of
A. Napellus, except by taste; so that the custom
of gathering the root about the flowering period
is probably well founded.

Aconite root is collected chiefly from plants,
representing subspecies and varieties of A. Napel-
lus, growing wild in the cool mountainous re-
gions of Germany, Hungary, Switzerland, Spain
and France. The tuberous roots are dug up in
autumn, washed and carefully dried. The total
imports of this drug into the United States in
1952 were 4470 pounds, the suppliers being Italy
and Spain.

Commercial aconite root shows considerable
variation and is usually a mixture of six or seven
different kinds of tubers, as follows: 1. Single
fleshy tubers which are smooth, light brown and
full of starch. 2. Single tubers which are single,
somewhat elongated fusiform, crowned with short
stems, dark brown and longitudinally furrowed.
3. Twin or triplet tubers, one of two of which
(daughter tuber or tubers) being bud-crowned
and the other (parent tuber) having a short stem
at the summit. 4. Very small single tubers usually
crowned with stems, the lower portion being acute
or pointed. 5. Single tubers which are almost cyl-
indrical, crowned with stems and either fleshy and
nearly smooth or more or less shrunken and fur-
rowed. 6. Dark brown resinous tubers. 7. Frag-
ments of small and nearly filiform roots.

The root has a feeble earthy odor. Though
sweetish at first, it has afterward the same effect
as the leaves upon the mouth and fauces. It
shrinks much in drying, and becomes darker, but
does not lose its acridity.

Description. — "Unground Aconite occurs as a
more or less conical root, from 4 to 10 cm. in
length, and from 1 to 3.5 cm. in diameter at the
crown; externally weak brown to moderate brown,
smooth or longitudinally wrinkled, the upper end
with a bud, or remains of bud-scales and stem-
scar. The other portions possess numerous root-
scars or short rootlets. The fracture is short,
horny, or somewhat mealy; and the internal color
is yellowish white through very pale orange to

Aconite

Part I

moderate yellowish brown. The bark is 1 to 2 mm.
in thickness, and the cambium zone is usually
5- to 8-angled. Aconite has a very slight odor and
a sweet taste soon becoming acrid and developing
a tingling sensation, followed by numbness."
N.F.X. For histology see N.F.X.

"Powdered Aconite is pale brown to weak yel-
lowish orange. Starch grains are numerous, spheri-
cal, somewhat planoconvex, single or 2- to 5-com-
pound, the individual grains from 3 to 20 jx in
diameter and frequently with a central cleft;
vessels mostly with slit-like, simple pits, some-
times with spiral or reticulate thickenings or with
bordered pits; stone cells single, or in small
groups, tabular, irregular, rectangular, or elon-
gated in shape, from 100 to 400 n in length, walls
strongly lignified and having simple pores. Also
present are a few fragments of cells with brown-
ish or yellowish walls; numerous fragments of
parenchyma, the cells of which are filled with
starch grains. Fibers from stems are few, very
long, with lignified walls and marked by trans-
verse or oblique, slit-like pits." N.F.

Standards and Tests. — Aconite contains not
more than 5 per cent of its stems and not more
than 2 per cent of foreign organic matter, other
than stems. N.F.

Assay. — The N.F. directs that a tincture of
the drug shall be prepared and assayed as directed
under Aconite Tincture. The studies of Wolff e
and Munch, described under Uses, cast doubt on
the reliability of this bioassay as an evidence of
the therapeutic value. Hoppe and Mollett (/. A.
Ph. A., 1943, 32, 215), investigating the assay
technic of Rowe in which white mice are used
instead of guinea pigs, reported results having a
standard error of approximately one per cent. A
biological assay method for aconite tincture, em-
ploying intravenous injections in mice and com-
paring the LD50 doses of a reference standard
aconitine solution and of dilutions of the tincture
under test, has been developed by Barr and
Nelson (/. A. Ph. A., 1949, 38, 518); the stand-
ard error of a series of assays was found to be
less than 2 per cent. A method based on the mini-
mum dose necessary to produce emesis in pigeons
has been suggested by Christensen and Nelson
(/. A. Ph. A., 1940, 29, 97).

The LP. assay for total alkaloids specifies ex-
traction of the alkaloids by macerating the pow-
dered drug with ether in the presence of ammonia;
an aliquot portion of the ether solution is evapo-
rated to dryness, and the residue titrated with
0.1 N hydrochloric acid in the presence of methyl
red and methylene blue as a mixed indicator.
Each ml. of 0.1 N hydrochloric acid represents
64.5 mg. of total alkaloids, calculated as aconitine.
The determination of the proportion of aconitine
is based on the residual titration, with 0.01 N
sodium hydroxide and 0.01 N hydrochloric acid,
of the benzoic acid obtained from this alkaloid
upon alkaline hydrolysis.

A chemical assay for aconite described by
Bronkhorst (Pharm. Weekblad, 1935, 72, 1056) is
based on hydrolysis of the alkaloids and estima-
tion of the liberated acids. The method distin-
guishes aconitine, benzoylaconine, and aconine.
Baker and Jordan (/. A. Ph. A., 1936, 25, 291)

suggested a method of analysis which takes ad-
vantage of the difference in basic dissociation
constants of aconitine and benzoylaconine, the
latter being a stronger base. Other assay methods
have been suggested by Schulze (Apoth.-Ztg.,
1933, 48, 94) and Neugebauer {Pharm. Zgt., 1933,
78, 1077).

Constituents. — Aconitum Napellus contains
several alkaloids, though there seems to be some
disagreement as to their identity.

Aconitine is the most important alkaloid of the
official drug. First isolated by Peschier in 1820,
apparently in an impure form, it was first obtained
in a crystalline state by Groves in 1860. There
has been much discussion regarding the empirical
formula for aconitine, but C34H47NO11 is now
generally accepted; it is acetylbenzoylaconine.

The alkaloid melts between 192° and 196° (with
decomposition), is dextrorotatory, crystallizes in
rhomic prisms, is soluble in chloroform and in
benzene, less soluble in ether and in alcohol,
and almost insoluble in water and in petroleum
ether. It forms well-crystallized salts which are
laevorotatory.

Aconitine is precipitated from its solution by
caustic alkalies, but not by ammonium carbonate,
nor by potassium or sodium bicarbonate. It is
easily hydrolyzed by acids or alkalies. In general,
it has the incompatibilities characteristic of
alkaloids.

Many facts are known concerning the structure
of aconitine, but it has not yet been fully eluci-
dated. The molecule contains four methoxyl
groups, three hydroxyl groups, and an ethylimino
group. On hydrolysis by water under pressure, or
by boiling with dilute acid, a molecule of acetic
acid and one of benzoylaconine are produced;
hydrolysis by alkalies releases both acetic and
benzoic acids and yields aconine. Outstanding
contributions to knowledge of the structure of
aconitine have been made by Majima (Ann.
Chem., 1936, 526, 116), Freudenberg (Ber., 1937,
70B, 349) and Suginome (Ann. Chem., 1937, 533,
172). For further information see Henry's Plant
Alkaloids (1949), p. 674.

Benzoylaconine, also known as benzaconine,
isaconitine, and pier aconitine, accompanies aconi-
tine in A. Napellus. Its empirical formula is
C32H45NO10, and it is formed by the elimination
of the acetyl group from aconitine. The base melts
at 130°, is dextrorotatory, but forms crystalline
salts which are levorotatory. Its toxicity is less
than that of aconitine and it appears to differ
somewhat in the type, as well as in the degree, of
its physiological action.

Aconine results from the hydrolysis of aconitine
by alkali, but also occurs naturally in A. Napellus.
It represents aconitine deprived of its acetyl and
benzoyl groups, and has the formula C25H41NO9.
It melts at 132°, is dextrorotatory, and likewise
yields crystalline salts which are levorotatory.
Aconine behaves as a cardiac stimulant and is
antagonistic to aconitine.

The alkaloid neopelline, C28H330s(OCH3)3-
(NCH3).3H20, was isolated by Schulze and
Berger (Arch. Pharm., 1924, 262, 553) from com-
mercial "amorphous aconitine." It is amorphous;
on alkaline hydrolysis acetic and benzoic acid

Part I

Aconite

are eliminated and neoline, C23H39NO6, is formed.
The latter base is given the formula C24H11NO6
by Freudenberg and Rogers (J.A.C.S., 1937, 59,
2572) and said to be normally present in A. Napel-
lus. The latter authors isolated the new alkaloid
napelline, C22H33NO3, and found sparteine and
/-ephedrine in amorphous acontine from A. Napel-
lus. For an informative historical review on the
chemistry of aconite see the article by Husa in
A. Ph. A. Monograph No. 1, 1938, on Aconite.

Alkaloids from other species of Aconite.
— The alkaloids of Aconitum are mainly of two
kinds: (1) aconitines, which are di-acyl esters of
a series of polyhydric, amino-alcohols (aconities)
and are highly toxic, and (2) the atisines, which are
polyhydric amino-alcohols and of low toxicity.

Some of the more toxic aconitines include
pseudaconitine, from A. deinorrhizum and A. Bal-
fourii (India) ; japaconitine, from A. uncinatum
(Japan); indaconitine, from A. chasmanthum
(India) ; and bikhaconitine, from A. spicatum
(India). The group of less toxic alkaloids in-
cludes atisine from A. heterophyllum and palm-
atisine from A. palmatum. For a complete list of
aconite alkaloids and their distribution among the
species, see Henry {Plant Alkaloids, 1949).

Many, probably all, species of aconite contain
one or more alkaloids. While most of these alka-
loids are poisonous, there is not sufficient evidence
that their physiological action is the same as that
of the official drug. It is therefore imperative
that none of the other species be employed as a
substitute for the official aconite; the fact that
they may show a similar degree of toxicity on
bio-assay provides no assurance of similarity of
action, for the method of assaying aconite gives
no indication of how it acts, only the amount re-
quired to kill.

For a description of other aconite species see
U.S.D., 24th ed., p. 22.

Uses. — Aconite is not widely used in the
United States. The pharmacologic action of its
chief alkaloid, aconitine, is stimulating and then
depressing on the central and peripheral nervous
system and resembles that of protoveratrine in
some respects. On the cardiovascular system the
action suggests that of quinidine. Topically, it is
a counterirritant.

History. — Aconite was well known to the an-
cients as a powerful poison; it appears to have
been used as an arrow poison early in Chinese
history and perhaps also by the inhabitants of
ancient Gaul. It is the basis of the legend of the
"love poison" according to which the victim could
be poisoned by sexual contact with a woman who
had been fed aconite daily since infancy (Bull.
Hist. Med., 1944, 15, 420). Although mentioned
in the Meddygon Myddfai, published in Wales in
the 12th century, it was introduced into regular
medicine by Baron Storck of Vienna, whose ex-
periments were published in the year 1762. Geiger
(Annaien d. Pharm., 1834, 7, 269) described
aconitine.

Action. — Locally aconite is actively irritant
and also a paralyzant to the peripheral sensory
nerves. When applied to a mucous surface it pro-
duces at first a burning, tingling sensation followed
in a few minutes by a numbness. This sensation

may even be perceptible after the systemic in-
gestion of large doses. When administered inter-
nally the first effect is generally a slowing of the
pulse due to stimulation of the cardio-inhibitory
centers, with consequent fall in the blood pressure
and usually some slowing of respiration. With
large doses, in the lower animals, the slow pulse
suddenly becomes irregular and rapid with further
fall of the blood pressure. These irregularities
are apparently due to excitation of heteropic (mis-
placed) impulses in the heart (Hueber and Lehr,
Arch. exp. Path. Pharm., 1938, 189, 25). The
heart becomes more and more irregular and even-
tually passes into ventricular fibrillation (Tripod,
Arch, internat. pharmacodyn. therap., 1951, 85,
121), which is antagonized by a-fagarine or pro-
caine in the isolated mammalian heart. According
to Hueber and Lehr, magnesium antagonizes these
cardiac irregularities. Aconite increases the toxic
effects of calcium and digitalis on the heart.

Wolffe and Munch (/. Pharmacol., 1934, 51,
471) believe that the cardiac arrhythmia is due
to the aconitine; they report that aconine will
slow the pulse but not cause irregularities. There
is apparently great variability in the potency of
aconite; thus Wolffe (4. Ph. A. Monograph No. 1,
1938) gave from 20 to 60 drops of an official tinc-
ture to a number of patients with no apparent
effect. Wolffe and Munch believe that the con-
stituents of aconite that are not toxic to guinea
pigs when tested by the official assay — chiefly
aconine — may be the therapeutically desirable
substances. Such constituents result from the
hydrolysis of aconitine; hence such a preparation
as aconite tincture may be of greater value when
it has been allowed to stand long enough for the
aconitine to have been hydrolyzed, which effect,
paradoxically, is accompanied by diminished po-
tency as measured by the guinea pig assay. This
may account for the reports, from many practi-
tioners, of good clinical results obtained from an
old aconite preparation which had decomposed on
standing.

In the frog, large quantities of aconite produce
a loss of reflex activity, which is apparently due to
a paralysis of sensation as voluntary motion is
preserved for some time later, although it too may
eventually be abolished. The drug appears to
affect both the sensory nerves and the receptive
side of the spinal cord, although the latter is in-
volved comparatively late in the poisoning.

Therapeutic Use. — Aconite was formerly used
in the treatment of febrile complaints ; any benefit
it may have exerted is attributable to the lower-
ing of blood pressure, which tends to promote
sweating. It has been used to reduce overaction
of the heart, especially in the absence of organic
lesions, and occasionally to reduce high blood
pressure. The variability of its potency and the
closeness of its therapeutic and toxic closes have
been responsible, in large measure, for its decline
as a therapeutic agent.

Aconite was formerly employed for its local
irritant effect and anesthetic action in peripheral
neuralgias; if used too freely for this purpose it
may be absorbed through the skin in sufficient
quantity to cause serious poisoning. It has been
employed as a local anesthetic for the stomach in

Aconite

Part I

various types of vomiting or gastralgia but be-
cause of its systemic effect is no longer thus used.

For internal use the tincture (q. v.) is employed.
As a febrifuge this was formerly given in a dose
of 0.12 ml. every 10 minutes for an hour, then
every hour until the fever subsided. For external
application the fluidextract (N.F. IX) has been
employed but an ointment was generally pre-
ferred. This may be prepared by incorporating
the fluidextract in 2 or 3 parts of lard or other
base. Aconite and Chloroform Liniment, official
in N.F. VIII, was prepared by mixing 45 ml. of
aconite fluidextract, 80 ml. of alcohol, 125 ml. of
chloroform, and 750 ml. of camphor and soap
liniment; it was once a popular counterirritant
liniment. The U.S. P. 1870 recognized a plaster of
aconite. S

Toxicology. — Aconite is a rapidly acting and
powerful poison (Hartung, J.A.M.A., 1930, 95,
1265). The symptoms produced by an overdose
of it are sensations of warmth in the stomach,
sometimes with nausea but usually without vomit-
ing, slowing of the pulse and of the respiration;
the skin is cool and moist, and there is profound
prostration. As the poisoning progresses the res-
pirations become more slow and shallow, the pulse
becomes increasingly feeble, and toward the end
rapid or very irregular. The only symptom of
diagnostic importance is the characteristic numb-
ness and tingling first felt in the lips and mouth,
but later often also in the fingers. At times there
is dimness of vision, the pupils may be either con-
tracted or dilated, and occasionally delirium and
stupor or convulsions may precede the fatal
termination. Death, from cardio-respiratory fail-
ure, occurs in Yz to 6 hours. As little as 5 ml. of
the tincture may cause death. Poisoning has re-
sulted from mistaking aconite for other plants,
such a horse radish.

In the treatment of aconite poisoning the pa-
tient should be kept absolutely in a horizontal
position, or with the feet higher than the head.
If respiration is depressed, oxygen is indicated;
artificial respiration may be needed. Gastric lavage
is preferable to emetics as the latter cause strain
upon the circulation. Hatcher (J.A.M.A., 1935,
105, 502) recommended potassium permanganate
as a chemical antidote. Hueber and Lehr (loc.
cit.) and Mladoveanu (Arch, internat. pharm.,
1939, 63, 494) suggested parenteral use of mag-
nesium sulfate to antagonize the cardiac effects
in aconite poisoning. Hartung (Arch. exp. Path.
Pharm., 1912, 69, 176) demonstrated experi-
mentally the value of atropine. Other circulatory
stimulants, such as strychnine or ammonia, may
also be used. Body temperature should be main-
tained by external application of heat. Bar-
biturates may be used to control convulsions.

Dose, of aconite root, 30 to 60 mg. (approxi-
mately y2 to 1 grain). A dose of 150 mg. in 24
hours should seldom be exceeded.

ACONITE TINCTURE. N.F. (LP.)

[Tinctura Aconiti]

"Aconite Tincture possesses a potency per ml.
equivalent to 150 meg. of Reference Aconitine."
N.F. The LP. Tincture of Aconite contains 0.045

to 0.055 per cent w/v of total alkaloids, of which
not less than 30 per cent consists of aconitine.

Tincture of Aconite Root. Fr. Teinture d'aconit (racine).
Ger. Eisenhuttinktur. It. Tintura di aconito. Sp. Tintura
de aconito.

Prepare the tincture from 100 Gm. of aconite,
in fine powder, by Process P as modified for
assayed tinctures (see under Tinctures), using a
menstruum of 3 volumes of alcohol and 1 volume
of water. Macerate the drug during 24 hours,
then percolate at a rapid rate. Adjust the pH of
the percolate to 3 ± 0.2, using hydrochloric acid;
after assaying the liquid, dilute it to the required
potency, including sufficient acid to maintain the
specified pH. The official formula produces ap-
proximately 1000 ml. of tincture. N.F.

The adjustment of the reaction of this tincture
is based on the finding of Swanson and Har-
greaves (/. A. Ph. A., 1927, 16, 296), confirmed
by Haag and Hawkins (J. A. Ph. A., 1930, 19,
1284), that deterioration of the tincture (as meas-
ured by the official assay — but see under Uses of
Aconite) is in large measure prevented by adjust-
ing it to a pH of 2.5 to 3.0. Hydrochloric acid was
used for the acidification.

Assay. — Opinion as to the relative merits of
chemical and biological assay of aconite is di-
vided, as is apparent from the number of methods
of both types which have been proposed, some of
which are described in the monograph on Aconite.
The N.F. employs a biological method of assay.

The first of the biological methods to have been
used for testing aconite — in fact probably the
oldest of all biological methods of standardizing —
was that suggested by Dr. E. R. Squibb, this being
based upon an observation of the characteristic
effects of aconite on peripheral sensory nerve end-
ings. The principle of the method consisted in
determining the lowest dilution in which a given
sample taken into the mouth of the experimenter
produced the first perceptible degree of tingling
in the tongue. The method was carried out as fol-
lows : After rinsing the mouth with distilled water,
4 ml. of an aqueous solution, representing one
part of aconite root to 600 parts of water, was
taken into the anterior part of the mouth and held
there for one minute and then expelled. If the
drug was of standard quality there resulted in a
few minutes a characteristic sensation, too slight
to properly be called tingling and yet closely allied
to it. If, at the end of fifteen minutes, there was
no distinct sensation the drug was considered to
be below standard and stronger solutions were
tested in the same manner. On the other hand, if
it produced a sharp, distinct tingling it was
stronger than normal and less concentrated solu-
tions were tested. It is evident that personal sus-
ceptibility played a considerable part in this
method and it was necessary for the experimenter
to standardize himself by determining his sensi-
tiveness toward a sample of known potency.
Even then, the test was hardly more than of
qualitative value.

The second method, adopted as the N.F. assay,
is based on a comparison of the toxicity of a
known dilution of the tincture with a standard
solution of reference aconitine. Guinea pigs weigh-

Part I

Acriflavine

ing between 250 Gm. and 350 Gm., but not dif-
fering by more than 50 Gm. in weight and all
from the same colony of pigs, are used in the
assay. Injections of the diluted aconite tincture,
and of the reference aconitine solution, are in-
jected under the skin of the abdomen of the guinea
pigs; the experiment consists in determining the
dose of each preparation which will kill not more
than 7 and not less than 3 animals of groups of 10
animals used for each solution, within 6 hours.
When the respective mortalities from the refer-
ence standard and the preparation being assayed
differ by not more than 2 animals the doses may
be considered equivalent and a comparison of
relative potencies of the preparations made. The
N.F. states, however, that "owing to many vari-
able factors in this assay which make it difficult
for different operators to obtain identical results,
the evidence of potency within 20 per cent above
or 20 per cent below the standard is accepted."
For other methods of assay see under Aconite.

Alcohol Content. — From 65 to 70 per cent by
volume of C2H5OH. N.F.

There was formerly employed in the United
States, and at one time recognized by the N.F.,
a preparation known as Fleming's Tincture of
Aconite, which represented 70 per cent of aco-
nite root.

Uses. — For discussion of uses of aconite, in-
cluding the tincture, see the preceding monograph.
At one time aconite tincture was a popular prep-
aration but the variation in its potency and the
uncertainty of its action have materially limited
its use.

Dose, 0.3 to 1 ml. (approximately 5 to 15
minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight or
to excessive heat." N.F.

ACONITINE.

Aconitinum

LP.

The LP. defines aconitine as acetylbenzoylaco-
nine, and requires it to contain not less than 99.0
per cent of C34H47NO11.

Aconitine is usually obtained from Aconitum
Napellus. In one of the several extraction proce-
dures which may be used the drug is exhausted
with methanol containing 1 per cent of tartaric
acid. The extract is concentrated, diluted with
several volumes of water, and treated with pe-
troleum ether to remove fatty impurities. The
aqueous solution is then alkalinized with ammonia
and the total alkaloids extracted with ethyl or
isopropyl ether, or with benzene or toluene. From
this solution the alkaloids are extracted with small
volumes of 36 per cent hydrobromic acid; on
cooling this solution aconitine hydrobromide
crystallizes, particularly if some ammonium bro-
mide is added. Instead of using hydrobromic acid,
a 10 per cent solution of hydrochloric acid may
be used; to this is added sodium iodide to pre-
cipitate the aconitine as hydriodide.

For information concerning chemical charac-
teristics of aconitine see Constituents, under
Aconite.

Description. — Aconitine occurs in colorless

crystals or as a white, crystalline powder; it is
odorless; a sensation of tingling, free from bit-
terness, is produced by as small a quantity as
6 micrograms placed on the tongue (the alkaloid
is extremely poisonous!). Aconitine dissolves in
about 4500 parts of water, in about 40 parts of
ethanol (90 per cent), in about 70 parts of ether,
in about 2800 parts of petroleum ether, and in
about 10 parts of benzene; it is very soluble in
chloroform. It melts between 192°and 196°, with
decomposition. LP.

Standards and Tests. — Identification. — An
aqueous solution, made slightly acid with acetic
acid, yields a colorless, well-crystallized pre-
cipitate upon addition of potassium iodide T.S.
Pseudoaconitine. — A yellow residue is produced
on moistening aconitine with fuming nitric acid
and evaporating to dryness on a water bath; on
moistening the residue with a freshly-prepared
10 per cent (w/v) solution of potassium hydrox-
ide in alcohol no purple color is produced. LP.

Assay.— About 300 mg. of aconitine is dis-
solved in 10 ml. of 0.1 N hydrochloric acid and
the excess acid is titrated with 0.1 A7 sodium
hydroxide, using methyl red as indicator. Each
ml. of 0.1 N hydrochloric acid represents 64.6 mg.
of C34H47NO11. LP.

Uses. — While aconitine was long ago deleted
from both the U.S. P. and the B.P. it maintains a
degree of popularity in some European and South
American countries for which reason, apparently,
it is included in the LP.

In neuralgia aconitine is applied externally in
the form of a 2 per cent ointment; the alkaloid
is dissolved in 8 parts of oleic acid and this solu-
tion is incorporated in an ointment base, gener-
ally lard. A 2 per cent solution of aconitine in
oleic acid is employed for the same purpose.
Care must be observed in applying these prepara-
tions to avoid contact with mucous membranes
or raw skin.

Aconitine is sometimes given internally for its
diaphoretic and depressant effect, but such use
may be dangerous because of the powerful cardiac
action of the drug (see Uses, under Aconite).

The average dose of aconitine is 0.1 mg. (ap-
proximately %40 grain) ; doses up to 0.3 mg. (ap-
proximately %oo grain) are sometimes given,
which in very rare instances have been cau-
tiously increased to a single dose of 1 mg. (ap-
proximately Vm grain).

Storage. — Preserve in a well-closed container,
protected from light. LP.

ACRIFLAVINE. N.F.

Acriflavine Base, Neutral Acriflavine, [Acriflavina]

"Acriflavine is a mixture of 3,6-diamino-10-
methylacridinium chloride and 3,6-diaminoacri-
dine containing, when dried at 105° for 2 hours,
not less than 13.3 per cent and not more than 15.8
per cent of CI." N.F.

Trypaflavine {Delta) ; Gonacrine; Neutroflavine; Eufla-
vine. Acridinum Hydrochloricum. Fr. Chlorhydrate de
diaminoacridine.

Derivatives of acridine have long been em-
ployed in the dye industry, "acridine yellow"
having been first marketed in 1889. In 1896
Tappeiner, because of the similarity in the struc-

Acriflavine

Part I

ture of acridine and quinoline, made some experi-
ments on the antimalarial activity of acridine de-
rivatives, which, however, were not encouraging.
It was not until 1912 when Benda introduced
diamino-acridinium-methyl-chloride, which Ehrlich
(Ber., 1913, 46, 1931) showed to be definitely
trypanocidal, that acridine dyes became of medici-
nal importance. Since then a number of com-
pounds chemically related to acriflavine have been
used.

Acriflavine is sometimes called acriflavine base
or neutral acriflavine but this designation is hardlv
correct, for Collins (/. A. Ph. A., 1929, 17, 659)
showed that in aqueous solution the pH is be-
tween 3 and 5 ; that is, it is distinctly acid.

The preparation of acriflavine involves a series
of reactions which may be summarized as fol-
lows: Aniline and formaldehyde undergo inter-
action to form 4,4-diaminodiphenylmethane; this
is nitrated to 2,2'-dinitro-4,4'-diaminodiphenyl-
methane and the latter is reduced with tin and
hydrochloric acid to form the stannichloride of
3,6-diaminoacridine; after acetylation of the
amino groups, the nitrogen atom in the ring is
methylated by the use of methyl ^-toluenesulfon-
ate and the acetyl groups are subsequently re-
moved by heating with hydrochloric acid.

The preparation of pure acriflavine from com-
mercial samples containing much diaminoacridine
may be achieved by treatment with sodium hy-
droxide and subsequent recrystallization.

Description. — "Acriflavine occurs as a deep
orange, odorless, granular powder. Solutions of
Acriflavine are reddish orange in color and become
fluorescent on dilution. One Gm. of Acriflavine dis-
solves in about 3 ml. of water. It is incompletely
soluble in alcohol, is nearly insoluble in ether, in
chloroform, and in fixed oils." N.F.

Standards and Tests. — Identification. — (1)
On adding a few drops of hydrochloric acid to a
solution of acriflavine that has been diluted until
it just exhibits fluorescence the fluorescence dis-
appears but reappears partially on dilution with
distilled water. (2) A reddish-orange crystalline
precipitate is formed on adding 2 drops of sulfuric
acid to 1 ml. of a 1 in 250 aqueous solution of
acriflavine. (3) No effervescence results on mix-
ing equal volumes of a solution of acriflavine with
a saturated solution of sodium bicarbonate (acri-
flavine hydrochloride does produce an efferves-
cence). Loss on drying. — Not more than 8 per
cent, when dried for 2 hours at 105°. Residue on
ignition. — Not over 35 mg. from 1 Gm. of acri-
flavine ignited with 1 ml. of sulfuric acid. Water-
insoluble substances. — Not over 0.5 per cent.
Arsenic. — 200 mg. of acriflavine meets the re-
quirements of the test for arsenic, corresponding
to a limit of 10 parts per million. N.F.

Assay for Chlorine. — A sample of about 250
mg. of acriflavine, previously dried for 2 hours
at 105°, is dissolved in water and heated with a
solution containing silver nitrate, sulfuric acid
and potassium permanganate to precipitate silver
chloride while oxidizing the remainder of the acri-
flavine molecule. The precipitate is filtered on a
Gooch crucible, washed first with 1 in 3 nitric
acid, then with distilled water, and dried to con-

stant weight at 105°. Each Gm. of silver chloride
represents 247.4 mg. of CI. N.F.

For an account of therapeutic properties see
under Acriflavine Hydrochloride. For intravenous
injection the "acriflavine base" is preferable to
the hydrochloride because of its lower acidity.
The beginning dose which has been used is about
100 mg. (approximately \l/i grains) administered
intravenously once a day, which may be cautiously
increased, bearing always in mind the possible
injurious effects on the liver.

Storage. — Preserve "in tight containers." N.F.

ACRIFLAVINE HYDROCHLORIDE.

N.F.

[Acriflavinae Hydrochloridum]

"Acriflavine Hydrochloride is a mixture of the
hydrochlorides of 3,6-diamino-10-methylacridin-
ium chloride and 3,6-diaminoacridine, yielding,
when dried for 1 hour at 105°, not less than 23
per cent and not more than 24.5 per cent of CI."
N.F.

Acid Acriflavine; Acid Trypaflavine.

The two NHs groups of acriflavine are capable
of reacting with acids to form salts; thus, acri-
flavine may form a monohydrochloride and a
dihydrochloride. The official substance is the
monohydrochloride. For information concerning
the chemistry of acriflavine see the preceding
monograph.

Description. — "Acriflavine Hydrochloride oc-
curs as a strong reddish brown, odorless, crystal-
line powder. Solutions of Acriflavine Hydrochlo-
ride are dark red in color and become fluorescent
on dilution. One Gm. of Acriflavine Hydrochlo-
ride dissolves in about 3 ml. of water, and is
soluble in alcohol. It is nearly insoluble in ether,
in chloroform, in liquid petrolatum, and in fixed
or volatile oils. One Gm. of Acriflavine Hydro-
chloride, dissolved in 50 ml. of warm distilled
water, forms a clear solution, which remains clear
and free from sediment on standing in the dark
for 24 hours. Dissolve 200 mg. of Acriflavine
Hydrochloride in 100 ml. of isotonic sodium chlo-
ride solution: a clear solution is obtained, which
remains clear and free from sediment on standing
in the dark for 24 hours." N.F. The solubility of
acriflavine hydrochloride varies somewhat with
the proportions of its components, hence commer-
cial samples do not always have identical solu-
bilities. It is of interest that the mixture is more
soluble than either component.

Standards and Tests. — Identification. — Acri-
flavine hydrochloride responds to the tests pre-
scribed for acriflavine except that its solutions are
dark red, and in test (3) an effervescence is pro-
duced. Loss on drying. — Not over 7 per cent on
drying for 1 hour at 105°. Residue on ignition. —
Not over 10 mg. from 1 Gm. of acriflavine hydro-
chloride with 1 ml. of sulfuric acid. Arsenic. — The
requirement is the same as for acriflavine. N.F.

Assay. — The N.F. directs that the assay be
performed as specified under Acriflavine.

Incompatibilities. — Acriflavine and its hydro-
chloride are incompatible with solutions contain-

Part I

Adrenal Cortex Injection 27

ing chlorine, phenol or mercuric chloride. With
alkalies and with silver nitrate a precipitate is
produced. While acriflavine hydrochloride is com-
patible with normal salt solution for immediate
use, precipitation occurs upon standing. Salt solu-
tions stronger than 5 per cent produce a pre-
cipitate immediately. Solutions of acriflavine
hydrochloride are acid and may give rise to in-
compatibilities for this reason.

Uses. — The most important use of acriflavine
is as a wound antiseptic. This antiseptic is an out-
come of investigations, commencing with Ehrlich,
to find a dye which will stain the microorganism,
and thereby injure it, without staining the tissues
of the host; thus it would have low toxicity to
the host. In addition to acriflavine, the related
substances aminacrine hydrochloride and pro-
flavine hemisulfate are official in the B.P.

Acriflavine is not an extremely powerful bac-
tericide but it is a very active bacteriostatic sub-
stance. It is usually employed in strengths of
about 1 in 1000 in physiological saline solution.
Browning, who advocated use of acriflavine as a
surface antiseptic in 1917, reviewed the more re-
cent status of this drug (Brit. M. J., 1943, 1, 341)
as follows: it is bacteriostatic against important
pyogenic bacteria; serum does not diminish its
action but blood and pus do ; its systemic toxicity
is low (100 mg. intravenously every other day
for 10 doses is well tolerated) and it is not ab-
sorbed sufficiently from wounds to be toxic; in
the 1:1000 solution concentration it causes little
tissue damage; phagocytosis is but little dis-
turbed; skin idiosyncrasy is rare; it is able to
destroy infection in a fresh wound before sig-
nificant invasion occurs; established infection is
cleaned up better by the 1 :1000 solution than by
the local use of the sulfonamide drugs; it does
not delay healing; in serum a concentration of 1
in 200,000 sterilizes either Staphylococcus aureus
or Bacillus coli within 24 hours and is active
against Streptococcus pyogenes in even higher di-
lutions; Bacillus pyocyaneus, proteus and some
strains of coli are highly resistant to acriflavine.

Extensive comparisons of the bacteriostatic and
bactericidal action of acriflavine with other acri-
dine antiseptics have been published (/. Pharma-
col., 1944, 80, 217; /. Lab. Clin. Med., 1944, 29,
134 and 1177 and 1945, 30, 145). Martin and
Fisher (J. Lab. Clin. Med., 1944, 29, 383) re-
ported that the bacteriostatic action of the acri-
dine antiseptics is due to inhibition of adenine-
containing factors such as coenzymes I and II,
which are essential to bacteria (see also O'Connor,
Brit. J. Exp. Path., 1951, 32, 547). Garrod (Brit.
M. /., April 4, 1931) pointed out that it is not ad-
visable to apply it on cotton dressings because the
affinity for cotton reduces its antiseptic action.

Acriflavine has been employed as an injection
in gonorrheal urethritis in 1 in 1000 concentration
and as a bladder irrigation in 1 in 5000 concentra-
tion. It has also been used for sterilizing the skin
as a 5 per cent solution in alcohol, acetone and
water (see Tinker and Sutton, J. A.M. A., 1926,
87, 1347 and Berry, Pharm. J., 1937, 139, 541,
571). Roxburgh (Pract., 1941, 146, 289) advo-
cated treatment of impetigo by removal of the

crusts and painting of the raw area with 1 in 1000
acriflavine.

Acriflavine has been given by mouth as a uri-
nary antiseptic in doses of 200 mg. daily; for best
effect the urine must be kept alkaline. Assinder
(Lancet, 1936, 1, 304) reported great variation in
the toxicity of different samples.

According to Crittenden (/. Pharmacol., 1932,
44, 423) small doses cause a moderate transient
rise in blood pressure, while large doses cause a
fall in blood pressure with a slowing of the heart.
He also found considerable difference in the
toxicity of individual samples. Heathcoat and
Urquhart (/. Pharmacol., 1930, 38, 145) reported
the acutely fatal intravenous dose for animals as
about 25 mg. per Kg. but that repeated injections
of less than half of this quantity eventually
proved fatal, with evidence of injurious effects on
the fiver and the kidney (see also Levrat, Compt.
rend. soc. biol., 1933, 114, 60).

Prior to the availability of the sulfonamides
and antibiotics, a 2 per cent aqueous solution was
used intravenously in doses of 10 to 15 ml., slowly,
or diluted with 250 ml. of isotonic sodium chlo-
ride solution, at intervals of 1 or 3 days, in the
treatment of brucellosis (Debono, Brit. M. J.,
199, 1, 326), tularemia (Loria, Am. J. Med. Sc,
1941, 202, 803), psittacosis (Koch, Deutsche
med. Wchnschr., 1940, 32, 877), blastomycosis
(Pupo, J.A.M.A., 1928, 91, 1733), trypanosomi-
asis (Hawking, Ann. Prop. Med., 1938, 32, 367),
leishmaniasis (Senekji, J. Path. Bact., 1940, 50,
171), and schistosomiasis (Fisher, Lancet, 1934,
1, 897 and 2, 1017); however, Khali and Salah
(Lancet, 1934, 2, 862) reported it to be ineffec-
tive in the last-named condition, [v]

The N.F. states that acriflavine and its hydro-
chloride are used locally in 1:1000 solution, and
for irrigation in 1:10,000 to 1:1000 solution. For
intravenous dosage see under Acriflavine.

To remove stains of acriflavine or its hydro-
chloride from the hands it is recommended that a
little dilute sulfurous acid be applied, followed by
dilute hydrochloric acid, then washed with water.

Storage. — Preserve "in tight containers." N.F.

ADRENAL CORTEX INJECTION.
U.S.P.

"Adrenal Cortex Injection is a sterile solution
in alcohol and water for injection containing a
mixture of the endocrine principles derived from
the cortex of adrenal glands of healthy domestic
animals used for food by man. Each ml. of Ad-
renal Cortex Injection exhibits a biological activity
equivalent to that of 100 micrograms of U.S.P.
Hydrocortisone Acetate Reference Standard. It
contains a suitable antibacterial agent." U.S.P.

The adrenal glands, also known as suprarenal
glands and suprarenal bodies and suprarenal cap-
sules, are small glandular bodies found in all
mammals, being located immediately above the
kidney. In man they weigh about 6 or 7 Gm. They
consist of two distinct portions: an outer layer,
known as the cortex, varying in thickness from
0.25 to 1.2 mm., and an inner, medullary portion.
It has long been recognized that extirpation of

28 Adrenal Cortex Injection

Part I

these glands in lower animals is almost invariably
fatal within a week or two.

The physiologically important principle of the
medullary portion of adrenal glands is epinephrine
(for information see under Epinephrine), while
the cortex contains a large number of compounds,
several of which have pronounced physiological
activity. Fractionation of pure extracts of adrenal
cortex (about 9 Gm. of extract is obtained from
1000 pounds of adrenal glands) by Kendall,
Reichstein, Wintersteiner, Kuizenga, Cartland
and others has led to the isolation of 28 crystalline
steroids and a residual amorphous fraction from
which latter there was recently isolated still an-
other crystalline steroid. At least seven of the
crystalline compounds (including the one most
recently isolated) have activity which is charac-
teristic of the adrenal cortex. Several androgens
and estrogens are included in the group of hor-
mones which have been isolated but since their
activity is not specific for the adrenal gland they
are not of primary interest in any discussion of
characteristic adrenal cortex hormones. The seven
hormones of interest in this connection are: 11-
desoxycorticosterone, the one which possesses the
greatest activity in maintaining life in adrenalec-
tomized animals, official in the U.S. P. as Desoxy-
corticosterone Acetate; 11-dehydrocorticosterone,
known also as Kendall's Compound A; corticos-
terone, known also as Kendall's Compound B and
Reichstein's Substance H; 17-hydroxy-l 1-dehy-
drocorticosterone, known also as Kendall's Com-
pound E, Wintersteiner' s Compound F and Reich-
stein's Substance Fa, and official in the U.S. P. as
the acetate under the title Cortisone Acetate; 17-
hydroxycorticosterone, known also as Kendall's
Compound F and Reichstein's Substance M, and
official in the U.S. P. as Hydrocortisone and also,
in the form of the acetate, as Hydrocortisone
Acetate; 17 - hydroxy - 11 - desoxycorticosterone,
known also as Reichstein's Substance S; the new
crystalline hormone, with high activity in the
control of mineral metabolism, first called elec-
trocortin but renamed aldosterone after its chem-
ical structure was established to be llP,21-dihy-
droxy-3,20-diketo-4-pregnene-18-al (for details of
isolation and characterization see Harman et al.,
J.A.C.S., 1954, 76, 5035; for other information
see under Desoxycorticosterone Acetate).

For a summary of the procedure for preparing
active extracts of the adrenal cortex, and for their
fractionation, as well as the chemistry of the in-
dividual compounds, see Kuizenga in the A.A.A.S.
volume on The Chemistry and Physiology of
Hormones (1944). Manufacturing details may be
found also in U. S. Patents 2,053,549 (1936) and
2,096.342 (1937).

Under the title Suprarenal the dried, partially
defatted and powdered suprarenal gland of cattle,
sheep, or swine, representing approximately 6
parts by weight of fresh glands, was long offi-
cially recognized, most recently in N.F. VIII. For
information concerning it see U.S.D., 24th ed.,
p. 1171.

Description. — "Adrenal Cortex Injection is
a clear, colorless, or faintly colored solution."
U.S.P.

Standards and Tests.— pH— The pH of the

injection is between 4.0 and 6.0. Pyrogen. — The
injection meets the requirements of the official
pyrogen test, the test dose being 1 ml. per Kg.
Other requirements. — The injection meets the re-
quirements for Injections. Pressor substances. —
The injection exhibits a pressor activity equivalent
to not more than 0.2 mg. of epinephrine in each
100 ml. U.S.P.

Assay. — The assay is based on measurement of
the ability of the adrenal cortex injection under
test to promote deposition of glycogen in the liver
of adrenalectomized rats; in the assay the liver
glycogen content is determined through interac-
tion of glucose obtained from the glycogen with
alkaline cupric sulfate T.S., followed by estima-
tion of the excess of cupric ion by release of
iodine and titration with sodium thiosulfate volu-
metric solution. Quantitative evaluation of the
effect is obtained by comparison with the effect
produced by Hydrocortisone Acetate Reference
Standard under similar experimental conditions.
U.S.P.

Uses. — The chief indication for suprarenal ex-
tract is in the management of acute crises in
Addison's disease; maintenance therapy is simpler,
more effective, and less costly when cortisone or
hydrocortisone, desoxycorticosterone and sodium
chloride are used. Since the adrenal extract is
more efficient in the muscle work test than any
combination of isolated adrenal steroids it is pos-
sible that it contains unidentified factors which
may have therapeutic value in various conditions.
On the other hand Thorn et al. (New Eng. J.
Med., 1953, 248, 420) found that intravenous
injections of hydrocortisone produce rapid meta-
bolic effects of maximal intensity and believe that
this dosage form will eventually replace adrenal
extract for use in the correction of acute adrenal
insufficiency. The characteristics and treatment of
adrenal insufficiency are discussed under Desoxy-
corticosterone Acetate, while hyperfunction of
the adrenal gland is discussed under Cortisone
Acetate.

History. — Thomas Addison described, in 1855,
the syndrome of adrenal insufficiency which is
commonly referred to as Addison's disease. In
1856 Brown-Sequard reported his experimental
demonstration, in animals, that the adrenal gland
is essential for life. Osier's report (Internat. Med.
Mag., 1896, 5, 3) that oral administration of a
glycerin extract of fresh hog adrenal glands pro-
duced marked improvement in a patient with
Addison's disease was obscured and forgotten
when the vasopressor action of adrenal extracts
was recognized by Oliver and Schafer in 1895
(see Brit. M. J., 1901, 1, 1009) and by the failure
of epinephrine to improve the patient with adre-
nal insufficiency. That it is the cortex of the
adrenal gland which is essential for life was dem-
onstrated by Houssay and Lewis (Am. J. Physiol.,
1923, 66, 512) and others. About three decades
after Osier's report. Hartman et al. (Proc. S. Exp.
Biol. Med., 1927, 25, 69), and Rogoff and Stewart
(Science, 1927, 66, 327) reported prolongation of
life in adrenalectomized animals following admin-
istration of an extract of the adrenal cortex.
Swingle and Pfiffner (ibid., 1930, 71, 321) pre-
pared a potent extract which proved to be clini-

Part I

Adrenal Cortex Injection 29

cally effective (see Rowntree, J. A.M. A., 1940,
114, 2526) and which came into use under the
name Eschatin (Parke, Davis); Hartman and
Brownell (Proc. S. Exp. Biol. Med., 1930, 27,
938) simultaneously produced a potent extract
which was also useful in patients. In the light of
later knowledge of the activity of adrenal cortical
steroids, these extracts were weak, costly, and
available in insufficient quatnity for many thera-
peutic requirements. Improved extraction meth-
ods were reported by Kuizenga et al. (J. Biol.
Chem., 1943, 147, 561). Currently available ex-
tracts are standardized on adrenalectomized rats
to have a liver glycogen deposition activity cor-
responding to that of 0.1 mg. of hydrocortisone
acetate per ml. (see U.S. P. requirement and assay
above j. Extracts have also been standardized using
adrenalectomized dogs (Cartland and Kuizenga,
Am. J. Physiol., 1936, 117, 678); a dog unit is
the amount of material per Kg. of body weight
required daily to maintain the animal in good
condition with a normal blood non-protein nitro-
gen level. Dog units may be transposed in terms
of hydrocortisone on the assumption that 50 dog
units are equivalent to 0.1 mg. of hydrocortisone.
The most active extract developed, Lipo-Adrenal
Cortex, Sterile Solution (Upjohn), contains in 1
ml. the activity of 1 mg. of hydrocortisone.

Action. — Physiologically, the adrenal cortex
hormones, which are present in extracts, fall into
two categories: 11-desoxycorticosterone, 17-hy-
droxy-11-desoxycorticosterone and, apparently,
aldosterone (electrocortin) are concerned chiefly
with electrolyte and fluid balance; corticosterone,
1 1-dehydrocorticosterone, 1 7-hydroxycorticoster-
one (hydrocortisone), and 17-hydroxy-l 1-dehy-
drocorticosterone (cortisone) are more active in
carbohydrate and protein metabolism. The loss of
sodium seems to be related to the inability of
renal tubules to reabsorb sodium; this is perhaps
the most serious defect in adrenal insufficiency
and is corrected by adrenal cortical extracts
(Thorn et al., Endocrinology, 1937, 21, 213).
The hormones of the second category, which have
an oxygen or a hydroxyl group in the 11 position,
seem to increase conversion of protein to carbo-
hydrate (gluconeogenesis) and utilization of car-
bohydrate in the liver but to decrease peripheral
utilization of glucose (Long, ibid., 1942, 30, 870);
this antagonizes the action of insulin which tends
to promote protein synthesis and increase periph-
eral utilization of carbohydrate. Adrenal cortex
extracts correct the abnormality in carbohydrate
metabolism (Hartman et al., J.A.M.A., 1932, 98,
788). The decreased ability of muscles to work is
perhaps related to this defect in protein and car-
bohydrate metabolism (Lewis et al., Endocrinol-
ogy, 1940, 27, 971; Ingle, ibid., 1942, 31, 419)
but these metabolic effects are inadequately under-
stood and a complex interaction of pituitary,
thyroid, pancreas and other organs is probably
involved. Adrenal hormones also maintain normal
capillary permeability. The bronze pigmentation
of the skin of the patient with Addison's disease
becomes lighter when adrenal cortex extract is
employed (Hartman et al, J.A.M.A., 1932, 99,
1478). Resistance to infection and stress of all
types is related to adrenal function. Increase in

blood lymphocytes (White and Dougherty, Endo-
crinology, 1945, 36, 207) and decrease in serum
gamma globulin content (immune bodies) in defi-
ciency states are corrected by the steroid hor-
mones.

For therapeutic purposes both groups of adre-
nal steroid hormones are needed, and are provided
by the available extracts. However, very large
doses are necessary, and the cost is sometimes
prohibitive. The less costly synthetic compound
desoxycorticosterone acetate has made it possible
to control the disturbance in water and electrolyte
metabolism, though this compound does not pre-
vent hypoglycemia, particularly in association
with infections, gastrointestinal disturbances or
other states of stress. The present availability of
cortisone and hydrocortisone provides an ample
supply of glycocorticoid activity.

Therapeutic Uses. — The management of
adrenal insufficiency, as presented by Thorn
(J.A.M.A., 1944, 125, 10) involves several fac-
tors (see also under Desoxycorticosterone Ace-
tate, Cortisone Acetate, and Hydrocortisone Ace-
tate). In the acute crisis, bed rest is essential.
Water and salt are greatly needed, and up to 4
liters of isotonic sodium chloride solution should
be given intravenously during the first 24 hours.
Dextrose is also needed, being given intravenously
in 5 per cent solution in water for injection or
isotonic sodium chloride solution but it must be
administered with caution because fatalities have
resulted from rapid and unintelligent administra-
tion. Adrenal cortex extract is started at once in
a dose of 30 to 50 ml. intravenously and, simul-
taneously, 10 ml. intramuscularly; the latter is
repeated every hour until the patient reacts from
the crisis (usually about 12 hours), then every 2
to 3 hours during the second 12-hour period, and
subsequently every 3 to 6 hours until the patient
is afebrile and well. In addition to adrenal cortex
injection, 20 mg. of desoxycorticosterone acetate
in oil should be given intramuscularly immedi-
ately, followed by a dose of 5 to 10 mg. daily until
the patient is well. If the systolic blood pressure
is less than 90 mm. of mercury, epinephrine or
ephedrine should be used hypodermically. If the
blood pressure remains low, whole blood or plasma
is indicated intravenously. Oral fluids may be
permitted as tolerated. Morphine is contraindi-
cated.

In chronic states of deficiency or after recovery
from an acute crisis, infection, fasting and exces-
sive stress and strain must be avoided. A diet
high in sodium chloride but low in potassium is
indicated; from 3 to 10 Gm. of sodium chloride,
as enteric-coated tablets, should be administered
daily. Although some mild cases may be kept in
a state of health with the high sodium diet only,
the majority of patients will require some form
of adrenal cortical hormone. Desoxycorticosterone
acetate, which regulates only the water and salt
metabolism, may suffice. It has the important
virtue of being cheaper therapy; implantation of
pellets (see under Desoxycorticosterone Acetate)
about once a year is often effective and avoids
repeated injections. Adrenal cortical extract,
which provides the carbohydrate as well as the
water and salt regulating substances, may be

Adrenal Cortex Injection

Part I

required in doses as high as 15 to 20 ml. intra-
muscularly daily. Cortisone acetate by mouth and
extra salt in the diet will control many cases
without the necessity for injections of desoxycor-
ticosterone or adrenal cortex extract. Therapy is
guided by the disappearance of clinical symptoms,
weight gain and the maintenance of a normal
blood pressure. Infection increases the amount of
cortical hormone needed.

In addition to the treatment of Addison's dis-
ease, the adrenal steroid hormones have been
employed with benefit in the management of the
shock of severe thermal burns (Scudder and
Elliott, South. Med. Surg., 1942, 104, 651) and
of traumatic or surgical shock (Helfrich et al.,
Am. J. Surg., 1942, 55, 410). However, Rhoads
et al. {Ann. Surg., 1943, 118, 982) reversed their
preliminary impression of the value of these
hormones in the shock due to burns. Likewise,
Koster and Kagman {Arch. Surg., 1941, 45, 2 724)
denied any benefit, in surgical shock. Some of this
controversy doubtless arose from the use of the
relatively weak extracts which were available. In
the Waterhouse-Friderichsen syndrome (acute
adrenal insufficiency in meningococcal infections
which is often due to hemorrhage into the adre-
nals), early diagnosis and vigorous treatment for
the Addisonian crisis may alter the otherwise
hopeless prognosis (Weinberg and McGavack,
New Eng. J. Med., 1945. 232, 95). Rich (Bull.
Johns Hopkins Hosp., 1944, 74, 1) has shown
that adrenal damage also plays a role in death
from severe infections with streptococcus, pneu-
mococcus. diphtheria bacillus, etc. (see also Sara-
son, Arch. Int. Med., 1943, 71, 702); the clinical
use of adrenal extracts in the management of
serious toxic infections (London and Holman,
South. M. J., 1945, 38, 596; Perla and Marmors-
ton. Endocrinology, 1940, 27, 367; Farah. Lancet,
1938, 1, 777) seems therefore to be justified.

In alcoholism, Tintera and Lovell (Geriatrics,
1949, 4, 274) employed the extract according to
the regimen used for the crisis of Addison's dis-
ease on the basis of findings indicating that adre-
nal insufficiency exists in such patients; recovery
from a period of severe alcoholism was speeded
and the discomfort was minimized. Voegtlin
(Quart. J. Stud. Alcohol, 1953, 14, 28) confirmed
initial benefit with cortisone and corticotropin but
found no benefit with continued use in preventing
recurrence of alcoholic excesses. Adrenal cortex
injection has been recommended for a variety of
disorders for which no effective therapy is avail-
able. B

Toxicology. — Toxic effects from extracts of
adrenal cortex are almost unknown (Gordon,
J.A.M.A., 1940, 114, 2549), although desoxycor-
ticosterone has caused serious untoward effects.
If the intake of sodium chloride is high, edema
may develop with adrenal cortex extract. Rapid
intravenous injection of 5 ml. or more causes the
effects of epinephrine transiently even though only
traces of epinephrine remain in most extracts.

Route of Administration. — Aqueous ex-
tracts of adrenal cortex, which are usually pre-
pared from beef adrenal glands, are readily ab-
sorbed on subcutaneous or intramuscular injec-
tion; their cortical steroid action persists for 1 to

4 hours. Although the adrenal steroid hormones
are absorbed after oral administration (Rogoff,
J. A.M. A., 1932, 99, 1309; Grollman and Firor,
/. Biol. Chem., 1935, 109, 189), this route of
administration has seldom proved to be practical
(Thorn et al., Endocrinology, 1938, 23, 403, and
see also under Desoxycorticosterone Acetate).
There is no apparent therapeutic value in the
dried suprarenal gland which was long used in
medicine.

The usual dose of adrenal cortex injection is
10 ml., intramuscularly or intravenously, with a
range of 10 to 100 ml. The dose is repeated as
often as necessary (see above for details). The
maximum safe dose is limited by the trace of
epinephrine (up to 0.2 mg. per 100 ml.) remain-
ing in the injection.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass.
It may be packaged in 50-ml. multiple-dose con-
tainers." U.S.P.

Usual Sizes. — 10 and 50 ml.

AGAR. U.S.P

Agar-Agar, [Agar]

"Agar is the dried hydrophilic, colloidal sub-
stance extracted from Gelidium cartilagineum
(Linne) Gaillon (Fam. Gelidiacece), Gracilaria
confervoides (Linnej Greville (Fam. Sphcero-
coccacem), and from related red algae (Class
Rhodophycece) ." U.S.P.

Vegetable Gelatin; Japanese or Chinese Gelatin; Japanese
Isinglass. Gelosa. Fr. Gelose; Colle du Japon. Ger. Agar
agar; Vegetabilischer Fischleim; Japanischer Fischleim.
Sp. Agar-Agar; Agar; Gelosa.

Quite a number of the algae belonging to the
Rhodophycece, growing on the coast of southern
and eastern Asia, California, and the Eastern
United States, contain large quantities of mucilage
which is extracted and sold under the name of
agar-agar. The most important species are Geli-
dium cartilagineum (L.) Gaillon. Gelidium
Amansii Lamouroux, Ahnjeltia plicata (Huds.)
Fries, Endocladia muricata (P. & B.) J. G. Ag.,
Gracilaria confervoides (L.) Greville, and Hypnea
musciformis (Wulfen) Lamouroux. The algae are
usually collected during the summer and fall,
bleached or unbleached, and dried, but the process
of the manufacture of agar-agar does not take
place until cold weather, and usually extends from
November to February.

According to Tseng (Sci. Monthly, 1944, 59,
37), Gelidium cartilagineum, a reddish-purple,
fern-like agarophyte, occurs from Point Concep-
cion southward along the southern California
coast, growing on rocks from the low tide mark
to a depth of 30 or more feet. It is chiefly har-
vested with a diving rig, the diver pulling the alga
off by hand. It is dried in the sun and baled, but
not bleached.

In processing agar in California, the seaweed
is soaked in cleaning vats to remove sand, etc.,
placed in pressure cookers where the amorphous
gelatinous substance is dissolved from the plants
by hot water, then the resultant hot solution
passed through filter presses to tubs where it
forms a gel on cooling. The gel is crushed and

Part I

Agar

poured into cans in the freezing room ; the frozen
gel is thawed, and the cold water containing im-
purities is separated from the agar particles in
rotary vacuum filters. The agar flakes resulting
are then carried to huge cylindrical stack driers
where they are dried by ascending currents of hot
air. Along the coast of Japan the species yielding
agar are cultivated, poles being anchored in the sea
to provide supports upon which they multiply.
The poles are withdrawn and the algae stripped off,
taken ashore, and dried, then beaten to remove
sand and shells, and bleached by alternate wash-
ing and exposure to sunlight preparatory to ex-
tracting the gelose.

Wood (/. Council Sci. Ind. Res., 1942, 15,
295) reported that Gracilaria confervoides is the
most abundant source of agar in Australia. There
the algae are gathered from sandy flats, sometimes
bleached on grass, washed with beaters to remove
sand, minced, cooked with live steam for 2 to 4
hours at 95° to 98°, using 4 per cent of the algae
in the digestion liquid, and adjusting the reaction
to pH 5 to 6. Solids are removed from the hot
liquid by centrifuging or by filtration through
steam heated bag filters; the clarified liquid is
run into a steam pan, treated with activated char-
coal and filtered through a plate and frame
press. The colorless liquid is concentrated at a
low temperature and allowed to set at 21°, effect-
ing separation of certain organic impurities. The
resultant gel is thawed at 35°, washed in running
water and dried at 40° to 50° in a tunnel drier.

Most of the agar used in the United States be-
fore World War II was imported from Japan, al-
though considerable is produced from red algae
growing along the coast of lower California. In

1952, the U. S. imported 337,240 pounds of agar,
most of which came from Japan and the Korean
Republic. During the last war production of
Pacific agar in California was greatly increased
and, in addition, large amounts of so-called
"Atlantic coast agar" were manufactured from
Gracilaria confervoides (L). Greville and allied
species of red algae gathered off the coast. By

1953, production of Atlantic coast agar had
greatly increased and it now represents consider-
able of the American drug.

The following varieties of agar are known:

1. — Ceylon Agar-agar, consisting chiefly of
Gracilaria lichenoides, Greville, the alga used by
the Hirundo esculenta in the formation of its
edible nest.

2. — Macassar Agar-agar, coming from the
straits between Borneo and Celebes, consisting
of impure Eucheuma spinosum, Ag., incrusted
with salt.

3. — American Agar-agar, derived from red algae
growing in the Pacific Ocean off the coast of Cali-
fornia, including Gelidiutn cartilagineum, G.
Amansii and Ahnfeltia plicata, which yield the
product known as "Pacific Coast Agar" and from
red algae growing in the Atlantic Ocean off the
coast of southern U. S. and Massachusetts, in-
cluding Gracilaria confervoides and Hypnea mus-
ciformis, which yield the "Atlantic Coast Agar."

4. — Japanese Agar-agar, known as Japanese
isinglass, derived from a number of algae, espe-
cially Sphoerococcus compressus, Ag., Gloiopeltis

tenax, J. Ag., G. cartilagineum (L.) Gaill. and
other species of Gelidium. Japanese agar differs
chiefly from American agar by containing the
large discoid diatom, Arachnoidiscus Ehrenbergii
Baill. Both varieties contain other species of
diatoms and sponge spicules.

5. — Australian Agar-agar, yielded by Gracilaria
confervoides.

Constituents. — Agar is composed mainly of
the calcium salt of a complex carbohydrate sub-
stance commonly called gelose. Percival and
Somerville (/. Chem. S., 1937, 1615) were the
first to establish the structural characteristics of
the carbohydrate component; they showed the
major part of it to consist of D-galactose residues
united by 1,3-glycosidic linkages chiefly of the
P-type. The presence of L-galactose as well as of
an esterified sulfuric acid group was also estab-
lished. Jones and Peat (/. Chem. S., 1942, 225)
consider the chief constituent of agar to be the
sulfuric acid ester of a linear polygalactose in
which the repeating unit is composed of nine
D-galactopyranose residues terminated at the re-
ducing end by one residue of L-galactose. The
D-galactose units are mutually combined by 1,3-
glycosidic linkages, but the L-galactose residue is
attached to the chain through position 4; this
residue is esterified at the sixth carbon atom with
sulfuric acid. Percival and Thomson (/. Chem. S.,
1943, 750) reported analytical data on the hy-
drolysis of certain agar derivatives which are at
variance with those of Jones and Peat and are
of the opinion that the structure proposed by the
latter investigators is oversimplified.

Itano (Proc. Imp. Acad. Tokyo, 1933, 9, 398)
found that commercial agar may contain from
24.5 to 101.9 parts per million of iodine. This
may be reduced to 6 or 7 p.p.m. by suitable
purification.

When a solution of agar is cooled, even that
of 1 in 500 parts of water a colorless, trans-
parent, and stiff jelly is obtained, which, when
heated with moderately strong nitric acid, yields
mucic and oxalic acids. It dissolves on heating
with acidulated water without yielding a jelly on
cooling.

Description. — "Unground Agar usually oc-
curs in bundles consisting of thin, membranous,
agglutinated pieces or in cut, flaked or granulated
forms. It may be externally weak yellowish
orange, yellowish grc.y or pale yellow or colorless.
It is tough when damp, brittle when dry. It is
odorless or has a slight odor and a mucilaginous
taste.

"Histology. — In water mounts Agar appears
granular and somewhat filamentous; a few frag-
ments of the spicules of sponges and a few frus-
tules of diatoms may be present; in Japanese
Agar, the frustules of Arachnoidiscus Ehrenbergii
Baillon occur, which are disc-shaped and from
100 to 300 \i in diameter.

"Powdered Agar is white to yellowish white or
pale yellow; in chloral hydrate T.S. its fragments
are transparent, more or less granular, striated,
angular, and occasionally containing frustules of
diatoms.

"Solubility. — Agar is insoluble in cold water,
but soluble in boiling water." U.S.P.

32 Agar

Part I

Standards and Tests. — Identification. — (1)
Some fragments of agar are colored bluish black,
and some areas reddish to violet, by iodine T.S.
(2) On boiling agar with 65 times its weight of
water for 10 minutes, with constant stirring, then
adjusting to 1.5 per cent concentration of agar by
addition of hot water, a clear liquid results; at
32" to 39° it congeals to form a firm, resilient gel,
the melting point of which is not below 85°.
Water. — Not over 20 per cent when determined
by drying at 105° for 5 hours. Acid-insoluble ask.
— Not over 0.5 per cent, on a dry weight basis.
Total ash. — Not over 6.5 per cent, on a dry weight
basis. Foreign organic matter. — Not over 1 per
cent. Foreign insoluble matter. — When calculated
on a dry weight basis not over 1 per cent of resi-
due is obtained by filtering a solution of 1.5 Gm.
of agar in 200 ml. of hot aqueous solution through
a Gooch crucible and drying the latter at 105°.
Foreign starch. — No blue color is produced on
adding iodine T.S, to a solution prepared by boil-
ing 100 mg. of agar with 100 ml. of water, then
cooling. Gelatin. — No turbidity develops in 10
minutes following addition of 5 ml. of picric acid
T.S. to an equal volume of a solution made by
dissolving 1 Gm. of agar in 100 ml. of boiling
water and cooling to about 50°. Water absorption.
— 5 Gm. of agar is placed in a 100-ml. graduated
cylinder and enough water added to the 100 ml.
mark; after 24 hours of maceration at 25° not
more than 75 ml. of water should be obtained by
pouring off the liquid, through glass wool, into
another graduated cylinder, corresponding to the
absorption by agar of at least five times its weight
of water. U.S.P.

Tseng (Science, 1945, 101, 597) observed that
it is not yet definitely known whether the so-
called agar from sources (agarophytes) other than
species of Gelidium is identical with the latter.
He suggested that a definition or specification for
agar should include the requirement that a one
per cent neutral, aqueous solution of it should
set at 35° to 50° to a firm gel, and the latter
melt at 80° to 100°. Tseng also proposed the new
term phycocolloid to designate the polysaccharides
which are derived from the brown and the red
seaweeds and which are able to form colloidal
systems when dispersed in water.

The presence of Japanese agar may often be
detected by the characteristic diatoms; a proce-
dure based on this was described by Schneider
(Pac. Pharm., 1912, p. 35). Identification meth-
ods utilizing characteristic color and precipitation
reactions are described by Cannon (J.A.O.A.C.,
1939, 22, 92, 726) and by Pirie (Brit. J. Exp.
Path., 1936. 17, 269).

Uses. — The therapeutic value of agar is de-
pendent on its ability to absorb and retain water
as it passes through the gastrointestinal tract,
giving bulk to the intestinal contents and also
serving as a lubricant. Its mechanical action is.
therefore, analogous to that of the cellulose of
vegetable foods. Because it aids in maintaining
regularity of bowel movements, agar has been
widely used in the treatment of chronic constipa-
tion. It is frequently combined with cascara or
some other vegetable cathartic because it is com-
monly believed that agar does not stimulate peri-

stalsis in atonic intestinal muscle, although Chase,
cited by Tseng (Sci. Monthly, 1944, 58, 24),
stated that it does contain laxative principles
which excite peristaltic activity. Eisner et al.
(Ztschr. physiol. Chem., 1937, 246, 244) re-
ported that agar is an anticoagulant.

Agar is best administered in the form of a gel,
prepared by dissolving it in hot water and cool-
ing, flavored and sweetened as desired; at body
temperature agar absorbs little water and does
not provide much more bulk than when dry
(Gray and Tainter, Am. J. Digest. Dis., 1941,
8, 130). It is, however, also commonly cut into
small pieces and eaten like cereal; chocolate-
coated preparations of agar have been marketed.
In many proprietary preparations it is combined
with mineral oil as an emulsion; in such prepara-
tions the agar serves primarily as an emulsifying
agent and, although the character of the stool is
modified, little is added to the bulk (Nelson,
Internat. Med. Digest, 1943, 42, 308) because
of the relatively small amount of agar present.

Agar is much used in the preparation of suspen-
sions, emulsions, jellies, hydrophilic suppositories,
etc. For years it has served as the basis of many
culture media employed by bacteriologists. War-
time dearth of supply stimulated development of
methods for recovering agar from used culture
media (Blundell, Science, 1943, 97, 76; Brodie
and Stiven, /. Hygiene, 1942, 46, 498). Agar is
used as food in the Orient; while it contains 60
per cent of carbohydrates the latter consist largely
of indigestible hemicelluloses which may actually
decrease absorption of the nutrient substances
that are present. Agar is also extensively used in
bakery products, in clarifying liquids, in making
"health foods," in confections, and in ice cream.
In dentistry it serves as an impression mold. For
further information concerning uses of agar see
Tseng (Sci. Monthly, 1944, 58, 24; 1944, 59,

37). m

Dose. — The usual dose is 4 Gm. (approxi-
mately 60 grains) once or twice daily; the range
of dose is 4 to 16 Gm.

Off. Prep. — Phenolphthalein in Liquid Petro-
latum Emulsion, N.F.

NORMAL HUMAN SERUM
ALBUMIN. U.S.P.

Normal Serum Albumin (Human), [Albuminum Seri
Humanum Normale]

"Normal Human Serum Albumin is a sterile
preparation of serum albumin obtained by frac-
tionating blood from healthy, human donors. It is
either a solution containing, in each 100 ml., 25
Gm. of the serum albumin osmotically equivalent
to 500 ml. of normal human plasma, or a dried
preparation suitable for restoration to an appro-
priate volume for clinical use. It contains no
added bacteriostatic agent, but each 100 ml. of
the liquid form may contain as a stabilizing
agent either 0.04 mol of sodium acetyltryptopha-
nate or 0.02 mol each of sodium acetyltryptopha-
nate and sodium caprylate. If prepared from
plasma containing a mercurial preservative, it
contains not more than 20 meg. of mercury per
Gm. of albumin. Not less than 97 per cent of the

Part I

Albumin, Normal Human Serum 33

total protein of Normal Human Serum Albumin
is albumin." U.S.P.

Normal human serum albumin is obtained by
fractionation of human plasma and constitutes up
to 90 per cent of fraction V (for further informa-
tion see Normal Human Plasma).

Description. — "Liquid Normal Human Serum
Albumin is a moderately viscous, clear, brownish
fluid. It is substantially odorless. Dried Normal
Human Serum Albumin has a light yellow to deep
cream color." U.S.P.

Standards and Tests. — Sodium content. —
Not more than 0.0132 Gm. of Na per Gm. of
albumin. Water content of dried serum albumin.
— Not over 1 per cent, when determined by drying
to constant weight at room temperature over
phosphorus pentoxide at a pressure of not more
than 1 mm. of mercury. Other requirements.
— Complies with the identity, safety, sterility,
and stability tests and other requirements of the
National Institutes of Health of the United States
Public Health Service, including the release of
each lot individually before its distribution. U.S.P.

Uses. — Human serum albumin was developed
during World War II as a compact, stable, easily
transportable blood substitute for use in emer-
gency treatment of shock (see under Normal
Human Plasma). When its use was later ex-
tended to include treatment of hypoproteinemic
states and nephrosis, a salt-poor form was pre-
pared in which the sodium content is one-seventh
or less than that of an osmotically equivalent vol-
ume of plasma. Heating to 60° for 10 hours de-
stroys the virus of serum hepatitis and also
bacteria so that mercurial preservatives are no
longer needed. Use of human albumin intrave-
nously does not carry the risk of homologous
serum hepatitis that exists when pooled plasma
or serum is used and to a lesser extent with
single blood donations (Paine and Janeway,
J.A.M.A., 1952, 150, 199).

Shock. — In emergency treatment of shock
serum albumin is of unquestioned value. An in-
crease in plasma volume of 8 to 18 ml. for each
Gm. of albumin administered is to be expected
but extra fluid must be given to dehydrated pa-
tients to achieve maximum benefit (Gibson, New
Eng. J. Med., 1948, 239, 579). Human serum
albumin does not restore loss of oxygen-carrying
capacity resulting from loss of blood due to
hemorrhage.

Nephrosis. — Serum albumin has been used ex-
tensively in the nephrotic syndrome, but with dis-
appointing results. Seegal and Wertheim (Bull.
N. Y. Acad. Med., 1949, 25, 605) reported ob-
servations on 81 patients given 103 courses of
albumin under well-controlled conditions. Daily
doses varied from 7.5 to 100 Gm. Transient and
incomplete diuresis was seen in 47 per cent of
treatments; questionable effect was noted in 10
per cent; no diuresis was found in the remaining
43 per cent. Most of the injected albumin ap-
peared in the urine in 24 hours. Such therapy did
not affect the natural course of the underlying
disease. Janeway (J.A.M.A., 1948, 138, 864)
concluded that the place of albumin in the ther-
apy of nephrosis is limited, that its use is enor-
mously wasteful and expensive, and that it does

not alter the course of the disease. However, in
certain cases in which other methods of therapy
fail, and in which edema is incapacitating, he has
found it useful.

Cirrhosis of the Liver. — Conflicting reports
have appeared on the use of albumin in cirrhosis.
Kunkel et al. (I. Clin. Inv., 1948, 27, 305) treated
17 patients with doses of 100 to 2000 Gm. of
albumin. Patients with low serum albumin and
ascites of short duration responded most readily,
although 14 of 15 patients with ascites eventually
lost their fluid after albumin therapy. With
smaller doses for shorter periods, Thorn et al.
(ibid., 1946, 25, 304) and Patek et al. (ibid.,
1948, 27, 135) were unable to produce a favor-
able result. Falcon and coworkers (ibid., 1949,
28, 583) saw 3 fatal hemorrhages from esophageal
varices shortly after giving albumin to 20 cirrhotic
patients. Jacobi et al. (J. Pediatr., 1946, 29, 177)
found an excellent response in 2 infants with
erythroblastosis fetalis and edema following ad-
ministration of 30 and 12.5 Gm. of albumin,
respectively. Post et al. (Arch. Int. Med., 1951,
87, 775) used salt-poor human albumin intrave-
nously in patients critically ill with decompen-
sated hepatic cirrhosis with general clinical im-
provement, gain in appetite, strength and body
tissue, as well as decline of icterus along with the
diuresis. They concluded that albumin has a place
in the management of patients with severely de-
compensated hepatic cirrhosis for whom adequate
dietary therapy cannot be provided. Ricketts et
al. (J. Clin. Inv., 1951, 30, 1157) found that
albumin intravenously did not correct the de-
creased renal excretion of sodium in these cases;
the albumin increased in the ascitic fluid and
tissue edema fluid moved to the abdominal peri-
toneal space. Abnormal capillary permeability
during the active disease is probably a factor.

The final evaluation of the place of albumin in
therapy must await definitive studies of the me-
tabolism of injected albumin in normal and ab-
normal states. This agent has potent osmotic
activity the extent of which depends upon the
state of protein nutrition and the permeability of
capillaries throughout the body and especially in
the glomerulus. There is no evidence of renal
damage from increased proteinuria. A positive
nitrogen balance following administration of albu-
min may merely mean inert retention in extra-
cellular fluid rather than actual metabolism.

Studies with albumin tagged with radioactive
iodine-131 demonstrated that depletion of labile
albumin stores can be correlated with presence of
ascites (Tyor and Gayer, South. M. J., 1952, 45,
144) ; it is suggested that albumin metabolism
proceeds at a constant rate and is demonstrably
altered only in the terminal stages of liver dis-
ease. Albumin tagged with iodine-131 has also
been used for the study of peripheral circulation
(Krieger et al., Ann. Surg., 1952, 136, 357).

The usual dose, intravenously, is 100 to 200
ml., representing 25 to 50 Gm. of albumin, re-
peated as necessary. In terms of body weight the
dose is 2.2 ml. per Kg., injected at a rate of 2 ml.
per minute.

Labeling. — "The container label bears the
name Normal Serum Albumin (Human); the

34 Albumin, Normal Human Serum

Part I

amount in Gm. of albumin present; in the case of
liquid serum albumin the total volume of the
contents and the amount and kind of stabilizing
agent; the osmotic equivalent in terms of plasma;
the lot number; the expiration date, which for
liquid serum albumin is not more than 5 years
after date of manufacture or date of issue, and
for dried serum albumin not more than 8 years
after date of manufacture or date of issue; the
manufacturer's name; the statement, 'Contains no
preservative'; and in the case of liquid serum
albumin the statements, 'Caution: Do not use if
turbid,' and 'Salt Poor. Additional fluids are re-
quired when administered to patient with marked
dehydration,' and in the case of dried serum albu-
min the statement, 'Use within 3 hours after res-
toration.' The package label bears, in addition to
the above, the manufacturer's license number
and address, and the recommended storage tem-
perature." U.S.P.

Storage. — Preserve "at a temperature between
2° and 10°. Exposure for short periods to a higher
temperature will cause no significant deterioration.
Preserve dried Normal Human Serum Albumin
at room temperature, not exceeding 37°. Dis-
pense Normal Human Serum Albumin in the
unopened container in which it was placed by the
manufacturer." U.S.P.

Usual Sizes. — 20 and 50 ml., equivalent to
100 and 250 ml. of plasma.

ALCOHOL. U.S.P,. B.P. (LP.)

Ethanol, Ethyl Alcohol, Spiritus Vini Rectificatus,
[Alcohol]

CH3.CH2OH

"Alcohol contains not less than 92.3 per cent by
weight, corresponding to 94.9 per cent by volume,
at 15.56°, of C2H5OH." U.S.P. The B.P. requires
from 94.7 per cent to 95.2 per cent v/v (92.0 to
92.7 per cent w/w) of C2H6O. The LP. requires
Ethanol to contain not less than 95.1 per cent
v/v and not more than 96.8 per cent v/v, corre-
sponding to not less than 92.5 per cent w. w and
not more than 95.0 per cent w/w of C2H5OH.

Ethyl Hydroxide; Rectified Spirit; Spirit of Wine.
Spiritus Rectificatus; Spiritus. Fr. Alcool ethylique a 95
degres centesimaux; Alcool officinal. Ger. Weingeist; Al-
kobol; Athylalkohol ; Branntwein. It. Alcool rettificato;
Spirito di vino. Sp. Alcohol; Espiritu de vino.

Alcohol has been made for many centuries by
the fermentation of carbohydrates by yeast.
Utilizable carbohydrate-containing materials in-
clude molasses, sugar cane, fruit juices, corn,
barley, wheat, potato, wood and waste sulfite liq-
uors. As yeast is capable of fermenting only
D-glucose, D-fructose, D-mannose, and D-galactose
it is essential that more complex carbohydrates
be converted to one or more of these simple
sugars before they can be fermented. This is
variously accomplished; for example, yeasts con-
tain enzymes which hydrolyze disaccharides to
monosaccharides, starches may be saccharified by
hydrolysis with acids or by the enzyme diastase
from malt, cellulose is converted to sugars by
hydrolysis with acid under pressure.

The net reaction that occurs when a hexose,
glucose for example, is fermented to alcohol may

be represented as follows: CeHi20ff-»2C2H50H-f
2CO2. The mechanism of the process is, however,
exceedingly complex and many investigators have
studied it in detail. Of the several theories which
have been proposed, that of Meyerhof is sup-
ported by considerable experimental evidence.
According to this theory, both glucose and fruc-
tose are by several steps converted to the common
intermediate substance fructose- 1,6-diphosphoric
acid, the phosphoric acid being supplied through
the "adenylic acid system" of yeast. The fruc-
tose-l,6-diphosphoric acid is enzymatically split
into an equilibrium mixture of the three-carbon
molecules 3-glyceraldehyde phosphate and dihy-
droxyacetone phosphate, which are isomeric and
convertible one into the other. In the main
sequence of fermentation reactions the former
substance is successively converted to 3-phospho-
gly eerie acid, 2-phosphoglyceric acid, phospho-
pyruvic acid and pyruvic acid, which last under-
goes decarboxylation to acetaldehyde and then, in
a reaction involving a molecule of 3-glyceralde-
hyde phosphate, is enzymatically reduced to ethyl
alcohol. A minor sequence of reactions, leading
to the production of a small amount of glycerin,
starts with dihydroxyacetone phosphate which is
first reduced to alpha-glycerol phosphate and then
dephosphorylated to glycerin. Fusel oil and suc-
cinic acid are also obtained in very small amounts.
Formation of both constituents appears to be
associated with nitrogen metabolism of the yeast
cell and is minimized if a readily available source
of nitrogen is present in the fermentation mixture.
The chief constituents of fusel oil are isoamyl
alcohol and D-amyl (active amyl) alcohol.

In the years immediately before World War II
approximately 90 per cent of the alcohol pro-
duced in the United States utilized black-strap
molasses as the starting material. Manufacture
of alcohol from molasses is much simpler than
from grain in that the milling, cooking and malt-
ing (by which saccharification of starch is accom-
plished) are omitted; molasses does not require
an initial hydrolysis as it contains fermentable
sugars. The process consists of the following
steps: (1) weighing of the molasses, (2) mixing
with water, (3; sterilizing, to prevent contami-
nation with organisms which may influence the
course of the fermentation, (4) cooling or dilut-
ing with cold water, (5) charging the fermenters
with the dilute molasses, (6) addition of pure
yeast culture (generally Saccharomyces cerevisia),
sulfuric acid (to invert the sucrose in the mo-
lasses), and yeast food (ammonium sulfate), (7)
fermentation for 36 to 48 hours, (8) distillation
of the "beer," which contains 6.5 to 8.5 per cent
by volume of alcohol, to yield a distillate contain-
ing 95 per cent by volume of alcohol.

Ethyl alcohol from cellulose was first produced
commercially in this country during 1910, in a
plant constructed for this purpose in South Caro-
line. Approximately 20 gallons of alcohol was
produced from each ton of sawdust; the latter
was hydrolyzed by sulfuric acid under pressure.
A process developed by the German Bergius in-
creases the yield to 75 to 80 gallons per ton of
wood. A plant under construction at Springfield,
Oregon, had been planned to have a capacity of

Part I

Alcohol

about 11,500 gallons of alcohol daily from some
230 tons of wood waste; construction of it was
stopped at the close of World War II.

At present, approximately half of the total in-
dustrial alcohol production is by synthesis in-
volving hydration of ethylene. Abundant supplies
of ethylene are obtained from natural and coke
oven gases, from waste gases of the petroleum
industry, and from pyrolysis of ethane, propane,
and butane. The older and by far the more widely
used synthesis involves indirect hydration of
ethylene; in this process ethylene is reacted with
concentrated sulfuric acid to form ethyl hydrogen
sulfate and dimethyl sulfate, both of which react
with water to yield ethyl alcohol and sulfuric
acid. This indirect process was developed because
the process of direct hydration originally em-
ployed was slow. Recently, however, direct hydra-
tion has become feasible through use of high
pressures, low temperatures, suitable catalysts
(such as aluminum oxide), and by recycling of
reactant gases. It is expected that production of
alcohol from ethylene will increase, not only be-
cause of the growing availability of ethylene but
also because, when molasses prices are high, alco-
hol can be produced more cheaply from ethylene
than from any other raw material.

In another synthesis acetylene is catalytically
hydrated to acetaldehyde, which is then hydro-
genated, in the presence of a catalyst, to ethyl
alcohol; this process was used during World
War I.

The term proof spirit, as used in the United
States, refers to a product containing 50 per cent
by volume of C2H5OH; it is sometimes desig-
nated as 100 proof alcohol. The strength of any
other solution of ethyl alcohol may be expressed
in "proof" by multiplying the concentration of
C2H5OH, by volume, by two. Thus an alcohol
containing 60 per cent by volume of C2H5OH
is 120 proof, and official alcohol of 95 per cent
by volume concentration of C2H5OH is 190
proof. English proof spirit contains 49.3 per cent
C2H5OH by weight, or 57 per cent by volume;
it is materially stronger than United States proof
spirit.

Alcohol represents a constant-boiling mixture
of ethanol (95.57 per cent by weight) and water
(4.43 per cent by weight) ; the boiling point is
78.2°, while anhydrous alcohol boils at 78.3°. It is
not possible to obtain anhydrous alcohol by direct
distillation (see Dehydrated Alcohol).

Alcohol has many and varied industrial uses.
It is important as a general solvent, and is in-
dispensable for dissolving perfumes, flavoring ex-
tracts, and in the preparation of pharmaceuticals.
In addition it is essential in the synthesis of many
organic substances, including ether and chloro-
form. It serves as a fuel, either liquid or in the
form of "solidified alcohol," and has been used
alone or mixed with gasoline as a motor fuel.
"Solidified alcohol" contains 5 per cent methanol.

Denatured Alcohol. — The U. S. government
has established regulations authorizing the addi-
tion of substances to alcohol which render it unfit
for beverage purposes although it is suitable for
industrial use. The liquid so treated is termed
denatured alcohol.

The U. S. Internal Revenue Department has
authorized the use of a number of substances for
denaturing alcohol, but such alcohol must be pre-
pared under the supervision of an official of the
Department, at specified depots. Some of these
formulas provide an alcohol for burning purposes
or for use as a special solvent, other represent
the reactant mixture for preliminary manufactur-
ing processes, such as a mixture of sulfuric acid
and alcohol for the subsequent production of
ether, while still other formulas, identical with
official formulas such as iodine tincture, soap lini-
ment, etc., have been authorized and thus make
it possible to have these products manufactured
from tax-free alcohol at greatly reduced cost. (See
also Alcohol Rubbing Compound.) These prep-
arations may therefore be purchased from large
dealers at prices which are less than the cost of
the raw material if bought through the usual
channels of trade.

Under the title Industrial Methylated Spirit
(Spiritus Methylatus Industrialis) the B.P. recog-
nizes a mixture, made by a legally authorized
methylator, of 19 volumes of 95 per cent alcohol
with 1 volume of approved wood naphtha. It is
of the quality known as "66 O.P. industrial meth-
ylated spirits." Use of this product is permitted
by the B.P. in the preparation of certain liniments
and test solutions and in the manufacture of cer-
tain extracts and resins in which none of the
solvent remains in the finished product.

Description. — "Alcohol is a transparent, color-
less, mobile, volatile liquid. It has a slight, char-
acteristic odor and a burning taste. Alcohol is
readily volatilized even at low temperatures and
boils at about 78°. It is flammable. Alcohol is
miscible with water, with ether, and with chloro-
form. When Alcohol is diluted with an equal
volume of water the mixture is clear and remains
clear for 30 minutes after cooling to 10°. The
specific gravity of Alcohol is not more than 0.816
at 15.56°, indicating not less than 92.3 per cent
by weight, or 94.9 per cent by volume, of
C2H5OH." U.S.P. The temperature 15.56° C. is
equivalent to 60° F., the standard temperature
employed in stating concentrations of alcohol in
per cent by volume.

Standards and Tests. — Acidity. — Not more
than 0.9 ml. of 0.02 N sodium hydroxide is re-
quired to neutralize 50 ml. of alcohol, using
phenolphthalein T.S. as indicator. Non-volatile
residue. — Not over 1 mg. from 40 ml. of alcohol,
the residue being dried at 105° for 1 hour. Fusel
oil constituents. — No foreign odor is perceptible
when the alcohol is spontaneously evaporated
from a mixture of 10 ml. of alcohol, 5 ml. of
water and 1 ml. of glycerin placed on odorless
absorbent paper. Amyl alcohol or non-volatile,
carbonizable substatices, etc. — No red or brown
color is produced on adding a few drops of sulfuric
acid to the nearly dry residue from the evapora-
tion of 25 ml. of alcohol in a porcelain dish, pro-
tected from dust. Aldehydes and other foreign
organic substances. — The pink color produced by
the addition of 0.1 ml. of 0.1 TV potassium per-
manganate to 20 ml. of alcohol in a thoroughly
cleansed glass-stoppered cylinder, the solution
being maintained at 15°, does not entirely disap-

Alcohol

Part I

pear in 5 minutes. Ketones, isopropyl alcohol,
and tertiary butyl alcohol. — No precipitate forms
within 3 minutes when a mixture of 1 ml. of
alcohol, 3 ml. of water and 10 ml. of mercuric
sulfate T.S. is heated on a bath of boiling water.
Methanol. — No violet color appears on heating
for 10 minutes at 60° a mixture of 5 ml. of freshly
prepared chromotropic acid T.S. and a solution
obtained when 1 drop each of alcohol, water,
dilute phosphoric acid (1 in 20), and potassium
permanganate solution (1 in 20) are mixed, al-
lowed to stand 1 minute, treated with 1 in 20
sodium bisulfite solution to discharge the per-
manganate color and, if a brown color remains, 1
drop of the diluted phosphoric acid added to pro-
duce a colorless solution. U.S.P.

The B.P. specific gravity range is 0.815 to 0.817
at 15.5/15.5° and the refractive index, measured
at 20°, may vary from 1.3637 to 1.3639.

Incompatibilities. — The addition of alcohol
to aqueous solutions may cause the precipitation
of alcohol-insoluble compounds, such as numerous
inorganic and organic salts, and gums such as
acacia. Oxidizing agents may convert alcohol into
acetaldehyde and acetic acid.

Uses. — Alcohol has a variety of external and
internal uses in medicine and is important in
pharmacy. The local action of alcohol is mildly
irritant, feebly anesthetic and distinctly germi-
cidal and astringent. Some have contended that
the most effective concentration for local anti-
sepsis is from 60 to 70 per cent by weight in
water; careful studies by Hatfield et al. (Surgery,
1943, 13, 931), in which numerous antiseptics
were compared by a modification of the Price
technic (v.i.), showed that 95 per cent ethyl
alcohol by volume is superior in its ability to kill
bacteria on the skin (see also Morton, Ann. N. Y.
Acad. Sc, 1950, 53, 191). Such concentrations
of alcohol will destroy most pathogenic bacteria
within a relatively short time, but more resistant
spore-bearing organisms survive even prolonged
exposure. Alcohol is used for general anesthesia,
local destruction of nerves in lieu of surgical
excision, as an appetizer and even for parenteral
or oral nutrition. Its misuse creates vast social
and economic and police problems and treatment
of intoxication is a frequent chore.

Psychomotor Action. — Alcohol belongs, phys-
iologically as well as chemically, to the group of
aliphatic narcotics. In large doses it produces
coma analogous to ether anesthesia. Extensive
studies have permitted correlation of the con-
centration of alcohol in blood, and also in urine
and expired air, with action on the central nervous
system. This information is more of medicolegal
than therapeutic importance and the figures must
be interpreted in the light of knowledge of absorp-
tion and excretion in relation to time. Alcohol is
absorbed rapidly from the gastrointestinal tract;
in the ordinary doses of alcoholic beverages about
20 per cent is absorbed by the stomach and the
remainder in the intestine. The rate of absorption
is altered by the presence or absence of food, as
well as the type of food present; protein as well
as fat delay absorption. Alcohol is easily and
rapidly diffusible and at equilibrium attains a
concentration in tissues related to the concentra-

tion of water present in the extracellular and
intracellular compartments. From 90 to 98 per
cent of ingested alcohol is metabolized in the body
(v.i.) and only 2 to 10 per cent is excreted as
such, chiefly in the urine and to a lesser extent in
expired air. Only traces are found in sweat, milk
and bile. According to Ladd and Gibson (Ann.
hit. Med., 1943, 18, 564), the concentration in
urine is about 1.35 times that in arterial blood;
it must be remembered that a large collection of
urine in the bladder represents the arterial blood
concentration over the period of time this urine
was secreted by the kidneys and not the blood
concentration at the time the urine is voided. In
expired air the concentration is approximately
1/2000 of that in arterial blood. In the obviously
intoxicated person, the urine may contain as much
as 5 Gm. per liter and the expired air a few mg.
per liter. With ingestion of cocktails containing
1 ounce of whisky (45 per cent alcohol by vol-
ume) the following blood concentrations may be
observed, on the average: 20 minutes after the
first cocktail, 20 mg. per 100 ml.; at 45 minutes,
having consumed a second cocktail at 20 minutes,
40 mg. per 100 ml.; at 60 minutes, having con-
sumed a third cocktail at 40 minutes, 60 mg. per
100 ml.; subsequently one ounce of whisky per
hour will maintain a blood concentration of ap-
proximately 60 mg. per 100 ml. Without further
intake the concentration decreases at the rate of
about 10 mg. per 100 ml. per hour. As an ap-
proximation, 12 ounces of beer or 3 ounces of
wine represent the alcohol content of 1 ounce of
whiskey.

The initial "stimulating" effect of alcohol, which
is actually a depression of the inhibitory activi-
ties of the cerebral cortex, is associated with a
blood concentration of about 30 mg. per 100 ml.
(Miles, /. Pharmacol., 1922, 20, 265). At this
stage performance may be improved insofar as
elimination of embarrassment is helpful but tests
show that there is some loss in fine discrimination.
At 50 mg. per 100 ml., the individual is not
"drunk" but is in the flippant stage of unbounded
self-confidence and pleasure with himself and the
world in general. He may neglect some social
niceties and knock over an occasional article. At
100 mg. per 100 ml., the individual is "giddy,"
and at 150 mg. becomes clumsy. There is then
definite difficulty in adjusting to the environment
and the individual may be amused, ashamed or
angry with his incapacity. Between 150 and 300
mg. per 100 ml. there is progressive deterioration
of the function of the central nervous system; at
200 mg. the person is incoordinated and uncon-
trollable and at 300 mg. sleepy and maudlin; in
common parlance, he is "drunk." There is usually
emotional disturbance from bitter tears to raucous
laughter, progressive incoordination resulting in
inability to dress or undress, and drowsiness with
intermittent sleep. With concentrations over 300
mg., the condition resembles that of the second
stage of anesthesia (see under Ether) ; respiration
is deep and irregular, vomiting is frequent, even
when the alcohol has been injected intravenously
and there is no gastric irritation, persuasion is
futile and coercion causes violent struggling. At
a concentration of 400 mg., anesthesia is pro-

Part I

Alcohol

found; at 500 mg., the respiratory center is de-
pressed and death is likely if the concentration
remains above 500 mg. for 12 hours. Up to the
anesthetic concentration, however, there is little
effect on the respiratory or vasomotor centers in
the medulla oblongata. Newman (Science, 1949,
109, 594) estimated that the maximum consump-
tion in 24 hours short of producing coma in a
70-kilogram man was 26^ ounces of 100 proof
whisky.

Circulation. — The question of the effects of
alcohol on the circulation has been the subject
of much study and dispute. When administered
in moderate quantity, it usually does not produce
any marked change in the blood pressure. On the
other hand, the rapidity of the flow of blood
through the vessels is distinctly accelerated. This
combination of effects can be most readily ex-
plained by simultaneous increase in the cardiac
action and dilatation of the blood vessels. In-
creased muscular activity accounts for some in-
crease in circulation. Grollman (Quart. J. Stud.
Alcohol, 1942, 3, 5) believes the vasodilatation
is due to the depressant effect of alcohol on the
vasomotor centers in the brain. Further, he attrib-
uted much of what effect alcohol does have on
the circulation to reflex activity from the mouth
and to psychic components.

The widening of the blood vessels is most
noticeable in the vessels of the skin. Horwitz et al.
(Am. J. Med. Sc, 1949, 218, 669) compared
the efficacy of various vasodilators and found that
a dose of 60 to 100 ml. of whisky was most effec-
tive in increasing blood flow to the fingers and
to a lesser extent to the toes. Except for the
habituating action of alcohol it is an effective
symptomatic remedy in Buerger's disease. It may
also be useful in cases of embolism of the smaller
peripheral arteries. With blood concentrations
which permit ambulation there is little effect on
the heart. McDowall (/. Pharmacol., 1925, 25,
289) found that large doses of alcohol cause a
marked fall in the venous pressure and believes
that many of the clinical benefits which have fol-
lowed the use of alcohol can be attributed to a
dilatation of the veins. Grollman points to its
capacity to allay worry and anxiety as the most
valuable effect of alcohol on the circulation, the
sedative action being paramount.

In angina pectoris alcoholic beverages have a
long-established reputation. Stearns et al. (New
Eng. J. Med., 1946, 234, 578) found that alcohol
decreased the duration of the symptoms but not
of the objective findings as a result of the 2 -step
exercise test in cases of coronary insufficiency.
In an attack of angina pectoris, nitroglycerin is
certainly preferred, since the action of alcohol is
that of a sedative rather than a coronary dilator
(Russek et al., J.A.M.A., 1953, 153, 207). Pro-
phylactic use of wine at the end of the day's work
seems rational. Studies of cerebral blood flow by
Battey et al. (ibid., 1953, 152, 6) found that
alcohol is not an effective cerebral vasodilator;
in humans, at a blood alcohol concentration of
68 mg. per 100 ml, there was no effect on cerebral
blood flow or oxygen consumption, but at 320 mg.
per 100 ml. the cerebral flow was increased while
the oxygen consumption was decreased.

Metabolism. — When a moderate quantity of
alcohol is ingested, from 90 to 95 per cent is com-
pletely oxidized in the system, only traces of the
drug being recoverable from either the urine or
breath. The oxidation of this hydrocarbon yields
energy amounting to 7 Calories per gram, the
oxidation products being carbon dioxide and water.
The experiments of Atwater and Benedict (Mem-
oirs of the National Academy of Science, 1902,
7), of Mitchell (/. Nutrition, 1935, 10, 311) and
of many others, seem to prove that small amounts
of alcohol are entirely capable of replacing, to a
considerable degree, a portion of the carbohydrate
foodstuffs.

The metabolism of alcohol is initiated in the
liver by conversion to acetaldehyde and thence
to acetic acid which may be metabolized in many
tissues in the manner of degradation products of
carbohydrate. The respiratory quotient of alcohol
is 0.667, and its combustion may spare that of
carbohydrate, fat and protein. Alcohol cannot be
stored in the body and in the absence of food it
will not form liver glycogen. Goldfarb et al.
(J. Clin. Inv., 1939, 18, 581) found that simul-
taneous administration of dextrose and insulin
increased the rate of oxidation of alcohol; this
may prove helpful in treatment of severe intoxi-
cation. Although the rate of metabolism of alcohol
varies with many circumstances, the average may
be about 10 Gm. per hour. The caloric sig-
nificance of alcohol may be illustrated by noting
that the ingestion of 1 pint of whisky in 24 hours
could result in the combustion of 170 Gm. of
alcohol and the production of 1,200 Calories,
which represents the basal caloric requirement of
a good-sized man. If his food consumption de-
creases accordingly, avitaminosis and other evi-
dences of malnutrition result; if food consump-
tion continues, obesity results. Usual concentra-
tions do not seem to effect liver function, but
Newman et al. (J. Pharmacol., 1940, 168, 194)
found decreased liver glycogen, increased blood
lactic acid and decreased hepatic oxygen con-
sumption following high concentrations of alcohol
in the blood. A low normal sulfobromophthalein
clearance was reported in chronic alcoholics with-
out obvious liver disease (Goodman and Kings-
ley, J.A.M.A., 1953, 153, 462).

Gastrointestinal. — Alcohol has a marked in-
fluence on gastric and probably also intestinal
digestion. As a carminative in flatulent dyspepsia,
alcoholic beverages or alcoholic solutions of essen-
tial oils (tinctures) are commonly used with
symptomatic benefit.

Dilute alcohol solutions stimulate gastric secre-
tion; 50 ml. of 7 per cent alcohol is commonly
used as a test meal in lieu of the classical tea-and-
toast meal and has the advantage of containing
no particulate matter to block the aspirating tube.
Roth et al. (J.A.M.A., 1944, 126, 814) reported
that the alcohol test meal caused a greater rise
in free hydrochloric acid in patients with peptic
ulcer than in normal persons. Concentrations up
to 10 per cent produce a gastric juice rich in
hydrochloric acid although poor in pepsin (Bloom-
field and Keefer, J. Clin. Inv., 1928, 5, 295).
Concentrations of 20 to 40 per cent alcohol or
more cause inflammation of the gastric mucosa

Alcohol

Part I

(Beazell and Ivy, Quart. J. Stud. Alcohol, 1940,
1, 45). After section of the vagi or their paralysis
by atropine this increase in the digestive secre-
tions does not occur. (For further information
on the effects of alcohol on digestion, see Gray,
Am. J. Physiol, 1937, 120, 657.) It has been
shown by Greenberg, Lolli, and Rubin {Quart. J.
Stud. Alcohol, 1942, 3, 371) that intravenously
administered alcohol delays the emptying time
of the stomach.

Skin. — Alcohol is widely used for application
to the skin. It serves as an irritant, an anhidrotic.
and an astringent by virtue of its precipitation of
cellular protein, thus being useful in the hygienic
care of the skin in bed-ridden patients and the
prevention of decubitus ulcers. Its cooling quality
on evaporation is well known in the nursing care
of febrile patients. It may be used to remove
phenol, poison ivy, etc., from the skin. There is
no more widely used antiseptic for the skin in
preparation for surgical procedures, as well as in
the disinfection of surgical instruments. Price
(Arch. Surg., 1950, 60, 492) reported that a
2-minute washing of the surgeon's hands in 70 to
95 per cent alcohol decreased the surviving bac-
terial flora to less than 10 per cent. Lesser con-
centrations were less effective. Some bacterial
spores are resistant to alcohol. Heat sterilization
is necessary for surgical instruments. Further-
more, storage in alcohol results in rusting of steel
instruments. Price (J.A.M.A., 1944, 124, 189)
recommended its use locally for the treatment of
furunculosis. For intractable pulmonary edema,
Gootnick et al. (New Eng. J. Med., 1951, 245,
842) and Luisada et al. (Circulation, 1952, 5,
363) nebuilized 50 per cent alcohol and caused
its inhalation with oxygen pressure in a meter
mask. The alcohol has an antifoaming action,
causing the fine bubbles in the smaller bronchi
to collapse and permit entry of the oxygen.

Xerve Block. — Alcohol is used by injection
for intractable pain, as in trigeminal neuralgia
(tic douloureux) (Sweet, J.A.M.A., 1950, 142,
392), angina pectoris (Levy and Moore, J. A.M. A.,
1941, 116, 2563), inoperable cancer of the pelvis,
and in sciatica.

In the management of intractable pain in the
pelvis or legs, 0.75 ml. of absolute or 95 per cent
alcohol is injected slowly over a period of 2 min-
utes through a lumbar puncture needle in the
fourth lumbar interspace with the patient lying
on the side opposite to that with the most pain.
The patient must remain in this lateral recumbent
position for 2 hours. The specific gravity of the
alcohol is less than that of the spinal fluid and
the alcohol in this lateral recumbent position
rises into contact with the posterior spinal roots.
Spinal fluid should not be withdrawn to mix with
the alcohol in the syringe. If needed the injection
may be repeated for the other side a week or two
later. Considerable neuritic pain may follow this
injection for 1 to 2 weeks and in some instances
the motor nerves may be damaged by the alcohol.
This procedure is indicated only for severe pain
in metastatic carcinoma or other hopeless condi-
tion (Bonica, /. Michigan M. Soc, 1953, 52,
284) because of the arachnoiditis, and damage to
the spinal cord it produces.

Stellar (Arch. Neurol. Psychiat., 1953, 69,
343) used subarachnoid injections of alcohol to
relieve spasticity and contractures in paraplegic
patients.

Retrobulbar injections of alcohol for painful
eyes which cannot be enucleated surgically for
some reason gave relief for several months and
did not permanently destroy remaining visual
ability (Maumenee, Am. J. Ophth., 1949, 32,
1502).

In prolonged, severe pain, alcohol injections
have been employed to destroy temporarily the
peripheral nerve from the involved area. This
has been done with the intercostal nerves in in-
stances of tuberculous or other chronic form of
pleurisy. Klein (Wien. klin. Wchnschr., 1949, 99,
512) reported successful use of alcohol injections
of the sympathetic nerve chain at the fifth and
tenth thoracic vertebral levels in lieu of sympa-
thectomy in cases of severe hypertension.

For intractable pruritus vulvae, Wilson (West.
J. Surg. Obst. Gynec, 1949, 57, 406) made multi-
ple subcutaneous injections of 0.1 to 0.25 ml.,
spaced about 1 to 2 cm. apart, with relief in about
half of the cases.

Anesthesia. — Intravenous alcohol anesthesia
was reported by Verkhovskaya (Am. Rev. Soviet
Med., 1945, 2, 260). His patients in an evacua-
tion hospital were prepared as for ether anesthesia.
The solution used is one part 95 per cent alcohol
with two parts of 5 per cent dextrose solution,
the average amount for narcosis being 2 to 2.5 ml.
per Kg. body weight. For example, a 60 Kg.
patient needs 120 ml. of alcohol and 240 ml. of
dextrose solution. The infusion is given slowly
over 15 or 20 minutes until the patient sleeps.
After deep anesthesia is present the vein is flushed
with 30 to 40 ml. of normal saline to prevent
thrombo-phlebitis. Sleep lasts two to five hours.
The dose is more difficult to regulate than with
ether by inhalation and the reflexes are less well
depressed than with ether. The prolonged re-
covery period is often undesirable.

Child (Ar. Y. State J. Med., 1951, 51, 1521)
found this solution, with added vitamins, useful
in the management of the withdrawal syndrome
of opium addicts.

Chapman and Williams (Am. J. Obst. Gyn.,
1951, 61, 676) used 7.5 per cent alcohol in 5 per
cent dextrose injection intravenously for ob-
stetrical analgesia, along with otherwise ineffective
doses of meperidine, successfully except for vomit-
ing in some cases and the difficulty of keeping
the needle in the vein. Determinations of alcohol
in the cord blood showed that alcohol reached
the fetus, but depression of respiration was not
observed.

In status asthmaticus in children, 5 per cent
ethyl alcohol in 5 per cent dextrose in isotonic
sodium chloride solution or distilled water for
injection has been employed in a dose of 40 ml.
per kilogram of body weight; the first 80 to 100
ml. is given in a period of 10 minutes and the
remainder of the dose at a rate of 2 drops per
kilogram per minute (Bacal and Pedvis, Can.
Med. Assoc. J., 1948, 59, 410). In the control of
intractable pain, 5 or 10 per cent alcohol in 5 per
cent dextrose may be given intravenously; relief

Part I

Alcohol

is transient and the resulting inebriation may be
unpleasant.

For postspinal-puncture headache, which is
often totally disabling and resistant to therapy,
Deutsch (Anesth., 1952, 13, 496) gave 1 liter of
5 per cent alcohol in 5 per cent dextrose injection
intravenously over a period of 4 hours with relief
in 10 of 15 cases.

Parenteral Nutrition. — Rasmussen (Jackson
Clin. Bull., 1945, 7, 45) recommended intravenous
alcohol as supportive treatment postoperatively,
administering 1 to 3 liters of 5 to 10 per cent
solution in 5 per cent dextrose and saline solution.
Alcohol may be administered intravenously to
adults at a rate up to 15 ml. per hour without
causing significant inebriation. In addition to some
sedative action, it has nutritional value in the fre-
quently malnourished postoperative case (Karp
and Sokol, J.A.M.A., 1951, 146, 21). Pending
the availability of stable fat emulsions for in-
travenous injection to supply calories in sufficient
quantity to spare protein tissue from combustion
for the daily caloric requirement such an alcohol-
saline-dextrose mixture with 5 per cent protein
hydrolysate is useful (Rice et al., J. -Lancet, 1948,
78, 91) ; the alcohol provides 7 Calories per gram.
In malnourished individuals, it is important to
add therapeutic doses of the B-vitamins to this
solution to avoid precipitation of the enceph-
alopathy of Wernicke with the large dose of
carbohydrate.

Stimulant. — As a circulatory stimulant there
is no doubt that in the past too much confidence
has been placed in alcohol. Nevertheless, if used
circumspectly, it is often of value. Myers
(/. Pharmacol, 1933, 49, 483), in studying the
treatment of the shock produced by diphtheria
toxin, found that alcohol was the only drug of
those he tested which caused a definite improve-
ment in the circulation. It is used especially when
it is desired to tide the patient over for a limited
period of time. It must never be forgotten that
large doses are depressant. While a small amount
of alcohol may prove useful in cases of snake bite,
it is no exaggeration to say that the injudicious
exhibition of this drug has been responsible for
many deaths after rattlesnake bites, where the
specific antivenin would have been life-saving.
In the circulatory failure due to anesthetics it
should be sedulously avoided; on account of its
close chemical relation to both ether and chloro-
form it acts as a synergist rather than an antag-
onist to these poisons. The use of alcohol in
infectious fevers, especially typhoid fever, in-
volves a large number of factors concerning some
of which we have at present no definite knowledge.
The impairment of digestion, which is so uni-
versal an accompaniment of these diseases, sug-
gests the use of alcohol both as a stimulant to
gastric secretion and as an accessory food. While
febrile patients are capable of burning up larger
quantities of alcohol than normal individuals, if
given too freely the unoxidized alcohol circulat-
ing in the blood may prove injurious. An alco-
holic odor to the breath is generally a sign that
the patient is receiving more than he can oxidize.
Many believe that the mild narcotic action of

alcohol is also of service in preserving the vitality
in these adynamic states.

Taken internally, alcohol tends to increase the
sweat by dilating the vessels of the skin and is
frequently used as an aid to more powerful
diaphoretic measures in the abortion of mild in-
fections, such as acute coryza.

In dysmenorrhea, alcoholic beverages are often
an effective analgesic but the general action is
undesirable in this recurrent condition.

In insomnia, particularly in older people, an
alcoholic beverage at bedtime may be most effec-
tive in bringing relaxation and sleep; for this
purpose the dose should not exceed 10 to 20 ml.
of whisky, lest excitement rather than sedation be
produced. Alcohol relaxes athetosis but it is hardly
possible to use it in the treatment of this chronic
disorder.

Raw alcohol is rarely used internally, prefer-
ence being shown for one of the alcoholic bever-
ages, such as whisky, brandy, or wine.

Pharmaceutical Uses. — Various strengths of
alcohol are used in pharmacy, as for preservation
of a variety of medicinals, extraction of active
principles of crude drugs, and for dissolving sub-
stances which are more soluble in hydroalcoholic
media than they are in water. IYJ

Toxicology. — The symptoms of acute alcohol
poisoning are unfortunately so widely known that
detailed description is unnecessary, but alcohol
poisoning is of great importance, not alone be-
cause of the frequency of serious results, but be-
cause of the similarity of its symptoms with those
of certain diseases or other narcotic poisons. The
odor of paraldehyde on the breath may be mis-
taken for alcohol. Barbiturate poisoning, skull
fracture, cerebral hemorrhage or schizophrenia
may simulate alcoholism. The important diag-
nostic symptoms are the characteristic odor on
the breath and the peculiar maudlin mentality, if
the patient can be aroused. Nystagmus, clumsy
performance of coordinated movements, such as
walking a straight line, and impaired perception
of fine differences are characteristic. In the coma-
tose state the pupils are usually somewhat dilated,
the face is flushed, the skin is cold and moist, the
pulse is rapid and the breathing noisy and re-
duced in frequency. The fatal dose of whisky
requires the ingestion of 1 quart within a few
minutes, which seldom occurs because of incoordi-
nation and pylorospasm.

The treatment of alcohol poisoning consists in
the immediate evacuation of the stomach, main-
tenance of body temperature by use of external
heat, and use of respiratory stimulants, notably
caffeine and sodium benzoate or enemas of strong
coffee. Inhalation of aromatic ammonia spirit
may arouse temporarily. Carbon dioxide (5 per
cent) and oxygen (95 per cent) inhalations are
required in profound coma. Apomorphine solu-
tion is often injected but in an alcoholic patient
it may produce still further depression rather than
initiating vomiting. Ephedrine or amphetamine
may be helpful.

Habitual alcoholism is a major health and eco-
nomic problem. More is spent annually on alco-
holic beverages than on health. Block (GP, Sept.
1952) estimated the cost of the effects of alco-

Alcohol

Part I

holism to exceed a half billion dollars yearly; 20
million by private and another 20 million by
public agencies in the care of the families of
problem drinkers, 30 million for the care of alco-
holics in mental hospitals, 25 million for the care
of alcoholic prisoners in jails, 125 million expense
of preventable accidents due to alcohol, and over
a half billion in loss of productivity in industry
due to alcoholism. About half of all chronic alco-
holics have an underlying mental disorder. The
other half, commencing as "social drinkers,"
enjoy the escape from the frustrations of life and
by virtue of frequent excessive indulgence become
less able to cope with their problems and sink into
the results of chronic alcoholism. Gastritis is not
infrequent. Alcoholism is present in most cases
of cirrhosis of the liver but the relation is not one
of a toxic effect of alcohol on the liver. Malnutri-
tion secondary to a failure to eat an adequate
diet is important. The glucose tolerance may be
altered (see Voegtlin, Quart. J. Stud. Alcohol,
1943, 4, 163). Dewan (Am. J. Psychiat., 1943,
99, 565) indicates that riboflavin and niacin are
components of the oxidation mechanism of alcohol
within the brain substance, this mechanism acting
as a hydrogen carrier between reduced diphospho-
pyridine nucleotide and the cytochrome system.
Spies and Aring (J. A.M. A., 1938, 110, 1081)
snowed that "alcoholic polyneuritis" could be
cured by correcting the malnutrition without dis-
continuing the alcohol intake. Emaciation and
general ill health in the alcoholic seems to be
due to malnutrition. The red nose and the acne-
form skin lesions may be related to ariboflavinosis.
Korsakoff's psychosis described in chronic alco-
holics resembles the mental aberration seen in
pellagra. Wernicke's syndrome is related to a
deficiency of vitamin B.

Figueroa et al. (J. Clin. Nutrition, 1953, 1,
179) comment on the low incidence of frank
avitaminosis in chronic alcoholics at the present
time in contrast to the higher incidence in the
past.

Delirium tremens is characterized by an acute
panic, excitement and fear, visual and auditory
hallucinations and marked exhaustion. It may be
precipitated in the chronic alcoholic by inter-
current disease, sudden withdrawal of alcohol or
an increased consumption of alcohol. Cerebral
edema is often present and may cause death.
Alcohol tends to cause an increase in extracellular
fluid. Alcoholics are seriously ill and require care-
ful supportive therapy. Much folklore concerns
the increased tolerance of the chronic drinker to
alcohol but the increased consumption never ap-
proaches the magnitude of the morphine addict.
Schweisheimer {Deutsch. Arch. f. klin. Med.,
1912-3. 109, 271) showed that the non-drinker
reacted much more violently to a given concen-
tration of alcohol in the blood than did the
habitual consumer of alcoholic beverages. Animal
studies by Newman and Lehman (/. Pharmacol.,
1938, 62, 301) showed that symptoms appeared
in habituated animals only at higher concentra-
tions in the blood than in previously unexposed
animals; since the brain in these habituated ani-
mals was equally permeable to the alcohol, it was
suggested that the cells had become resistant to

the effects of the lower concentration. At the
most this increased tolerance is not more than
2 or 3 times that of the unexposed individual.
The resistance of chronic alcoholics to the related
anesthetics such as ether and chloroform is com-
patible with such an explanation.

The management of the chronic alcoholic is
initially protective and supportive until malnutri-
tion can be corrected and health restored. Defini-
tive treatment is psychiatric in nature and has
been most successful under the auspices of such
organizations as Alcoholics Anonymous, in which
group psychotherapy and occupational therapy
are conducted by individuals who themselves
have recovered from chronic alcoholism. This
voluntary approach has been the most successful,
particularly in the older individual with previous
skills and with family obligations. It is unfortu-
nate that the individual must often be hurt so
badly before he voluntarily associates himself
with such a group, but the desire to reform is
essential to the discontinuance of alcohol. As
already noted delirium tremens requires expert
medical care. The former practice of lumbar
puncture to withdraw spinal fluid to relieve pres-
sure resulted in many fatalities, perhaps as a re-
sult of herniation of the brain stem through the
foramen magnum; the use of magnesium sulfate
by mouth or, in emergencies, 50 per cent dextrose
intravenously is effective and safer. Smith
(J.A.M.A., 1953, 152, 384) recommended the
following regimen: hospitalize under careful nurs-
ing care; inject 1 liter of 5 per cent dextrose in
isotonic sodium chloride solution (for injection)
containing 500 mg. ascorbic acid, 200 mg. thia-
mine hydrochloride and 100 mg. nicotinamide
intravenously and repeat in 12 hours; give paral-
dehyde 10 to 16 ml. or chloral hydrate 1 to 2
Gm. by mouth as often as needed to control
delirium and mephobarbital 200 mg. four times
daily by mouth. Feldman and Zucker (J.A.M.A.,
1953, 153, 895) confirmed the value of adrenal
cortical extract to shorten convalescence (see
under Adrenal Cortex Injection). Under sanato-
rium control, the use of alcoholic beverages along
with nauseants, such as ipecac or apomorphine
(Feldman, Praxis, 1952, 41, 871), may be useful
but cannot substitute for the determination of the
individual to discontinue use of alcohol com-
pletely. The use of tetraethylthiuram disulfide
(see in Part II), which causes intense discomfort
if alcohol is ingested, may be useful in the same
way as the nauseants.

Because of the medicolegal importance in auto-
mobile accidents resulting from driving while
intoxicated, and also in the investigation of violent
deaths (Wilentz, Am. Pract. Dig. Treat., 1953, 4,
21), tests of alcohol levels in blood and urine are
of great importance. A useful quantitative test is
described in Levinson and MacFate's Clinical
Laboratory Diagnosis, 4th Edition, 1951; in this
test alcohol is quantitatively oxidized to acetic
acid by a standard potassium dichromate solution
used in excess, the excess of the latter being de-
termined through liberation of iodine from potas-
sium iodide and titration with standard sodium
thiosulfate solution. The National Safety Coun-
cil (Progress Report of the Committee on Tests

Part I

Alcohol, Diluted 41

for Intoxication of the Street and Highway Traffic
Section, 1937) recommended that a blood concen-
tration of more than 0.15 per cent is conclusive
evidence of intoxication; levels of 0.05 per cent
to 0.15 per cent may be associated with mild
intoxication, which must be evaluated by tests
of psychomotor performance; if the level is less
than 0.05 per cent the driver should not be
prosecuted (Newman, /. Clin. Psychopath.,
1946-7, 8, 83). Alcohol should not be applied to
the skin before taking blood samples. Sodium
fluoride (500 mg. for a blood specimen of 3 to 6
ml.) will serve as an anticoagulant and preserva-
tive of the alcohol for many hours if analysis
must be delayed. An alcoholmeter for simple and
almost automatic estimation of alcohol in expired
air was developed by Greenberg and Keator
(Quart. J. Stud. Alcohol, 1941-2, 2, 57) for use
by trained, nonmedical personnel in police de-
partments. In this apparatus the alcohol in the
breath reacts with pentoxide and in turn pro-
duces a starch-iodine blue color which is recorded
by a photoelectric cell.

Storage. — Preserve "in tight containers, re-
mote from fire." U.S.P.

DEHYDRATED ALCOHOL. N.F. (LP.)

Dehydrated Ethanol, "Absolute Alcohol" [Alcohol
Dehydratum]

"Dehydrated Alcohol contains not less than
99 per cent by weight of C2H6O." N.F. The LP.
Absolute Ethanol is ethyl alcohol with not more
than 2 per cent w/w of water; not less than 98.8
per cent v/v, corresponding to not less than 98.1
per cent w/w, of C2H5OH is required.

Alcohol Absolutus; Alcohol Ethylicum; Spiritus Abso-
lutus. Fr. Alcool ethylique; Ethanol; Alcool absolu; Alcool
a cent degres centesimaux. Ger. Absoluter Alkohol. It.
Alcool etilico assoluto. Sp. Alcohol absoluto; Alcohol
deshidratado.

The term "absolute alcohol" is properly applied
only to 100 per cent C2H5OH; the correct desig-
nation for a liquid containing over 99 per cent,
but less than 100 per cent, of C2H5OH, is de-
hydrated alcohol.

As mentioned previously, the maximum concen-
tration of C2H5OH obtainable by the regular
methods of fractional distillation is 95.57 per
cent, corresponding to the composition of the
constant-boiling mixture of alcohol and water.
By azeotropic distillation in which a third compo-
nent, such as benzene, is present, it is possible to
prepare even absolute alcohol. The process de-
pends on the fact that when a mixture of ordinary
alcohol and benzene is distilled the initial frac-
tion, passing over at 64.8°, contains benzene,
water and alcohol; the second fraction, distilling
at 68.2°, is composed of benzene and alcohol; the
third, boiling at 78.3°, is absolute alcohol. This is
the commercial process for preparing dehydrated
alcohol. A similar use of ether as an entraining
agent has been proposed.

Prior to the use of the azeotropic distillation
process, dehydrated alcohol was prepared by add-
ing to alcohol various substances which possess
an affinity for water. The British Pharmacopoeia
of 1895 directed that alcohol be kept in contact
with anhydrous potassium carbonate during 24

hours, decanted, then allowed to stand in contact
with fused calcium chloride for a like period, and
finally distilled from the latter. Other drying
agents which have been used, and still are em-
ployed in laboratory preparation of dehydrated
alcohol, are freshly calcined lime, anhydrous
potassium and sodium acetates, barium oxide, and
metallic calcium, which last reacts with water to
form calcium hydroxide.

Description and Tests. — "Dehydrated Al-
cohol is a transparent, colorless, mobile, and vola-
tile liquid, having a characteristic odor, and a
burning taste. It is hygroscopic and flammable.
Dehydrated Alcohol is readily volatilized even at
low temperatures and boils at about 78°. Dehy-
drated Alcohol is miscible with water without any
trace of cloudiness. It is also miscible with ether
and with chloroform. The specific gravity of
Dehydrated Alcohol is not more than 0.798 at
15.56° (the U. S. Government standard tempera-
ture for Alcohol)." N.F.

The N.F. prescribes the same tests for this
liquid as does the U.S.P. for alcohol and, in
addition, requires that dehydrated alcohol meet
the requirements of the tests for alkaloids and
formaldehyde under Whisky.

Absolute (100 per cent) alcohol has a specific
gravity, at 15.56°, of 0.7936.

The tests frequently employed to prove the
absence of water by dropping into dehydrated
alcohol anhydrous barium oxide or anhydrous
copper sulfate are not reliable, as Squibb demon-
strated that when one-half of one per cent of
water is added to absolute alcohol no change in
either the barium oxide or the anhydrous copper
sulfate took place. Gorgeu's test of forming a clear
solution when mixed with an equal bulk of pure
benzene is more delicate. The test of Henle (Ber.,
1920, 53, 719) is capable of detecting 0.05 per
cent of water in ethyl alcohol; in this test a solu-
tion of aluminum ethoxide in benzene forms a
voluminous precipitate when added to ethyl al-
cohol containing water.

Uses. — Dehydrated alcohol is sometimes in-
jected into the immediate neighborhood of nerve
ganglia, or even into the spinal cord, for the
relief of pain (see also under Alcohol). It is used
as a reagent in certain tests, as a solvent in sys-
tems where water must be excluded, and in certain
syntheses.

Storage. — Preserve "in tight containers, re-
mote from fire." N.F.

DILUTED ALCOHOL. U.S.P.

Diluted Ethanol, [Alcohol Dilutum]

"Diluted Alcohol is a mixture of alcohol and
water containing not less than 41 per cent and
not more than 42 per cent by weight, correspond-
ing to not less than 48.4 per cent and not more
than 49.5 per cent by volume, at 15.56°, of
C2H5OH." U.S.P.

The B.P. does not use the title Diluted Alcohol,
but gives a series of eight formulas for prepara-
tion of Dilute Alcohols ranging from 20 per cent
to 90 per cent, by volume. These are prescribed
by specifying the concentration desired as, for
example, "Alcohol (70 per cent)."

42 Alcohol, Diluted

Part I

The I. P. Dilute Et Hanoi contains not less than
69.1 per cent v/v and not more than 71 per cent
v/v, corresponding to not less than 61.5 per cent
w/w and not more than 63.5 per cent w/w, of
CMoOH.

Sp. Alcohol Diluido.

The U.S. P. indicates that diluted alcohol may
be prepared by mixing equal volumes of alcohol
and purihed water, both measured at the same
temperature. At 25° the contraction in volume,
after cooling the mixture to the same tempera-
ture, is about 3 per cent.

Description and Tests. — "Diluted Alcohol
is a transparent, colorless, mobile liquid, having a
characteristic odor and a burning taste. The spe-
cific gravity of Diluted Alcohol is not less than
0.935 and not more than 0.937 at 15. 56°, indicat-
ing not less than 41 per cent and not more than
42 per cent by weight, or not less than 48.4 per
cent and not more than 49.5 per cent by volume,
of C2H5OH. In other respects Diluted Alcohol
complies with the tests under Alcohol, allowance
being made for the difference in alcohol concen-
tration." U.S.P.

Uses. — Diluted alcohol is employed chiefly as
a menstruum and solvent in various pharmaceu-
tical manufacturing processes. When the thera-
peutic effects of alcohol are desired it is cus-
tomary to employ either whisky or brandy. For
description of the physiologic and therapeutic
properties, see under Alcohol.

Storage. — Preserve "in tight containers, re-
mote from fire." U.S.P.

ALCOHOL RUBBING COMPOUND.

N.F.

Rubbing Alcohol, [Alcohol Fricamentum Compositum]

"Alcohol Rubbing Compound and all prepara-
tions coming under the classification of Rubbing
Alcohols must be manufactured in accordance
with the requirements of the Internal Revenue
Service, U. S. Treasury Department, using spe-
cially denatured alcohol Formula 23-G (3.5 parts
by volume of methyl propyl ketone, 0.5 part by
volume of methyl isobutyl ketone, and 100 parts
by volume of ethyl alcohol), or Formula 23-H
(8 parts by volume of acetone, 1.5 parts by vol-
ume of methyl isobutyl ketone, and 100 parts by
volume of ethyl alcohol). It contains not less than
68.5 per cent and not more than 71.5 per cent by
volume of absolute ethyl alcohol. Alcohol Rubbing
Compound contains in each 100 ml. not less than
355 mg. of sucrose octaacetate. Small quantities of
perfume oils may be added if desired. The prep-
aration may also be colored with one or more
coal-tar colors, certified by the Food and Drug
Administration for use in drugs. A suitable stabi-
lizer may also be added. Alcohol Rubbing Com-
pound complies with the requirements of the In-
ternal Revenue Service of the United States
Treasury Department. Note: Alcohol Rubbing
Compound must be packaged, labeled and sold in
accordance with the regulations issued by the
Internal Revenue Service, U. S. Treasury De-
partment." N.F.

Description. — "Alcohol Rubbing Compound

is a transparent, colorless or colored as desired,
mobile, and volatile liquid. It has an extremely
bitter taste, and in the absence of added odorous
constituents, a characteristic odor. It is flammable.
The specific gravity of Alcohol Rubbing Com-
pound, manufactured with specially denatured
alcohol Formula 23-G, is not less than 0.8797 and
not more than 0.8874, and the specific gravity of
Alcohol Rubbing Compound, manufactured with
specially denatured alcohol Formula 23-H is not
less than 0.8691 and not more than 0.8771 at
15.56° (the U. S. Government standard tempera-
ture for alcohol j." N.F.

Standards and Tests. — Non-volatile residue.
— The weight of residue obtained by evaporating
25 ml. of alcohol rubbing compound and drying
the residue at 105° for 1 hour is not less than
89 mg. Methanol. — 0.5 ml. of a dilution of 0.5 ml.
of alcohol rubbing compound to 1 ml. with water
meets the requirements of the test for methanol
under Whisky. Assay for sucrose octaacetate. —
The residue from the test for non-volatile residue
is neutralized with 0.1 N sodium hydroxide, using
phenolphthalein T.S., and then saponified by heat-
ing with a measured excess of 0.1 N sodium hy-
droxide. The excess alkali is titrated with 0.1 N
sulfuric acid. Each ml. of 0.1 N sodium hydroxide
represents 8.482 mg. of sucrose octaacetate (the
equivalent is based on the formation of 8 mole-
cules of acetic acid by hydrolysis). N.F.

For a discussion of the use of alcohol exter-
nally as a "rubbing compound" see under Al-
cohol. The N.F. rubbing alcohol has been ren-
dered unfit for beverage use and is. accordingly,
available at a much lower cost to the consumer
because it is not subject to the regular alcohol
tax. Under no circumstances should Alcohol Rub-
bing Compound be employed in place of alcohol.

Storage. — Preserve "in tight containers, re-
mote from fire." N.F.

ALLYLBARBITURIC ACID. N.F.

Allylisobutylbarbituric Acid

CH2CH=CH2

CHCH(CH )
2 32

Sandoptal (Sando:).

Allylbarbituric acid, more informatively desig-
nated 5-allyl-5-isobutylbarbituric acid, may be
prepared by the method described by Yolwiler
(J.A.C.S., 1925, 47, 2236) in which the diethyl
ester of mono-isobutylmalonic acid is condensed
with urea, producing mono-isobutylbarbituric acid,
into which is introduced the allyl substituent by
interaction with allyl bromide in sodium hydroxide
solution. Acidification of the reaction mixture pre-
cipitates the 5-allyl-5-isobutylbarbituric acid.

Description. — "Allylbarbituric Acid occurs as
a white, crystalline, odorless powder, with a
slightly bitter taste. It is stable in air. A saturated
solution is acid to litmus paper. Allylbarbituric
Acid is freely soluble in alcohol, in ether, and in
chloroform ; it is slightly soluble in cold water and
soluble in boiling water. It is soluble in solutions

Part I

Almond Oil, Bitter 43

of fixed alkalies and carbonates. Allylbarbituric
Acid melts between 138° and 139°." N.F.

Standards and Tests. — Identification. — (1)
A filtered solution of 300 mg. of allylbarbituric
acid in a mixture of 1 ml. of 1 N sodium hydrox-
ide and 5 ml. of water is divided into two por-
tions: one portion yields with 1 ml. of mercury
bichloride T.S. a white precipitate, soluble in 10
ml. of ammonia T.S.; the other portion yields
with 5 ml. of silver nitrate T.S. a white precipi-
tate, soluble in 5 ml. of diluted ammonia solu-
tion. (2) On boiling 500 mg. of the acid with
5 ml. of 1 in 4 sodium hydroxide solution am-
monia is evolved. (3) A saturated solution of
allylbarbituric acid in water is prepared: on add-
ing 1 ml. of acetic acid and 0.5 ml. of bromine
T.S. to 5 ml. of the solution the bromine color is
discharged immediately; on adding 0.1 ml. of
potassium permanganate T.S. to another 5 ml.
portion of the solution a yellow color appears im-
mediately, turning to brown. Loss on drying. —
Not over 1 per cent, when dried at 105° for 2
hours. Residue on ignition. — Not over 0.1 per
cent. Heavy metals. — About 100 mg. of allyl-
barbituric acid is boiled with 10 ml. of water for
2 minutes, cooled, and filtered: on saturating the
filtrate with hydrogen sulfide no coloration or pre-
cipitation results. Readily carbonizable substances.
— A solution of 500 mg. of the allylbarbituric
acid in 5 ml. of sulfuric acid has no more color
than matching fluid A. N.F.

Uses. — Allylbarbituric acid (see article on
Barbiturates, in Part II, for general discussion)
has been classified as being a barbiturate of inter-
mediate duration of action, according to the sys-
tem of Fitch and Tatum (/. Pharmacol., 1932,
44, 325). Its duration of action is of an order
comparable with that of aprobarbital and of amo-
barbital (Tatum, Physiol. Rev., 1939, 19, 472).
In general, it is employed as an hypnotic agent
or for mild sustained sedation. In this respect its
clinical indications are much the same as for bar-
bital or amobarbital.

Allylbarbituric acid is metabolized primarily
in the liver, according to Masson and Beland
(Anesth., 1945, 6, 483). Only trace amounts are
excreted as such by normal patients (Koppanyi
et al., J. Pharmacol., 1934, 52, 87). Staub re-
ported that some 20 per cent of the daily dose
administered to schizophrenic patients was ex-
creted as such (Schweiz. Arch. Neurol. Psychiat.,
1950, 65, 330). Allylbarbituric acid apparently
possesses no toxicologic characteristics that are
not shared on a pharmacodynamic basis with other
barbiturates. Nielsen et al. (J. Pharmacol., 1925,
26, 371) found that the minimum lethal dose of
allylbarbituric acid, when the sodium salt was in-
jected subcutaneously into white rats, was 175
mg. per Kg. of body weight, with the ratio of
minimum effective dose to minimum lethal dose
being next to the most favorable for the series of
15 barbiturates which they investigated.

Dose. — For sedation the dose range is 100 to
200 mg. (approximately l/2 to 3 grains); the
hypnotic dose varies from 200 to 800 mg., the
higher doses being used in obstinate cases of
insomnia.

Storage. — Preserve "in well-closed contain-
ers." N.F.

ALLYLBARBITURIC ACID
TABLETS. N.F.

"Allylbarbituric Acid Tablets contain not less
than 94 per cent and not more than 106 per cent
of the labeled amount of C11H16N2O3." N.F.

The assay is identical with that described under
Barbital Tablets.

Usual Size. — 200 mg. (approximately 3
grains).

BITTER ALMOND OIL.

[Oleum Amygdalae Amarae]

N.F.

"Bitter Almond Oil is the volatile oil obtained
from the dried ripe kernel (deprived of fixed oil)
of Primus Amygdalus Batsch var. amara (De
Candolle) Focke (Fam. Rosacea), or from other
kernels containing amygdalin, by maceration with
water and subsequent distillation with steam. It
contains not less than 80 per cent of CgHs.CHO,
and not less than 2 per cent and not more than 4
per cent of HCN. Bitter Almond Oil in which
crystals have formed must not be dispensed.

''Caution. — Bitter Almond Oil is intended for
medicinal use and neither it nor its solution should
be used or sold for flavoring foods." N.F.

This should not be confused with the B.P.
Volatile Bitter Almond Oil, which contains no
hydrocyanic acid.

Oil of Bitter Almond. Oleum Amygdalarum Amararum
^Ethereum. Fr. Essence d'amande amere. Ger. Atherisches
Bittermandelol. Sp. Esencia de almendre amarga.

The almond tree — Prunus Amygdalus Batsch
(Amygdalus communis Linne) — resembles some-
what the cherry. The leaves are elliptical,
petiolate, minutely serrated, and are of a bright
green color. The flowers are large, varying from
pink to white, with very short peduncles, and
petals longer than the calyx, and usually stand in
pairs upon the branches. The fruit is a drupe with
the outer covering thin, tough, dry, downy, and
marked with a longitudinal furrow, where it opens
when fully ripe. Within this covering is a rough
shell, containing the kernel or almond.

There are several varieties of this species of
Prunus, differing chiefly in the size and shape of
the fruit, the thickness of the shell, and the taste
of the kernel. The two most important are the
var. dulcis and the var. amara, the former bearing
sweet, the latter bitter, almonds. Both of these
varieties have been known since ancient times.
The almond tree is a native of subtropical Asia
and Asia Minor. It is now cultivated also in
southern Europe, northern Africa, southern Eng-
land, and California. Bitter almonds are chiefly
imported from France, Morocco and Sicily. Bitter
almond oil is usually imported from France,
United Kingdom and Netherlands. In 1952 these
countries shipped 3777 pounds to the United
States.

Bitter Almonds. — These seeds are smaller than
the sweet almonds, which they resemble in gen-
eral appearance, but are distinguished by being
shorter and proportionally broader, by their bitter
taste, and by the characteristic odor resembling

44 Almond Oil, Bitter

Part I

that of hydrocyanic acid when they are bruised
in a mortar and triturated with water.

They have the bitter taste of the peach kernel,
and, though when dry. are inodorous or nearly so,
have, when triturated with water, the fragrance
of peach blossom. They contain essentially the
same constituents as sweet almonds, and like them
form a milky emulsion with water. Their char-
acteristic flavor is due to the formation of benz-
aldehyde and hydrocyanic acid. These principles
do not preexist in the almond, but result from
the decomposition of the glycoside amygdalin.
Amygdalin is mandelonitrile-p-gentiobioside, a
glycoside of mandelonitrile, CoHsCHOHCN, with
gentiobiose, a disaccharide formed by the conden-
sation of two glucose molecules. It is white, crys-
tallizable, inodorous, of a sweetish bitter taste,
freely soluble in water and hot alcohol, very
slightly soluble in cold alcohol, and insoluble in
ether. It is hydrolyzed in the presence of diluted
acids or the enzyme emulsin, which accompanies
it in bitter almond. Destruction of emulsin, as by
heating, prevents the hydrolysis of amygdalin
and consequently of the development of the char-
acteristic flavor of bitter almond.

Mandelonitrile glucosides occur in three iso-
meric forms: sambunigrin found in elder flowers,
priilanrasin found in cherry laurel, and prunasin
found in wild cherry bark. All of these are op-
tically active, being levorotatory, but vary in
the degree of rotation. According to Power and
Moore {Trans. Chem. Soc, 1909, p. 243) they are
combinations of dextro-, racemic and levo-man-
delonitrile. respectively (see also Fischer and
Bergmann, Ber., 1917, 50, 1047).

Description. — "Bitter Almond Oil is a clear,
colorless or yellow, strongly refractive liquid, hav-
ing the characteristic odor and taste of benzalde-
hyde. Bitter Almond Oil is slightly soluble in
water. It is miscible with alcohol and with ether.
Bitter Almond Oil is soluble in 2 volumes of 70
per cent alcohol, forming a clear solution. The
specific gravity of Bitter Almond Oil is not less
than 1.05S and not more than 1.060 at 25V N.F

Standards and Tests. — Optical rotation. —
Bitter almond oil is optically inactive or does not
have a rotation of more than +0.167° when de-
termined in a 100-mm. tube at 25°. Refractive
index. — Not less than 1.5410 nor more than
1.5442 at 20°. Heavy metals. — The oil complies
with the requirements of the official test for
Heavy metals in volatile oils. Halogens. — No
turbidity is produced when silver nitrate T.S. is
added to products of the combustion of 3 or 4
drops of bitter almond oil which have been con-
densed on the moistened inside of an inverted
beaker after the oil is ignited. Nitrobenzene. —
No odor of phenyl isocyanide is apparent on
heating bitter almond oil, in which any nitroben-
zene that may be present has been reduced with
nascent hydrogen to aniline, with chloroform and
sodium hydroxide T. S. N.F.

Nitrobenzene was at one time a frequent adul-
terant of bitter almond oil. It may be detected
by the test given above.

Assay. — For benzaldehyde. — A sample of
about 1 Gm. of the oil is reacted with a hydro-
alcoholic solution of hydroxylamine hydrochloride,

with which the benzaldehyde forms benzaldoxime
and liberates a molecule of hydrogen chloride for
each molecule of aldehyde present. The acid is
titrated with 1 A7 sodium hydroxide. After cor-
recting for the acidity of the reagent each ml. of
1 N sodium hydroxide is equivalent to 106.1 mg.
of C-HoO. N.F. For hydrogen cyanide. — To some
freshly prepared magnesium hydroxide suspension
is added 1 Gm. of the oil, whereby the benzalde-
hyde cyanhydrin releases cyanide ion which is
titrated with 0.1 A7 silver nitrate, using potassium
chromate T.S. as indicator, until a permanent red
coloration is produced. Any impurities in the
magnesium hydroxide suspension which may react
with silver nitrate are corrected for by titrating
the suspension prior to addition of the oil. Each
ml. of 0.1 N silver nitrate represents 2.703 mg.
of HCN. N.F.

Uses. — As benzaldehyde has no recognized
medicinal action, bitter almond oil acts physio-
logically like hydrocyanic acid. Death is said to
have occurred in a man ten minutes after taking
two fluidrachms of the oil. Bitter almond oil has
been employed externally, dissolved in water in
the proportion of one minim (0.06 ml.) to a fluid-
ounce (30 ml.), in prurigo senilis and other cases
of troublesome itching. To facilitate solution in
water, the oil may be previously dissolved in alco-
hol. Bitter almond oil has been used to conceal
the taste of cod liver oil and of castor oil. It also
finds some use as a perfuming agent in cosmetic
preparations.

Amygdalin itself is practically non-toxic, but
when swallowed may be decomposed, by enzymes
present in ingested foods in the alimentary canal,
leading to the formation of hydrocyanic acid.

Storage. — Preserve "in well-filled, tight con-
tainers, and avoid exposure to excessive heat."
N.F.

PURIFIED VOLATILE OIL OF
BITTER ALMOND. B.P.

Oleum Amygdalae Volatile Purificatum

This is a very different preparation from the
N.F. Bitter Almond Oil. The B.P. oil is prepared
from the cake of seeds of bitter almonds, peach
kernels or apricot kernels, from which the fixed
oil has been expressed, by distilling with water
and subsequently removing the hydrocyanic acid.
It should contain not less than 95.0 per cent
w w of benzaldehyde.

The B.P. does not mention any method for re-
moving the hydrocyanic acid but this may be ac-
complished by treating the oil with ferrous sulfate
and calcium hydroxide, followed by redistillation.

Description and Standards. — This is a
colorless or pale yellow liquid with the character-
istic odor and taste of bitter almonds. Its weight
per ml., at 20°, is 1.042 to 1.046; it has a re-
fractive index at 20° of 1.542 to 1.546. It is
soluble in two parts of 70 per cent alcohol. The
absence of hydrocyanic acid is shown by shaking
the oil with sodium hydroxide solution, adding
ferrous sulphate solution, warming and acidulating
with dilute hydrochloric acid; no blue color
should be produced. A test, in which an alcohol
solution of the oil is titrated with 0.1 N alcoholic

Part I

Almond Oil, Expressed 45

potassium hydroxide, limits the amount of
benzoic acid which may be present.

Assay. — This is essentially similar to the
method employed for the assay of benzaldehyde
in bitter almond oil or in the official product
benzaldehyde.

This oil is intended as a flavoring agent for the
same purposes as benzaldehyde. The B.P. uses it
as a flavor for emulsion of cod liver oil.

EXPRESSED ALMOND OIL.

U.S.P. (B.P.)

Almond Oil, Sweet Almond Oil, [Oleum Amygdalae
Expressum]

"Expressed Almond Oil is the fixed oil obtained
from the kernels of varieties of Prunus Amygdalus
Batsch (Fam. Rosacea)." U.S.P. The B.P. rec-
ognizes as the sources of this oil the seeds of
Primus amygdalus Batsch. var. dulcis (DC.)
Koehne, or of Prunus amygdalus Batsch. var.
amara (DC.) Focke.

B.P. Almond Oil; Oleum Amygdalae. Oil of Sweet Al-
mond. Oleum Amygdalarum. Ft. Huile d'arr.ande. Ger.
Mandeldl. It. Olio di mandorle dolci. Sp. Aceite de
almendras; Aceite de Almendra por Expresion.

For description of Prunus Amygdalus Batsch,
also known as Primus communis Arcang., see
under Bitter Almond Oil.

In normal times we are supplied with sweet
almonds chiefly from Spain, Italy, France, and
southern California. They are separated into the
soft-shelled and hard-shelled varieties, the former
of which come from Marseilles and Bordeaux, the
latter from Malaga. From the latter port they
are sometimes exported without the shell. In
British commerce, the two chief varieties are the
Jordan and Valencia almonds, the former im-
ported from Malaga, the latter from Valencia;
the former are longer, narrower, more pointed,
and more highly esteemed than the latter. Each
kernel consists of two white cotyledons, enclosed
in a thin, yellowish-brown, bitter skin, which is
easily separable after immersion in boiling water.
Deprived of this covering they are called blanched
almonds. On exposure to the air they are apt to
become rancid; but, if thoroughly dried and kept
in well-closed glass vessels, they may be pre-
served unaltered for many years. They are, when
blanched, without odor, and have a sweet, pleas-
ant taste, which has rendered them a favorite
article of diet in all countries where they are
readily attainable.

Sweet almonds are no longer official. The B.P.
1914 described them, under the name Amygdala
Dulcis, as follows :

"About two and a half centimeters or some-
what more in length, nearly oblong in outline,
more or less compressed, pointed at one extrem-
ity and rounded at the other. Testa cinnamon-
brown, thin and scaly. Seed exalbuminous, con-
taining two large planoconvex oily cotyledons.
Taste bland; when triturated with water forms a
white emulsion with no marked odor." B.P. 1914.

The U.S.P. IX gave the following description of
microscopic appearance. "The powder is creamy-
white, exhibiting numerous very small oil globules,
0.001 mm. or less in diameter, and larger oil
globules and crystalloids, the latter sometimes

with adhering globoids; fragments of parenchyma
of endosperm, containing oil globules and aleurone
grains; also occasional fragments of seed-coat
with characteristic, more or less scattered, large,
elliptical, thin-walled, strongly lignified epidermal
cells and narrow, closely spiral tracheae. Starch
grains are absent." U.S.P. IX.

Sweet almonds contain up to about 54 per cent
of fixed oil, 24 per cent of protein, 6 per cent of
uncrystallizable sugar, 3 per cent of gum, 9 per
cent of fibrous matter, 3.5 per cent of water, and
0.5 per cent of acetic acid. They yield the enzyme
emulsion but do not contain amygdalin. "Almond
cake," a by-product in the manufacture of almond
oil, is largely used in the preparation of a class
of detergent powders known as "almond meal."
It is also used as a diabetic food and sometimes
as an adulterant of ground spices and powdered
drugs. Almond cake may be poisonous if it is
made with bitter almond as it would contain
emulsin and amygdalin and yield hydrocyanic
acid.

Expressed almond oil may be obtained equally
pure from sweet and from bitter almonds. In its
preparation, the almonds, deprived of a reddish-
brown powder adhering to their surface by being
rubbed together in a piece of coarse linen, are
ground in a mill or bruised in a stone mortar, and
then pressed in canvas sacks between slightly
warm plates of iron. The oil, which is at first
turbid, is clarified by filtration. Sometimes the
almonds are steeped in hot water, deprived of
their cuticle, and dried by heating, previous to
expression. The oil thus obtained is free from
color, but is in no other respect better; it is more
likely to become rancid on keeping. Bitter almonds
treated in this way impart an odor of hydrocyanic
acid to the oil. The yield of oil from sweet
almond is from 40 to 55 per cent, being slightly
less from the bitter. Though sometimes expressed
in this country from imported almonds, the oil is
generally brought from Europe. During World
War II, when the oil was not available, the
U.S.P. permitted the use of persic oil in ointments
in which expressed almond oil is an ingredient.

Description. — "Expressed Almond Oil is a
clear, pale straw-colored or colorless, oily liquid.
It is almost odorless, and has a bland taste. It re-
mains clear at —10°, and does not congeal until
cooled to nearly — 20°. Expressed Almond Oil is
slightly soluble in alcohol, but is miscible with
ether, with chloroform, with benzene, and with
petroleum benzin. The specific gravity of Ex-
pressed Almond Oil is not less than 0.910 and not
more than 0.915." U.S.P.

Standards and Tests. — Foreign kernel oils. —
Not more than a slight color develops on shaking
vigorously for 5 minutes a mixture of 2 ml. of ex-
pressed almond oil, 1 ml. of fuming nitric acid and
1 ml. of water. Cottonseed or sesame oil. — The
oil meets the requirements of the tests for cotton-
seed oil and for sesame oil under Olive Oil. Min-
eral oil and foreign fatty oils. — A clear solution
results on adding water to the residue remaining
after the evaporation of the alcohol from a mix-
ture of expressed almond oil, sodium hydroxide
solution, and alcohol which has been heated to
saponify the oil {mineral oil). On adding an ex-

46 Almond Oil, Expressed

Part I

cess of hydrochloric acid to the aqueous solution
the fatty acids which separate, after washing with
warm water and clarifying by heating on a water
bath, remain clear for at least 30 minutes when
cooled to 15° and kept at this temperature, with-
out stirring. Foreign oils. — A clear solution re-
sults when a portion of the fatty acids separated
in the preceding test is mixed with an equal vol-
ume of alcohol and cooled to 15° ; no turbidity de-
velops on adding another volume of alcohol (olive,
peanut, or other fixed oils). Free fatty acids. —
Not more than 5 ml. of 0.1 N sodium hydroxide is
required for neutralization of 10 Gm. of oil.
Iodine value. — Not less than 95 and not more
than 105. Saponification value. — Not less than
190 and not more than 200. U.S.P.

The B.P. gives the refractive index, at 40°, as
1.4624 to 1.4650, and the acid value as not more
than 4.0.

Expressed almond oil consists chiefly of olein
with traces of linolein; there is no stearin present.
It belongs among the "non-drying" oils or "vege-
table oleins."

Expressed almond oil has been adulterated with
oils from peach or apricot kernels, olive oil, lard
oil, cottonseed oil, and peanut oil; these may be
detected by the official tests. Many of these
adulterants may also be detected by determining
the absorption spectrum of the sample. Almond
oil differs from most vegetable oils in neither
giving a banded spectrum nor producing strong
absorption in the red or violet.

Uses. — Expressed almond oil possesses the
emollient properties of the other fixed oils, over
most of which it has the advantage of comparative
tastelessness, freedom from odor, and lack of
tendency to become gummy. It is widely used
as an emollient for chapped hands and other in-
flamed conditions of the skin. The oil is some-
times employed in the preparation of cold creams,
as in the official rose water ointment, and in
similar cosmetic preparations. Occasionally it is
used for its laxative effect.

Dose, 4 to 30 ml. (approximately one
fluidrachm to one fluidounce).

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep.— Rose Water Ointment, US.P.

ALOE. U.S.P. (B.P.)

Aloes, [Aloe]

"Aloe is the dried juice of the leaves of Aloe
Perryi Baker, known in commerce as Socotrine
Aloe, or of Aloe barbadensis Miller (Aloe vera
Linne'), known in commerce as Curasao Aloe, or
of Aloe ferox Miller and hybrids of this species
with Aloe africana Miller and Aloe spicata Baker,
known in commerce as Cape Aloe (Fam. Lili-
acetz). Aloe yields not less than 50 per cent of
water-soluble extractive." U.S.P.

The B.P. recognizes Aloes as the residue ob-
tained by evaporating to dryness the liquid which
drains from leaves cut from various species of
Aloe. Not less than 75.0 per cent of water-
soluble extractive is required.

B.P. Aloes. Fr. Aloes. Cer. Aloe. It. Aloe. Sp. Acibar;
Aloe.

The genus Aloe comprises about 170 species
mostly native to eastern and southern Africa, but
some have spread to the Mediterranean basin
and have been introduced into the West Indies,
East Indies, Europe, and the Americas. The leaves
of the Aloe plants are fleshy and succulent. In
cross section they exhibit a strongly cuticularized
epidermis surrounding a mesophyll of two zones,
viz.: an outer cortical zone composed of paren-
chyma containing numerous chloroplastids, as-
similation starch and occasional bundles of
raphides of calcium oxalate, and an inner, clear
central zone consisting of large, thin-walled
parenchyma with an abundance of mucilage and
scattered cells containing raphides of calcium
oxalate. On the border of the outer cortical and
clear central zones is to be noted an ellipse of
vascular bundles each of which is surrounded by
a pericycle and endodermis. The bitter juice is
contained within the pericyclic cells and some-
times in the parenchyma cells adjacent.

Most plants belonging to the genus are capable
of yielding a bitter juice which is laxative and
there is little doubt that in many cases a com-
mercial aloe exported from one country is the
product of the leaves of several species.

1. Aloe Perryi Baker. — The true Socotrine aloe
is a perennial herb, growing abundantly upon the
island of Socotra, especially in the limestone
tracts, from the sea level to an altitude of 3,000
feet and also found in eastern Africa and in
Arabia. It has a trunk one foot high which bears
on its summit a dense rosette of pale green or
reddish, succulent, lanceolate leaves which are
somewhat striate but not mottled. They are
channeled above, convex below and show brown-
tipped, marginal spines. From the center of the
leaf rosette there extends a long raceme of tubu-
lar, reddish flowers which later turn yellow. The
fruit is a membranous capsule.

2. Aloe barbadensis Mill. (A. vera "L."; A.
vulgaris Lamarck). — This species, which is the
source of Curasao aloe, has a very short, woody
stem, and lanceolate embracing leaves, which are
first spreading, then ascending, of a glaucous
green color, when young, irregularly mottled with
white spots, flat on the upper surface, convex
beneath, and armed with hard, pale spines, dis-
tant from each other, and perpendicular to the
margin. It has bright yellow flowers arranged in
a spicate inflorescence. A. barbadensis is a native
of southeastern Europe, northern Africa, and
Madagascar. It is cultivated in Italy, Sicily,
Malta, and especially in the West Indies, where
it contributes largely in the Curacao or Barbados
aloe.

3. Aloe ferox Miller, one of the three South
African, tree-like species yielding Cape aloe, is
one of the tallest species of the genus. It has a
forked stem ten to fifteen feet long, four to six
inches in diameter; furnished at the top with a
dense rosette containing thirty to fifty leaves,
which are lanceolate, one and one-half to two
feet long, very rigid, with copious prickles on
back and face, the purplish margin armed with
reddish brown-tipped, deltoid or cuspidate prickles
one-eighth to one-sixth of an inch long. Its in-
florescence consists of a panicle of tubular, striped

Part I

Aloe

whitish flowers. This species readily hybridizes
with A. africana and A. spicata and hybrids of
these yield some of the Cape aloes of the market.

4. Aloe africana Mill., an arborescent South
African species, has a simple tall trunk which
bears on its summit a few triangular-oblong,
glaucous, green leaves with large, horny, mar-
ginal teeth. Its flowers are tubular and yellow
and are borne on a candelabra-like panicle. It is
a native of the Cape Colony.

5. Aloe spicata Baker {A. Eru var. cornuta
Berger) is a tall, branched aloe indigenous to
tropical southern Africa. It possesses pale, glossy,
fleshy leaves with white blotches and a panicle
of campanulate yellow flowers.

For further details on species of Aloe, see
Baker (Jour. Linnean Soc, Botany, Vol. 1880,
pp. 148-241).

Commercial History and Varieties. —

Socotrine Aloe. — This variety appears to have
been the original aloe, having been produced in
the island of Socotra at least as early as the time
of Alexander the Great, 333 B.C., who is said to
have sent a commission to investigate its manu-
facture.

The leaves, which are cut at any time of year,
are allowed to drain into a goat's or sheep's skin,
and the gathered juice permitted to evaporate
spontaneously. In the course of about one month,
when it has become thick and viscid, it is known
by the Arabic name of Jayef Gesheeshah ; several
weeks subsequently when it has become hard, it is
called Jayef Kasahul. Due to its exposure through-
out the long process of desiccation, all the
varieties of Socotrine aloes contain much foreign
matter.

Socotrine aloe is brought from the island of
Socotra, the east coast of Africa, and from the
Arabian coast by Arab traders to Bombay and
exported in barrels, kegs, goats' skins, or tins
to London, whence it is shipped to the United
States.

The best Socotrine aloe occurs in pieces vary-
ing from a dark ruby-red to a yellowish or red-
dish-brown, more or less semi-transparent, with
a glossy surface and a smooth or ragged but not
conchoidal fracture, and yielding a bright golden-
yellow powder. Its odor is peculiar, almost
fragrant, especially developed by breathing upon
the aloe, and its bitter, disagreeable taste has a
somewhat aromatic tang. The poorest variety of
Socotrine aloe, Mocha aloes of the East, is soft,
dark, and malodorous.

Zanzibar Aloe is a hepatic variety of Socotrine
aloe made by slow evaporation of the juice. It
occurs in liver-brown masses, with a dull, waxy
but nearly smooth and even fracture, a character-
istic odor and a nauseous, bitter taste. It is poured
into skins which are packed in cases for ship-
ment. The variability of Socotrine aloe probably
depends upon not only different methods of
preparation but a different origin.

Curacao, or West Indian, Aloe. — This aloe,
which is produced in the Dutch West Indian
Islands, chiefly in the islands of Aruba, Bonaire
and Curasao, appears not to have entered com-
merce extensively before the early part of the
19th century, but at present constitutes a very

large proportion of commercial aloe. It occurs
chiefly in three forms: first, an opaque, brittle
aloe, showing abundant crystals under the micro-
scope, and sold in gourds usually as Barbados
aloe; second, aloes having an appearance like the
first variety but sold in cases; third, glossy
Curagao or Capey Curacao aloe, which occurs in
cases and is glossy and transparent. This variety
may become opaque upon long storage due to the
gradual crystallization of the aloin. Small frag-
ments show a garnet-red color.

Curagao aloe is collected in the Dutch West
Indies by workers during the early spring. The
leaves are cut off at their bases and placed cut end
downward in V-shaped troughs which are arranged
on an incline. The juice, in trickling from the
leaves, runs down the sides of the trough and
through an aperture at its lower end into a re-
ceptacle beneath. As the receptacles are filled
with the juice, their contents are poured into a
cask and either evaporated spontaneously or by
boiling in copper vessels. As soon as the juice has
thickened to the proper consistency, it is poured
into gourd shells or boxes and allowed to harden.
This aloes is shipped direct to the United States
from Aruba, Curagao and Bonaire.

Kremel gives a method to distinguish Curagao
aloe from other kinds by adding to it a little
cupric sulfate solution, then some saturated solu-
tion of common salt, which makes the color an
intense carmine. The reaction is due to cupro-
aloin. Curagao aloe, deprived of its aloin, has
occurred in the markets; this fraudulent product
was then sold as Cape aloe; the odor of the
Curagao variety still remains.

Cape Aloe. — This variety, while chiefly from
Aloe ferox, is derived, at times, from hybrids of
this species with Aloe africana and Aloe spicata.
The general method of collecting Cape aloe is to
allow the juice in the excised leaves to drain into
a canvas or goat's skin, which has been so placed
in a hole in the ground as to force the juice to
collect in the center. Later this juice is poured
into a drum or tin, in which it is boiled for 4 or
5 hours with constant stirring and, when suffi-
ciently concentrated, poured into boxes or bar-
rels and allowed to harden. In these containers
it is shipped from Mossel Bay and Port Eliza-
beth to Cape Town, thence to Europe and Amer-
ica. Cape aloe differs from Socotrine aloe, espe-
cially in its brilliant conchoidal fracture and
peculiar odor, which is strong, but neither nau-
seous nor aromatic. When freshly broken it has a
very dark olive or greenish color approaching to
black, presents a smooth, bright, almost glassy
surface, and if held up to the light appears trans-
lucent at its edges. The small fragments also are
semi-transparent, and have a tinge of yellow or
red mixed with the deep olive of the opaque mass.
Cape aloe, when quite hard, is very brittle and
readily powdered; but in very hot weather it is
apt to become somewhat soft and tenacious, and
the interior of the pieces is occasionally more or
less so even in winter.

Uganda, or crown, aloe is a brand of Cape aloe
formerly produced by manufacturers who bought
the aloe juice from the collectors, allowed it to
undergo a slight fermentation, and dried it in the

Aloe

Part I

sun in wooden troughs. It was sent into com-
merce in bags containing coarse or fine powder,
or chips, and in bricks wrapped in red paper; it
has a very bitter, aromatic taste and a strongly
aromatic odor. The bricks were of a hepatic
brown color, with a resinous fracture, which had
a bronzy-gold luster by refracted light. Uganda
aloe is now practically obsolete.

An adulterant in powdered Cape aloe is a
ferruginous clay associated with calcium carbon-
ate. The method of detecting this adulterant is
based on the fact that pure Cape aloe dissolves in
ammonium hydroxide solution diluted with nine
times its volume of distilled water. The adulterant
can be readily separated, and the amount esti-
mated by its insolubility, Leger (/. phartn. chim.,
1934, 19, 533).

Other Varieties. — Besides the above certain
other forms of aloe have appeared from time to
time in commerce. Barbados aloe, which is the
hepatic sub-variety of Curagao aloe, appears to
have been brought to London as early as 1693.
Small quantities still appear occasionally on the
American markets. Barbados aloe is produced
from A. barbadensis.

Barbados aloe which is erroneously recognized
by the B.P. as the same as Curasao aloes, varies
in color from very dark blackish-brown through
reddish-brown and liver-colored to orange-brown.
It yields a dull olive-yellow powder, of a dis-
agreeable, even nauseous odor, and it was de-
scribed in the British Pharmacopoeia as follows:
"Fracture either dull and waxy, in which case
small splinters are opaque; or smooth and glassy,
in which case the splinters are transparent; the
opaque variety examined under the microscope
exhibits numerous minute crystals embedded in
a transparent mass." B.P., 1898. "Mixed with
nitric acid, it acquires a red color. Barbados Aloes
is not colored, or acquires only a light bluish-
green tint, on being mixed with sulphuric acid
and blowing the vapor of nitric acid over the
mixture (difference from Natal aloe)." U.S.P.,
1890.

Natal aloe is a variety coming from Natal on
the southeast coast of Africa, the origin of which
is not definitely ascertained but is possibly A.
candelabrum Berger. It occurs in irregular, usually
opaque pieces, with a fracture much less shining
than that of Cape aloe and a totally different
color, having a greenish slate hue. It yields a
grayish-green or pale yellow powder, which has
the odor of Cape aloe. It is less soluble than
Cape aloe.

When powdered Natal aloe is mixed with a
little sulfuric acid and the fumes of nitric acid
are blown over it, a deep blue coloration is
produced.

Hepatic aloe, as well as fetid, caballine or horse
aloe, have no proper claim to be considered dis-
tinct varieties, being simply inferior aloe of
various origins, the first liver-colored, the second
blackish and fetid and full of impurities.

Jafferabad aloe, supposed to be the same as
Mocha aloe, has been shown to be the product of
A. abyssinica Lam., and is said by Shenstone to
contain ^-barbaloin. (Am. J. Pharm., 1883, 92.)
Aloe made in India from the A. barbadensis is

known as Musambra aloe. It appears to be a
very inferior variety, and rarely, if ever, reaches
Europe.

The labels under which aloe is sold often have
little or no connection with the place of produc-
tion, or with the variety of aloes in the package.
This fact has probably come about through the
indifference of users to the variety of the aloe
which they are purchasing, an indifference largely
due to the common habit of buying aloe in
powder.

Wilbert (Am. J. Pharm., 1903) proposed that
aloe should be classified as follows: Aloe A. — Con-
taining barbaloin; responds to Borntrager's test
for emodin, but does not give a distinct red color
with nitric acid, or with Klunge's test. Aloe B. —
Containing isobarbaloin with barbaloin; responds
to Borntrager's test for emodin, and also has a
deep red color with strong nitric acid, or with
Klunge's test.

Fairbairn (Pharm. J., 1946, 102, 381) has de-
scribed the microscopy of the common commercial
varieties of aloe.

In 1952 importations of aloe into the United
States amounted to 413,847 pounds, most of it
from the Union of South Africa and N. Antilles,
although considerable came also from the Do-
minican Republic and Venezuela.

Description. — "Unground Socotrine Aloe
occurs in reddish black to brownish black,
opaque, smooth, glistening masses. Its fractured
surface is somewhat conchoidal. It has a char-
acteristic odor.

"Unground Curagao Aloe occurs in brownish
black, opaque masses. Its fractured surface is
uneven, waxy, and somewhat resinous. It has a
characteristic, disagreeable odor.

"Unground Cape Aloe occurs in dusky to dark
brown irregular masses, the surfaces of which are
often covered with a yellowish powder. Its frac-
ture is smooth and glassy. Its odor is character-
istic, somewhat sour and disagreeable.

The taste of each variety of Aloe is nauseous
and very bitter.

"Powdered Aloe is yellow, yellowish brown to
olive brown in color. When mounted in a bland
expressed oil it appears as greenish yellow to red-
dish brown angular or irregular fragments, the
hues of which depend to some extent upon the
thickness of the fragments." U.S.P.

Standards and Tests. — Identification. — (1)
Powdered aloe dissolves in nitric acid with effer-
vescence; the solution is reddish brown to brown
or green. (2) The aqueous extract prepared by
shaking 1 Gm. of finely powdered aloe with 25
ml. of cold water during 2 hours, filtering, then
washing the filter and residue with cold water to
yield 100 ml. of filtrate exhibits the following
colors when viewed in the bulb of a 100 ml. volu-
metric flask: dark yellow with Socotrine aloe,
dark orange with Curagao aloe, and greenish yel-
low with Cape aloe. The filtrate darkens on stand-
ing. (3) Addition of 2 ml. of nitric acid to 5 ml.
of the filtrate from test (2) produces the follow-
ing colors: yellow with Socotrine aloe, reddish
orange with Curagao aloe, and a reddish brown
changing rapidly to green with Cape aloe. (4)
Addition of 45 ml. of water and 20 ml. of a 1 in

Part I

Aloe

20 solution of sodium borate to 5 ml. of the
filtrate from test (2) produces a greenish yellow
or yellowish green fluorescence which on standing
turns to a moderate yellowish orange to brown
color. Water. — Not over 12 per cent, when dried
at 105° for 5 hours. Ash. — Not over 4 per cent.
Alcohol-insoluble matter. — Not over 10 per cent,
when 1 Gm. of powdered aloe is extracted with
50 ml. of boiling alcohol, the residue being dried
to constant weight at 105°. U.S. P.

Rosenthaler (Pharm. Acta. Helv., 1937, 12,
96) proposed two tests for aloe: (1) An aqueous
solution of aloe is heated with sodium hydroxide
and ammonium sulfide; Cape aloe or Barbados
aloe turns green or greenish brown, Natal aloe
brown. The reaction is given by both aloin and
barbaloin. (2) A solution of aloe is heated with
sodium hydroxide and an ammonium salt: Bar-
bados aloe gives a purple color, Natal a bluish-
purple, Cape aloe does not react. The reaction is
a test for isobarbaloin.

Keenan and Welsh (/. A. Ph. A., 1942, 31, 535)
reported that a 5 per cent solution of gold chloride
gave superior results to the other commonly used
microchemical agents with barbaloin and isobar-
baloin, and suggest its use in distinguishing dif-
ferent varieties of aloe. With Curasao aloe it gave
an immediate red color, with Cape aloe a green,
while Socotrine aloe remained brown. For other
tests for distinguishing varieties of aloes see
Allen's Commercial Organic Analysis, Volume 8,
Fifth Edition (1930).

Assay.— Determine the per cent of water-sol-
uble extractive. U.S.P. The B.P. requires not less
than 75.0 per cent of water-soluble extractive,
calculated with reference to the air-dried drug.

Various methods of assaying aloe, utilizing a
determination of the content of aloin, have been
proposed. Goldner (/. A. Ph. A., 1932, 21, 658)
concluded that none of the seven methods he in-
vestigated was satisfactory. Eaton (J.A.O.A.C.,
1932, 15, 407) devised a method in which the
aloin is acetylized to aloin hexa-acetate and
weighed in this form; the method is officially
recognized in the A.O.A.C. Methods of Analysis.
Valaer and Mallory (Am. J. Pharm., 1934, 106,
81) proposed that aloe and its preparations be
assayed by determining the free emodin and the
total emodin content; their method is based on a
measurement of the depth of color produced by
emodin in a strongly alkalinized solution.

Constituents. — The chemistry of aloe is in-
completely known. It is generally believed that
aloe owes its purgative properties to the presence
of one or more of three pentosides known as bar-
baloin (aloin), isobarbaloin and beta-barbaloin.
For lack of satisfactory assay methods the con-
tent of these constituents is not known with any
degree of certainty (see under Aloin). Viehoever
(Am. J. Pharm., 1935, 107, 47) considers the
resin fraction of aloe to be of equal importance,
a view previously expressed by Kiefer (Pharm.
Ztg., 1925, 70, 1775). Chopra and Ghosh (Arch.
Pharm., 1938, 276, 348) reported that A. vera
var. officinalis (A. indica) contains no aloin.

Of the three pentosides, barbaloin (which is
probably identical with the substances previously
described as socaloin and capaloin) is the most

important. It crystallizes in the form of pale
yellow needles. Isobarbaloin is isomeric with bar-
baloin; the former remains in the mother liquor
when barbaloin is crystallized from methanol
solution; the two compounds also give different
color reactions (see above). Beta-barbaloin is a
non-crystallizable optical isomer of barbaloin.
Hydrolysis of barbaloin in acid solution gives a
complex mixture in which aloe-emodin (1,8-
dihydroxy-3-(hydroxymethyl)anthraquinone) and
D-arabinose have been identified. Leger (Bull. soc.
chim., 1936 [5], 3, 435) believes barbaloin is an
ether formed by the condensation of D-arabinose
with aloe-emodin, but objections to this formula-
tion have been raised by Rosenthaler (Pharm.
Acta. Helv., 1934, 9, 9) and by Foster and Gard-
ner (J.A.C.S., 1936, 58, 597). For data on the
hydrolysis of the aloins see Gardner and Camp-
bell (J.A.C.S., 1942, 64, 1378). Brody et al.
(J. A. Ph. A., 1950, 39, 666) isolated from
Curacao aloe, by chromatographic methods, aloe-
emodin, isoemodin (3,5,8-trihydroxy-2-methyl-
anthraquinone), and anthranols, which are re-
ported to exist both in the free state and in
glycosidal combination.

Uses. — Aloe was known to the ancients, being
cultivated in the island of Socotra as far back
as the time of Alexander the Great, and is men-
tioned in the works of Dioscorides and of Celsus.
It has been employed for eczematous skin condi-
tions in China, India and Tibet under the names
lu hid, musabbar and jelly leeks respectively (Cole
and Chen, Arch. Dermat. Syph., 1943, 47, 250).
Its cathartic action is due to a stimulation of
peristalsis, especially in the larger bowel, prob-
ably the result of a local irritant effect upon the
mucous membrane, although there is some evi-
dence that it exercises a specific stimulant effect
upon unstriped muscles; considerable griping pain
is often associated with its action. It is more irri-
tating than cascara sagrada, senna and rhubarb.
As its action is largely limited to the colon it is
not to be recommended in those conditions in
which it is desirable to clean out the whole ali-
mentary canal, and as its effect is largely the result
of local irritation it should be avoided in inflam-
matory conditions of the intestine. It does not
act until 8 to 12 hours after ingestion. In chronic
constipation, especially when dependent upon an
atonic condition of the lower bowel, it is very
useful. The presence of bile in the bowel seems
to be essential for the most effective action of
this drug, and when this secretion is lacking it is
advisable to administer some preparation of bile
in conjunction with the aloes. Soap also appears
to enhance the cathartic action of this drug. Ivy
and his associates (Quart. Bull. Northwest. U.
Med. Sch., 1945, 19, 102) reported that thera-
peutic doses of aloe produce no increase in the
bile content of the intestine. Aloe was formerly
used in the treatment of amenorrhea. It is, how-
ever, extremely doubtful whether it exercises any
action on the pelvic organs other than congestion
of the pelvic blood vessels.

In the 16th and 17th centuries aloe was used
locally in the treatment of wounds and burns
but its use for this purpose entirely disappeared
except as an ingredient in compound benzoin

Aloe

Part I

tincture. Collins and Collins (Am. J. Roentgen.,
1935, 33, 396) reported beneficial effects from the
local application of freshly split leaves of the
Aloe vera in the treatment of x-ray burns. After
an hour of contact the darkened gummy, gelati-
nous material was washed away with water. (See
also Lovemna. Arch. Dermat. Syph., 1937, 36,
838.) Crewe (Minn. Med., 1937, 20, 10) extended
this local use of aloe leaf to the treatment of
dermatitis and various ulcerated conditions of
the skin. Rowe and colleagues (/. A. Ph. A., 1941,
30, 266), in an experimental study of aloe leaf
in x-ray burns, found that the curative principle
occurs in both the pulp and rind of the leaf, but
was not present in all commercial leaves nor in
the official aloe. Cutaneous leishmaniasis was
benefited by injections of an extract of aloe
leaves (Filatov, Am. Rev. Soviet Med., 1945. 2,
484). E

Dose. — Aloe is today infrequently adminis-
tered; its usual dose is 250 mg. (approximately
4 grains), with a fange of 120 to 250 mg.

Aloe Tincture, prepared by macerating 10
per cent w/v of aloe and 20 per cent w/v of
glycyrrhiza with diluted alcohol, was official in
N.F.IX. Aloe Pills, made by massing a mixture
of equal parts of aloe and hard soap with water,
were also official in N.F.IX.

Off. Prep. — Compound Benzoin Tincture,
U.S.P., B.P.; Compound Colocynth Extract, N.F.

ALOIN. X.F., B.P.

[Aloinum]

"Aloin is a mixture of active principles ob-
tained irom aloe. It varies in chemical compo-
sition and in physical and chemical properties
according to the variety of aloe from which it
is obtained." N.F. The B.P. defines it as a mix-
ture of crystalline principles obtained from aloes.

Sp. Aloina.

Aloin, which consists principally of barbaloin
and isobarbaloin (see under Aloe), has been pre-
pared by many processes. That recommended
by Tilden is as follows: 1 part of aloe is dis-
solved in 10 parts of boiling water acidulated
with hydrochloric acid, and allowed to cool. The
liquid is then decanted from resinous matter,
evaporated to about 2 parts, and set aside two
weeks for crystals to form; the liquid portion is
poured off, the crystals pressed, and the adherent
resinous matter separated by shaking with etnyl
acetate, which dissolves the resin. This process
serves fairly well for obtaining aloin from Bar-
bados or Curagao aloe. Aloin from Socotrine aloe
is best obtained by digesting it in 3 parts of
alcohol for 24 hours, then transferring to a water
bath, and boiling for 2 hours. After cooling, the
liquid is filtered and set aside to crystallize. The
crystals are washed with alcohol and dried. The
yield is about 10 per cent. Schafer (Pharm. J.,
1897, p. 287) obtained from 15 to 30 per cent of
crystallized aloin from commercial aloe by the
following process: 50 Gm. of aloe dissolved in
300 ml. of hot water is slightly acidulated with
hydrochloric acid. The solution, after standing
(for the resins to separate), is decanted, mixed

with 50 ml. of 20 per cent ammonia water, fol-
lowed by a solution of 15 Gm. of calcium chloride
in 30 ml. of water. The liquid is agitated and the
aloin-calcium compound which separates is col-
lected, drained, and mixed in a mortar with a
slight excess of hydrochloric acid; the mixture of
aloin and calcium chloride is dissolved in the
smallest possible quantity of boiling water, fil-
tered, and the filtrate cooled by means of ice;
the aloin crystallizes. This method was recom-
mended by Snyder as a procedure for evaluating
aloe (see Viehoever, Am. J. Pharm., 1935, 107,
58) and was found by Smith, Jordan and De Kay
(/. A. Ph. A., 1944, 33, 57; to be best adapted
for extracting aloin in the assay of Barbados and
Curasao aloe. For chemistry of aloin, see under
Aloe.

Description. — "Aloin occurs as a lemon yel-
low to dark yellow, microcrystalline powder, or
as minute crystals. It is odorless, or has a slight
odor of aloe. Its taste is intensely bitter. Aloin
darkens on exposure to fight and air. A saturated
solution of Aloin is yellow but becomes brown
on standing. Its solutions are neutral or acid to
litmus paper. Aloin is soluble in water, in alcohol,
and in acetone, the degree of solubility varying
with its composition. It is slightly soluble in
ether." N.F.

Standards and Tests. — Identification. — (1)
Aloin dissolves in ammonia T.S. and in alkali
hydroxide solutions with formation of a red color
(or yellow turning to red) and a green fluores-
cence. (2) A brownish green color results when
a drop of ferric chloride T.S. is added to an
alcohol solution of aloin. Residue on ignition. —
Not over 0.6 per cent. Water-insoluble sub-
stances.— Not over 1.5 per cent of residue is ob-
tained when 1 Gm. of aloin is agitated during
2 hours with 120 ml. of water, at 25°, the insoluble
matter being collected on a filter paper or in a
filtering crucible, washed with 25 ml. of water,
and dried at 105° for 1 hour prior to weighing.
Emodin. — Xot more than a faint, pink color
results when the filtrate from a 1 in 10 benzene
extract of aloin is shaken with an equal volume
of a 5 per cent solution of ammonia. N.F.

Aloin of commerce has been frequently con-
taminated with large amounts of resin, indicat-
ing lack of care in manufacturing. The N.F. test
for water-insoluble substances limits the amount
of such contamination to 1.5 per cent. Smith
et al. (J. A. Ph. A., 1944, 33, 59) called atten-
tion to the fact that aloins from different species
of aloe give different reactions in the various
color tests.

Uses. — Because of the absence of resin the
cathartic action of aloin is relatively milder than
that of aloe. Although it is capable of producing
purgative effects, it is never used practically in
this manner. Aloin has enjoyed wide use in
chronic constipation. It is often combined with
belladonna to overcome the tendency to griping.
However, the action of belladonna is rapid and
brief compared with that of aloin. Aloin may pro-
duce renal irritation and color the urine red if
the latter is alkaline. S

Dose, 10 to 60 mg. (approximately % to 1
grain).

Part I

Alum

Storage. — Preserve "in tight, light-resistant
containers." N.F.

Off. Prep. — Aloin, Belladonna, Cascara and
Podophyllum Pills. N.F.

ALOIN, BELLADONNA, CASCARA
AND PODOPHYLLUM PILLS. N.F.

Hinkle's Pills, [Pilulae Aloini, Belladonna,
Cascarae et Podophylli]

Prepare 100 pills, according to the General
Directions (see under Pills), from 1.6 Gm. of
cascara sagrada extract, 1.6 Gm. of aloin, 1 Gm.
of podophyllum resin, 0.8 Gm. of belladonna ex-
tract, 0.4 Gm. of ginger oleoresin, and 1 Gm. of
glycyrrhiza, in fine powder, using liquid glucose
as the excipient. N.F.

Dose, as a laxative, one or two pills.

ALTHEA. N.F.

Marshmallow Root, [Althaea]

"Althea is the dried root of Althcea officinalis
Linne (Fam. Malvaceae), deprived of the brown,
corky layer and small roots." N.F.

White Mallow. Radix Bismalvae; Radix Hibisci. Fr.
Guimauve ; Racine de guimauve. Ger. Eibischwurzel ; Bis-
malvawurzel; Altheewurzel; Heilwurzel. It. Altea; Mal-
vischio; Malvaccioni. Sp. Raiz de altea; Altea.

Althcea officinalis is a perennial herb with a
perpendicular branching root and erect woolly
stems, from two to four feet or more in height,
branched and leafy toward the summit. The
plant is native to Europe, inhabiting salt marshes,
the banks of rivers, and other moist places. It is
found also in this country, from New England to
New York and westward to Michigan and Arkan-
sas. It is largely cultivated in Europe for medici-
nal use.

The roots should be collected in autumn from
plants at least two years old. They are usually
prepared for the market by removing the rootlets,
scraping the roots free of cork and drying either
entire or after slicing the thicker roots.

Description. — "Unground Althea. — When en-
tire, Althea occurs as slenderly tapering roots, up
to 30 cm. in length and 2 cm. in diameter; exter-
nally pale yellow to pale brown, longitudinally
furrowed, frequently spirally twisted and covered
with somewhat loosened bast fibers. The fracture
of the bark is fibrous, and of the wood, short and
granular. Internally it is yellowish; the bark is
1 to 2 mm. thick, porous, with mucilage cells and
is separated from the slightly radiating wood by
a distinct darker cambium zone. Althea is fre-
quently cut into small pieces about 5 mm. in
thickness. Sometimes the root is found split or
in slices. Althea has a slight odor and a sweetish,
mucilaginous taste." N.F. For histology see N.F. X.

"Powdered Althea is white to weak yellow. It
consists of numerous starch grains up to 30 n in
diameter, usually with a long central cleft; groups
of fibers with thick, more or less lignified walls;
vessels with scalariform thickenings or with bor-
dered pits, and a few calcium oxalate crystals in
rosette aggregates, from 20 to 35 (x in diameter."
N.F.

Standards and Tests.— Identification.— The
mucilage obtained by stirring a mixture of 1 Gm.

of comminuted althea with 10 ml. of cold distilled
water during 30 minutes, then filtering through
cotton, has a weak yellow color and is only
slightly acid to litmus; on addition of sodium
hydroxide T.S. it assumes a moderate to strong
yellow color, and has neither a sour nor an am-
moniacal odor. Foreign organic matter. — Not over
1 per cent. Acid-insoluble ash. — Not over 1 per
cent. N.F.

Constituents. — Althea contains on the aver-
age 37 per cent of starch, 35 per cent of gum, 11
per cent of pectin, 11 per cent of sugar, 1.25 per
cent of fat and up to 2 per cent of asparagin.

The principle, discovered in the root by Bacon,
by him called althein, has been found to be
asparagin. This substance belongs to the group
of amides and hence has been called asparamide,
also aspargine and agedoite. It is a-aminosuccin-
amic acid, NH2COCH2.CH(NH2)COOH. When
treated with a strong acid it yields aminosuccinic
(aspartic) acid which is also a product of pancre-
atic digestion of certain proteins. Asparagin is
found in many other plants but is of no medicinal
importance.

Under the title of Althcece. Folia (Marsh Mal-
low Leaves), the N.F. V recognized the dried
leaves of the Althcea officinalis collected in June
or July, while the plant is in flower, and dried.
They, like the root, have been used for their muci-
lage, which is, however, less abundant in the
leaves. For a description of the leaves, see U.S.D.,
22nd ed., p. 108.

The N.F. IX recognized Althea Syrup, which
has been used as a demulcent vehicle. It was pre-
pared as follows : Wash 50 Gm. of althea, cut into
small pieces, with cold distilled water. Macerate
this with a mixture of 400 ml. of distilled water
and 30 ml. of alcohol for 3 hours at room tempera-
ture, without stirring; strain the mixture without
expressing the residue, dissolve in the strained
liquid, by agitation and without heat, 700 Gm. of
sucrose. Add 100 ml. of glycerin and enough water
to make 1000 ml.

Uses. — The virtues of marshmallow are exclu-
sively those of a demulcent. The decoction of the
root has been much used in Europe in irritation
and inflammation of the mucous membranes. The
roots themselves, as well as the leaves and flowers,
boiled and bruised, have been employed as a
poultice. Althea also finds use as an excipient for
pills.

Off. Prep.— Ferrous Carbonate Pills, N.F.

ALUM. N.F., B.F.

Ammonium Alum, Potassium Alum, [Alumen]

"Alum contains not less than 99.5 per cent of
AlNH4(S04)2.12HoO or of A1K(S04)2.12H20.
The label of the container must indicate whether
the salt is Ammonium Alum or Potassium Alum."
N.F. The B.P. definition is essentially the same
and the purity rubric is identical with that of
the N.F.

Purified Alum. Alumen Purificatum. Sp. Alumbre.

The term alum is a generic name for a group
of double salts of the general formula:
R2S04.R,2(S04)3.24H20, or RR'(S04)2.12H20

Alum

Part 1

in which R is univalent and may be Na, K, Rb,
Cs, etc., or a radical such as NH4, and R' is
trivalent and may be Fe, Cr, Al, etc. Alums
have been prepared in which SeOi, or TeCh, have
replaced SO-t.

The alum officially recognized may be either
the double sulfate of aluminum and potassium, or
of aluminum and ammonium. These are distin-
guished as potassium alum and ammonium alum,
respectively. From time to time one or the other
of these has been given official preference, but
at present both are recognized under the common
title of Alum in the official compendia of the
United States and of Great Britain.

Potassium Alum. Potassium Aluminum Sul-
fate. Aluminii et Potassii Sulfas; Fr. Alun de
potassium; Alun; Sulfate double d'alumina et
de potasse. Ger. Alaun; Kaliumalaun. It. Allume
di potassa; Allume; Allume di rocca. Sp. Sulfato
de aluminio y de potasio ; Alumbre. — Alum has
been manufactured for centuries, the chemical
having been used in the time of Pliny as a mor-
dant for the production of bright colors. It may
be obtained from several natural sources, among
which the more important are the minerals alu-
nite, bauxite and cryolite.

Al unite (or alum stone), a mixture of alumi-
num sulfate and potassium sulfate, is subjected
to a roasting process, by which is formed alum
and insoluble alumina. Upon treatment with sul-
furic acid, the alumina passes into solution as
aluminum sulfate; this may be recovered from
the mother liquors after crystallization of the
alum, or potassium sulfate may be added in suf-
ficient quantity to convert the aluminum sulfate
to alum. .

Bauxite, a hydrated oxide of aluminum con-
taining from 30 to 76 per cent of aluminum oxide,
has become an important source of alum. Alumi-
num sulfate obtained from this mineral is treated,
in solution, with potassium sulfate and the alum
obtained by crystallization. Cryolite, a double
fluoride of sodium and aluminum, also serves as
a source of aluminum salts, from which can be
made also the alums. Various earths and clays,
known as aluminous schist, alum slate, and alum
shale furnish other sources of alum.

Potassium alum usually crystallizes in octahe-
dral crystals having a specific gravity of 1.75.
When heated to 92.5°, it forms a solution in its
water of crystallization; continued heating vola-
tilizes the water, leaving behind a white, opaque,
porous mass which is the official exsiccated alum
(see Exsiccated Alum). Exposed to high heat, it is
converted to a mixture of aluminum oxide and
potassium sulfate.

Ammonium Alum. Ammonium Aluminum
Sulfate. Alumen Ammoniatum; Aluminii et
Ammonii Sulfas; Fr. Alun d 'ammonium. Ger.
Ammonium-alaun ; Ammoniak alaun. It. Allume
di ammonio. Sp. Sulfato de aluminio y de amonio.
— The preparation of ammonium alum is analo-
gous to that of potassium alum. A solution of alu-
minum sulfate, prepared by any of the several
methods previously described, is treated with an
equivalent amount of ammonium sulfate. Upon
concentration, crystals of ammonium alum sepa-

rate, and these may be purified by recrystalliza-
tion. In crystalline structure and general physical
appearance it resembles closely potassium alum.
and it is necessary to apply chemical tests to
differentiate the two.

Ammonium alum forms crystals similar to
those of potassium alum, and having a specific
gravity of 1.63. When heated, ammonium alum
swells up and forms a porous mass, as water and
sulfuric acid are evolved; continued ignition at
high temperature leaves a residue of aluminum
oxide.

Description. — "Alum occurs as large, color-
less crystals, crystalline fragments, or as a white
powder. Alum is odorless, and has a sweetish,
strongly astringent taste. Its solutions are acid to
litmus paper. One Gm. of Ammonium Alum dis-
solves in 7 ml. of water, and in about 0.3 ml. of
boiling water. One Gm. of Potassium Alum dis-
solves in 7.5 ml. of water, and in about 0.3 ml. of
boiling water. Alum is insoluble in alcohol. It
is freely but slowly soluble in glycerin." N.F.

Standards and Tests. — Identification. — (1)
Ammonia is evolved and a precipitate, soluble in
an excess of reagent, formed when sodium hydrox-
ide T.S. is added to a 1 in 20 solution of am-
monium alum. (2) When potassium alum is simi-
larly tested no ammonia is evolved. (3) A violet
color is imparted by potassium alum to a non-
luminous flame. (4) A white, crystalline precipi-
tate forms within 30 minutes on adding 10 ml. of
sodium bitartrate T.S. to 5 ml. of a saturated
solution of potassium alum. (S) A 1 in 20 solu-
tion of alum responds to tests for aluminum and
for sulfate. Alkalies and alkaline earths.— 'Sot
over 5 mg. of residue is obtained on evaporating
the filtrate from 1 Gm. of alum dissolved in
100 ml. of water and precipitated with ammonia.
Arsenic. — A solution of alum meets the require-
ments of the test for arsenic. Heavy metals. — The
limit is 20 parts per million. Iron — Xo blue color
is produced immediately on adding 5 drops of
potassium ferrocyanide T.S. to 20 ml. of a 1 in
150 solution of alum. N.F.

The B.P. states that when heated alum melts
and at about 200° loses its water of crystalliza-
tion. The presence of ammonium salts in potash
alum is detected with alkaline potassium mercui-
iodide; the arsenic limit for both alums is 4 parts
per million. Otherwise the tests are similar to
those of the N.F.

Assay. — A sample of about 1 Gm. of alum is
dissolved in distilled water, ammonium chloride
is added, and the aluminum is precipitated as hy-
drous oxide (hydroxide) by the addition of a
slight excess of ammonia. The precipitate is fil-
tered off, washed, dried and ignited to AI2O3;
the weight is multiplied bv 8.894 to obtain the
weight of A1NH4(S04)2.12H20. or by 9.307 to
obtain the weight of A1K(S04)2.12H20. To
guard against the possibility of adding enough
ammonia to redissolve a portion of the hydrous
aluminum oxide precipitate, the otherwise similar
B.P. assay employs methyl red as an indicator to
limit the concentration of ammonia.

Incompatibilities. — Alum has the character-
istic incompatibilities of aluminum salts and of

Part I

Alum, Exsiccated

the sulfates. In alkaline solution, unless the con-
centration of hydroxyl ion is sufficiently high to
form soluble metaluminate ion, aluminum hy-
droxide is precipitated. Fixed alkalies liberate
ammonia from the ammonium alum.

Uses. — Alum is absorbed from the intestinal
tract only in relatively small quantities, although
Gies (J. A.M. A., 1911, 57, 57) has shown that the
former view that it was completely excreted, un-
absorbed, with the feces is incorrect. The anti-
septic power of alum is lower than that of most
salts of aluminum; according to Miquel it will
inhibit the multiplication of bacteria in the pro-
portion of about one part in two hundred.

Alum is a powerful astringent with very de-
cided irritant qualities, and when taken inter-
nally in sufficient quantities is emetic and pur-
gative, and may even cause gastrointestinal in-
flammation. It is rarely used as an internal
astringent. It has been occasionally employed
internally in the treatment of lead colic, as a
chemical precipitant of lead in the intestinal tract;
it was thought also to have some beneficial action
upon the intestines directly. It is occasionally em-
ployed as an emetic to empty the stomach in cases
of poisoning, but is inferior for this purpose to
zinc sulfate. It was formerly extensively used as a
gargle, but it exercises a destructive influence
upon the teeth and is inferior to aluminum acetate.

The most important use of alum today is as a
local astringent to check excessive local sweating
or to harden the skin, especially of the feet. Po-
tassium alum in 10 per cent aqueous solution is
efficient in removing flora from normal skin, but
less so than alcohol or 0.5 per cent hydrochloric
acid according to Myer and Vicher (Arch. Surg.,
1943, 47, 468). Such a solution hardens the skin,
imprisoning bacteria which may be released as the
skin softens when covered by rubber gloves. It is
also employed as an astringent in leukorrhea. un-
healthy ulcers, and similar conditions. As an
astringent it is usually employed in strengths
ranging from 1 to 5 per cent, according to the
location to which it is applied. Occasionally pow-
dered alum may be thinly dusted over the area.
As a styptic it is employed as an alum stick or as
the powdered chemical and applied directly to
the bleeding point if easily accessible. In epistaxis
the nares may be plugged with pledgets of cotton
soaked in a saturated solution. When used as an
astringent on the more delicate mucous mem-
branes, as in conjunctivitis, it is desirable to
modify its action by combining it with albuminous
matter as in the form of the alum curd. This is
made by boiling 8 Gm. of alum in 480 ml. of
milk and straining off the whey. Concentrations
with effective spermicidal action (0.5 to 1 per
cent) are uncomfortably astringent, [vj

Toxicology. — When taken in large dose,
alum acts as an irritant poison causing burning
in the mouth and throat followed by vomiting,
purging, collapse, and other symptoms of toxic
gastroenteritis. Several fatalities have been re-
ported. The treatment of alum poisoning consists
in the use of demulcent drinks, such as milk,
combined with an antacid as magnesia, and com-
bating the collapse with customary stimulants.

For consideration of the physiological question
of the effects of repeated small doses of alum, see
under Aluminum.

Dose, as an astringent, 300 mg. to 1 Gm. (ap-
proximately 5 to 15 grains); as an emetic, 4 Gm.
(approximately 1 drachm), dissolved in water.

Storage. — Preserve "in well-closed contain-
ers." N.F.

Off. Prep.— Exsiccated Alum, N.F.

EXSICCATED ALUM. N.F.

Dried Alum, Burnt Alum, Exsiccated Ammonium Alum,
Exsiccated Potassium Alum, [Alumen Exsiccatum]

"Exsiccated Alum, dried at 200° for 4 hours,
contains not less than 96.5 per cent of AINH4-
(S04)2 or of A1K(S04)2. The label of the
container must indicate whether the salt is Exsic-
cated Ammonium Alum or Exsiccated Potassium
Alum." N.F.

Alumen Ustum. Fr. Alun desseche. Ger. Gebrannter
Alaun. It. Allume usto; allume calcinato. Sp. Sulfato
de aluminio y de potasio anhidro; Alumbre Desecado;
Alumbre calcinado.

Exsiccated alum may be prepared by heating
alum, at a temperature of about 200°, until the
water of crystallization has been volatilized.

Description. — "Exsiccated Alum is a white,
odorless powder. It has a sweetish, astringent
taste, and absorbs moisture on exposure to air.
One Gm. of Exsiccated Alum dissolves very
slowly and usually incompletely in about 20 ml. of
water. One Gm. of it dissolves in about 2 ml. of
boiling water. It is insoluble in alcohol." N.F.

Standards and Tests. — Identification. — Ex-
siccated alum responds to the identification tests
under alum. Loss on drying. — Not over 10 per
cent, on drying at 200° for 4 hours. Water-
insoluble substances. — Not more than 50 mg. of
residue is obtained from 2 Gm. of exsiccated
alum added to 40 ml. of water and occasionally
agitated during 24 hours, the insoluble matter
being collected on counterbalanced filter papers
or in a tared filtering crucible and dried at 105°.
Alkalies and alkaline earths. — Exsiccated ammo-
nium alum meets the requirements of this test
under alum, allowance being made for the differ-
ence in water content. Arsenic, heavy metals, iron.
— Exsiccated alum meets the requirements of
these tests under alum, allowance being made for
the difference in water content. N.F.

Assay. — A sample of about 500 mg. of exsic-
cated alum, previously dried at 200° for 4 hours,
is dissolved in water, filtered if necessary, and
the aluminum precipitated as described under
Alum. The weight of the aluminum oxide is mul-
tiplied by 4.652 to obtain the equivalent weight
of A1NH4(S04)2, and by 5.066 to obtain the
weight of A1K(S04)2. N.F.

Uses. — Exsiccated alum has the same me-
dicinal properties as ordinary alum, but it is much
more powerful and irritant and must be employed
in correspondingly dilute solutions. It has mild
escharotic properties and is occasionally applied
to exuberant granulations, preferably diluted with
inert powders. H

Storage. — Preserve "in tight containers." N.F.

Aluminum

Part I

ALUMINUM. U.S.P.

Al (26.98)

Ft. Aluminium. Gcr. Aluminium.
Aluminio.

It. Alluminio. Sp.

Next to oxygen and silicon, aluminum is (he
most widely distributed and abundant element on
earth, comprising about 7.5 per cent of the earth's
crust. It occurs in nature only in combination.
Feldspar, mica, zeolite, hornblende, leucite, and
shales and clays are silicates of aluminum; corun-
dum, emery, and such gems as the ruby and sap-
phire are naturally occurring oxides of aluminum.
Many other gem stones contain aluminum in one
form or another. Cryolite, NaaAlFe, and bauxite,
a mixture of hydrated aluminum oxide and hy-
drated iron oxide, are other compounds of alumi-
num found in nature; bauxite is the ore commonly
used for extraction of the element.

Sir Humphry Davy in 1807 endeavored to ob-
tain aluminum by electrolysis, but was unsuc-
cessful. It was obtained by Wohler in 1827 by
decomposition of anhydrous aluminum chloride
with potassium. In 1854, Deville succeeded in
obtaining the pure metal in ingots by decomposing
aluminum chloride with sodium. The process of
Deville remained the only practical process for
its manufacture until 1886, when the Messrs.
Cowles of Cleveland, Ohio, succeeded in effecting
the reduction of corundum, the native oxide, by
charcoal with the aid of a powerful electric cur-
rent, using large carbon electrodes. This process
in turn has been practically displaced by that dis-
covered by Hall, in 1886, while a student at Ober-
lin College. This is to electrolyze pure alumina
(aluminum trioxide) dissolved in a bath of melted
cryolite. The cryolite is continuously regenerated,
so that by feeding in the pure alumina the process
can be made continuous.

Description. — The U.S.P. describes pow-
dered aluminum as follows: "Aluminum is a very
fine, free-flowing, silvery powder, free from gritty
or discolored particles. Aluminum is insoluble in
water and in alcohol. It is soluble in hydrochloric
and sulfuric acids, and in solutions of fixed alkali
hydroxides." U.S.P. The whole metal has a silvery-
white appearance; its specific gravity is about 2.7,
its melting point is 659°, its boiling point is 1800°.
It is ductile, soft, and moderately resistant to
oxygen. On exposure to air, the metal becomes
coated with a thin layer of oxide, which serves as
a protective covering. Aluminum is attacked
slowly by organic acids.

It has found wide use in many technical fields
due primarily to its light weight and relative sta-
bility. The strength of aluminum is greatly in-
creased by alloying with copper and magnesium.
Alloys of this type are magnalium and duralumin.
When a mixture of powdered aluminum and iron
oxide is ignited, as by flaming magnesium ribbon,
a reaction is started which produces a temperature
of about 3000°, the iron melting and being used
for welding. Thermite is such a mixture which
has been employed, among other uses, as an in-
cendiary in World War I.

Standards and Tests. — Insoluble matter. —
Not over 5 per cent is insoluble in dilute hydro-

chloric acid (1 in 2). Alkalies and earths. — Not
over 0.5 per cent, when determined by precipi-
tating the aluminum in the solution obtained in
the preceding test with ammonia, evaporating the
filtrate to dryness and igniting the residue.
Arsenic. — The limit is 10 parts per million. Heavy
metals. — The limit is 20 parts per million. Iron. —
The limit is 0.5 per cent. Suitability. — Aluminum
powder is smooth and unctous, and free from
gritty particles, when rubbed between the fingers.
U.S.P.

Physiological Actions. — Aluminum has very
feeble physiologic properties. After ingestion very
little aluminum is absorbed even in the case of
soluble salts. McGuigan (/. Lab. Clin. Med., 1927,
12, 790) finds that it is less toxic than iron, and
Underhill and Peterman (Am. J. Physiol., 1929,
90, 1) reported that the lethal dose of aluminum
chloride for various animals ranges from 5 to 7
Gm. per Kg. after subcutaneous injection; this
would correspond to a dose for the average man
of about 8 pounds. Small traces of aluminum are
found almost always in the tissues and blood
of man, as well as of the lower animals. (See
Schwartze, J.A.M.A., 1933, 101, 1722). From
time to time interested persons have made state-
ments, usually without much scientific evidence,
concerning the injurious effects of small quanti-
ties of aluminum and consequent danger from the
use of aluminum cooking utensils or alum baking-
powders. The U. S. Department of Agriculture in
1914 appointed a committee under the chairman-
ship of Prof. Ira Remsen to investigate whether
the use of aluminum baking-powders was injuri-
ous to the health. As a result of the study of
previous researches, as well as experimental work,
they concluded that aluminum, in the quantities
used in baking-powder, had no injurious effect
upon the body. Despite the assertions of Doellken
(Arch. exp. Path. Pharm., 1897, 40) that the re-
peated injection of aluminum causes degenera-
tion of the nerves, and the findings of Seibert and
Wells (Arch. Path., 1929, 8, 230) that such in-
jections caused anemia, the whole weight of our
present evidence points toward the innocuousness
of aluminum kitchenware. For further informa-
tion on this subject, see J. A.M. A., 1936, 106, 218;
1951, 146, 477.

Contact dermatitis in aircraft workers due to
aluminum or its alloys has been reported. Hall
(J. A.M. A., 1944, 125, 179) saw 202 cases of con-
tact dermatitis among 755 employees referred to
the skin clinic during 6 months from plants em-
ploying over 6,000 persons. Of the 202 cases, 10
were due to Dural (aluminum 95 per cent, copper
3.5 per cent, manganese and magnesium 0.5 per
cent each, and traces of iron and silica) ; the char-
acteristics were : scattered, pale-pink, fine papules,
which were usually excoriated, located on the
forearms in all cases and on the sides of the neck
in half the cases; the etilogy was confirmed by
means of a patch test with the metal which was
not read until 48 to 72 hours after removal of the
patch to avoid the immediate irritant effect of the
metallic particles. Four cases were due to alumi-
num alone and were distinctly different — evanes-
cent, wheal-like, extremely pruritic lesions de-
veloped on the wrists and flexor surface of the

Part I

Aluminum Acetate Solution

forearms during each work period and usually
cleared up over week ends.

Like others of the so-called heavy metals, alu-
minum when combined in an easily ionizable salt,
such as the sulfate or chloride, acts as an astrin-
gent. Its insoluble salts are used both as protec-
tives and adsorbents. The powdered metal or,
more conveniently, an aluminum paste (q.v.) has
been employed to protect the skin around intes-
tinal fistulae from the digestive action of the
intestinal contents. It is for this use that the
U.S. P. recognizes aluminum powder. A prepara-
tion containing finely powdered metallic aluminum
mixed with glycerin has been employed as a sub-
stitute for the insoluble salts of bismuth in the
treatment of gastric ulcers and anal fissures (see
Sussmann, Ther. Geg., May, 1908). A piece of
smooth, polished aluminum has been employed as
a dressing for indolent wounds with success
(Presse med., 1942, 50, 588). Brown (Am. J.
Surg., 1948, 76, 594) used aluminum foil as a
dressing for burns. Buettner (J.A.M.A., 1950,
144, 737) found that cloth coated with aluminum
foil provided the best protection from heat for
fire-fighting equipment.

Aluminum in the form of the powdered metal
or the amorphous hydrated alumina is employed
in the treatment of silicosis (pneumoconiosis).
The greatly differing incidence of silicosis in dif-
ferent industries suggested the presence of modi-
fying factors in addition to the number and size
of the silica particles in the air. Based on the
observation of Denny and Robson that small
amounts of aluminum formed a coating over the
silica particles which almost completely inhibited
the solubility of silica and that the addition of
aluminum powder to silica would prevent the de-
velopment of silicosis in animals, Crombie, Blais-
dell and MacPherson (Can. Med. Assoc. J., 1944,
50, 318) treated 44 employees with evidence of
silicosis by roentgen examination of the chest,
some of whom had mild symptoms of pulmonary
fibrosis, with daily inhalations of powdered alu-
minum produced in a special ball mill. Inhala-
tions were increased from 5 minutes to 30 minutes
daily and continued for about 200 treatments.
Symptomatic improvement was observed in some
of the men and none of them showed any progres-
sion of their silicosis by any criteria whereas 6 of
9 control cases were definitely worse at the end of
the year. Bamberger (Ind. Med., 1945, 14, 477)
and MacGregar (West Virg. M. J., 1945, 41, 229)
confirm these observations. Although the roentgen
appearance of silicosis has been reported in asso-
ciation with exposure to aluminum dust (Arch.
Gewerbepath. Gewerbehyg., 1941, 11, 102, cited
in J.A.M.A., 1945, 127, 190), this has not been
the experience of Crombie and his associates nor
of others (Gardner et al., J. Indus t. Hyg. Toxicol.,
1944, 26, 211; Hunter et al., Brit. M. J., 1944, 1,
159). However, bronchial asthma due to alumi-
num in an employee, who also showed the charac-
teristic contact dermatitis, has been reported by
Cotter (/. Indust. Hyg. Toxicol., 1943, 25, 421)
and by others previously. The therapeutic or pro-
phylactic use of aluminum powder does not elimi-
nate the necessity and preferability of dust con-
trol in industry (Tabershaw, New Eng. J. Med.,

1945, 233, 437). Furthermore, Brown and Van
Winkle (J. A.M. A., 1949, 140, 1024), in a joint
report for the Councils on Industrial Health and
Pharmacy and Chemistry of the American Medi-
cal Association, concluded that evidence for either
the safety or efficacy of prophylaxis with alumi-
num was not available and was not likely to be-
come available because of the nature of silicosis
and the problems of industrial exposure.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

ALUMINUM ACETATE SOLUTION.

U.S.P.

Burow's Solution, Liquor Alumini Acetatis

"Aluminum Acetate Solution yields from each
100 ml., not less than 1.2 Gm. and not more than
1.45 Gm. of AI2O3, and not less than 4.24 Gm.
and not more than 5.11 Gm. of acetic acid
(C2H4O2), corresponding to not less than 4.8
Gm. and not more than 5.8 Gm. of aluminum
acetate (CeHsAlOe)." U.S.P.

Add 15 ml. of glacial acetic acid to 545 ml. of
aluminum subacetate solution and sufficient water
to make 1000 ml. Mix and, if necessary, filter.
Up to 0.6 per cent of boric acid may be added to
stabilize the solution (against precipitation of a
basic compound). Other methods of producing
the aluminum acetate, as by reaction between
lead acetate and aluminum sulfate (see U.S.D.,
23rd edition, page 603, for formula), may be
used but the finished product must meet the
U.S.P. requirements. Only clear aluminum acetate
solution may be dispensed. U.S.P.

Description. — "Aluminum Acetate Solution is
a clear, colorless liquid having a faint acetous
odor, and a sweetish, astringent taste. Its specific
gravity is about 1.022." U.S.P.

Standards and Tests. — Identification. — Alu-
minum acetate solution responds to tests for alu-
minum and for acetate. pH . — The pH of the solu-
tion is about 4. Heavy metals. — The limit is 10
parts per million. Limit of boric acid. — After neu-
tralizing 25 ml. of aluminum acetate solution
with 0.5 JV sodium hydroxide, using phenolph-
thalein T.S. as indicator, glycerin is added and
the resulting strongly ionized complex of boric
acid is titrated with 0.5 N sodium hydroxide. A
blank determination is performed omitting the
aluminum acetate solution, the result of the titra-
tion of which is subtracted from that required
for the solution of the sample. Each ml. of the
difference, expressed as 0.5 N sodium hydroxide,
represents 30.92 mg. of boric acid (the hydrogen
equivalent of boric acid in this test is one).
U.S.P.

Assay. — For aluminum oxide. — From a sample
of 10 ml. of aluminum acetate solution the alu-
minum is precipitated as hydroxide by ammonia
T.S. in the presence of ammonium chloride. The
precipitate is collected on a quantitative filter,
washed with hot distilled water, dried and ignited
to AI2O3. For acetic acid. — From a 20-ml. sample
of aluminum acetate solution the acetic acid is dis-
tilled into a measured excess of 0.5 N sodium hy-
droxide and the excess of the latter determined by
titration with 0.5 N sulfuric acid, using phenol-

Aluminum Acetate Solution

Part I

phthalein T.S. as indicator. Each cc. of 0.5 N
sodium hydroxide represents 30.03 mg. of
C2H4O2. U.S.P.

Uses. — Burow's solution, properly diluted, is
very useful as a wet dressing in the treatment of a
wide range of dermatologic conditions. It is of par-
ticular value in treating acute vesicular and
weeping dermatitis of the eczematous, contact
type, but may be used on any acute or subacute
cutaneous inflammation. It acts by a combination
of detergent, antiseptic, astringent, and heat-
dispersing effects; Combes (N.Y. State J. Med.,
1940, 40, 37) stressed the importance of its
buffering action in maintaining normal skin pH
in the presence of inflammation. Cooper (Am. J.
Surg., 1948, 75, 475) found the solution of value
as cleansing, adjuvant therapy in stasis dermatitis
and ulcers.

Wet dressings of aluminum acetate solution
may be utilized in the form of open compresses
applied intermittently to affected areas, as fixed
closed dressings (the solution being applied to
the dressings), or as soaks in acute conditions of
the hands and feet (contact eczema, acute der-
matophytosis). For these uses the official alumi-
num acetate solution should be diluted with 20
to 30 volumes of water. A combination of alumi-
num sulfate and calcium acetate, known as
Domeboro (Dome Chemicals), is supplied in the
form of effervescent tablets and powders; one
tablet or powder dissolved in a pint of water
provides the equivalent of a 1:20 solution of
aluminum acetate.

Burow's solution is sometimes incorporated
in dermatologic lotions, in a concentration of
about 10 per cent; it is also an ingredient of
the "1-2-3" paste used in treating acute and
chronic eczematous dermatoses and containing
1 part of Burow's solution, 2 parts of hydrophilic
petrolatum or anhydrous lanolin, and 3 parts of
zinc oxide paste.

Aluminum acetate solution has been adminis-
tered by Ghormley and Hinchey (/. Bone Joint
Surg., 1944, 26, 811) to patients with malacic
diseases of bone. The treatment was based on
studies by Helfet. who used feedings of aluminum
acetate to diminish phosphorus intake as a sub-
stitute for a low phosphorus diet, which is nearly
impossible to achieve when a high calcium intake
is desired. Improvement was obtained in osteitis
fibrosa, osteoporosis. Paget's disease, and osteo-
genesis imperfecta. Their patients were given
Burow's solution in a vehicle of tolu syrup and
honey; adequate supplies of milk were given
daily. H

Aluminum acetate solution is applied topically,
commonly being diluted with 10 to 40 volumes of
water.

Storage. — Preserve "in tight containers."
U.S.P.

ALUMINUM CHLORIDE. U.S.P.

[Alumini Chloridum]

"Aluminum Chloride, when dried over sulfuric
acid for 4 hours, contains not less than 95 per
cent of AICI3.6H2O." U.S.P.

Aluminium Chloride. Aluminium Chloratum. Fr. Chlorure

d'aluminium. Get. Aluminiumchlorid. It. Cloruro di allu-
minio. Sp. Cloruro de aluminio.

Aluminum chloride may be prepared by heat-
ing aluminum in chlorine, or by reacting alumi-
num hydroxide with hydrochloric acid.

Description. — "Aluminum Chloride is a
white or yellowish white, deliquescent, crystalline
powder. It is nearly odorless, and has a sweet,
very astringent taste and its solutions are acid to
litmus paper. One Gm. of Aluminum Chloride
dissolves in about 0.9 ml. of water and in about
4 ml. of alcohol. It is soluble in glycerin." U.S.P.

Standards and Tests. — Identification. — A 1
in 10 solution of aluminum chloride responds to
tests for aluminum and for chloride. Sulfate. —
No turbidity is produced in 1 minute after adding
0.2 ml. of barium chloride T.S. to 10 ml. of a 1
in 100 solution of aluminum chloride. Alkalies
and alkaline earths. — Not more than 0.5 per cent
of residue is obtained on evaporating the filtrate
from a solution of aluminum chloride from which
the aluminum has been precipitated by ammonia
T.S. Arsenic. — Aluminum chloride meets the re-
quirements of the test for arsenic. Heavy metals.
— The limit is 20 parts per million. Iron. — The
limit is 10 parts per million. U.S.P.

Assay. — A sample of about 500 mg. of alumi-
num chloride, previously dried for 4 hours over
sulfuric acid, is dissolved in water and the alumi-
num precipitated as explained under Alum. Each
Gm. of aluminum oxide represents 4.736 Gm. of
AICI3.6H2O. U.S.P.

Uses. — Aluminum chloride is employed exter-
nally as an astringent and antiseptic, especially in
hyperhidrosis. It is commonly used as a 25 per
cent solution, applied lightly and only to un-
broken skin; solutions as dilute as 10 per cent
are sometimes used. If irritation occurs the
solution should be washed off. Aluminum chloride
is an ingredient in many proprietary preparations
for diminishing local sweating. The salt is no
longer used internally.

Storage. — Preserve "in tight containers."
U.S.P.

ALUMINUM HYDROXIDE GEL. U.S.P.

Colloidal Aluminum Hydroxide, Gelatum
Alumini Hydroxidum

"Aluminum Hydroxide Gel is a suspension con-
taining the equivalent of not less than 3.6 per
cent and not more than 4.4 per cent of aluminum
oxide (AI2O3), in the form of aluminum hydroxide
and hydrated oxide. It may contain peppermint
oil, glycerin, sorbitol, sucrose, saccharin, or other
suitable agents for flavoring purposes, and it may
contain sodium benzoate, benzoic acid, or other
suitable agents, in a total amount not exceeding
0.5 per cent, as a preservative." U.S.P.

Sp. Hidrato de Aluminio Gelatinado.

The U.S.P. LX recognized under the title Alu-
mini Hydroxidum the precipitate formed by mix-
ing solutions of sodium carbonate and of alum.
This was a white, bulky, amorphous powder,
relatively inefficient as a gastric antacid. It was
used as a protective and mild astringent in the
treatment of irritated conditions of the skin in
much the same way as zinc oxide is employed.

Part I

Aluminum Hydroxide Gel 57

Aluminum hydroxide gel may be prepared by a
number of methods; the products vary widely in
viscosity and particle size, and hence in the rate
of solution in acids. It is known that such factors
as the degree of supersaturation with respect to
aluminum hydroxide, the pH during precipitation,
the temperature, and the nature and concentration
of by-product ions present are important in deter-
mining the physical and, to an extent, the chemical
properties of the aluminum hydroxide.

While details of the manufacturing processes
are not disclosed one manufacturer of an elegant
preparation reacts aluminum chloride with a solu-
tion containing sodium carbonate and sodium
bicarbonate, the product of this reaction is re-
ported to be mixed with the precipitate obtained
by reacting solutions of aluminum chloride and of
ammonia. The mixed magma is dialyzed in canvas
bags, the product is mixed with some glycerin, so-
dium benzoate is added, and the mixture passed
through a colloid mill.

This product is available under its official name
and under several trade names including: Ampho-
jel (Wyeth), Creamalin (Winthrop-Stearns), and
Vanogel (Vanpelt & Brown). Hydrogel (Breon)
contains more aluminum hydroxide than does the
official product and Flaagel (Breon) differs in
that it contains color and orange flavor.

Description. — "Aluminum Hydroxide Gel is
a white, viscous suspension, from which small
amounts of clear liquid may separate on stand-
ing." U.S.P.

Standards and Tests. — Identification. — A so-
lution of aluminum hydroxide gel in hydrochloric
acid responds to tests for aluminum. Reaction. —
Both red and blue litmus paper are slightly af-
fected by aluminum hydroxide gel, but phenol-
phthalein T.S. is not reddened. Acid-consuming
capacity. — About 1.5 ml. of the gel, accurately
weighed, is reacted with SO ml. of 0.1 N hydro-
chloric acid, at 37.5° for 1 hour; the excess acid
is titrated with 0.1 N sodium hydroxide, using
bromophenol blue T.S. as indicator. Each Gm.
of gel requires not less than 12.5 ml. and not
more than 25 ml. of 0.1 N acid. Chloride. — The
limit is 0.28 per cent. Sulfate. — The limit is 500
parts per million. Arsenic. — The limit is 0.8 part
per million. Heavy metals. — The limit is 5 parts
per million. U.S.P.

Assay. — About 5 Gm. of gel, accurately
weighed, is dissolved in a solution of hydrochloric
acid and the aluminum ion precipitated as hy-
droxide by ammonia T.S. The precipitate is ig-
nited to constant weight as AI2O3. U.S.P.

Uses. — Colloidal aluminum hydroxide is used
almost exclusively as a gastric antacid, especially
in the treatment of peptic ulcer. In the stomach
it neutralizes hydrochloric acid, forming aluminum
chloride and water. Schiffrin and Komarov (Am.
J. Digest. Dis., 1941, 8, 215) reported that the
aluminum ion inhibits pepsin activity even in acid
solution. No more hydroxyl ions are liberated
than are necessary for neutralization of the acid.
Each Gm. of the official suspension will neutralize
to pH 3.5 from 12.5 to 25 ml. of gastric juice
having an acidity corresponding to 0.1 N hydro-
chloric acid. The rate of this neutralization is
comparable to that of milk or egg, requiring

from 5 to 15 minutes. It acts more slowly than
the soluble alkalies, such as sodium bicarbonate
which rapidly neutralizes acid to pH 7 or higher
(Adams, Arch. Int. Med., 1939, 63, 1030). In
a study of gastric antacids to determine the rate
and extent of neutralization of 0.1 N hydro-
chloric acid, added at 30 minute intervals to
simulate continuous gastric secretion, Hammar-
lund and Rising (J.A.Ph.A., 1949, 38, 586)
found that aluminum hydroxide gradually raises
the pH to about 4, maintains this value for 2
or 3 hours, and then gradually loses its antacid
effect, while magnesium trisilicate rather more
quickly raises the pH to 5 or 6 but main-
tains this for only a short time before its antacid
effect is almost completely and abruptly spent.
In the alkaline portion of the intestine the alumi-
num chloride reacts to produce insoluble alu-
minum compounds while releasing an equivalent
amount of chloride which is restored to the
system.

Aluminum hydroxide possesses adsorbent prop-
erties toward many substances. Because of its
lack of alkaline character it does not produce a
rebound secretion of hydrochloric acid in the
stomach, as is the case with the soluble alkalies.
Because of its insolubility it is practically unab-
sorbable from the alimentary tract and hence
there is no danger of disturbing the pH balance of
the system, of impairing renal function, or of
having toxic effects (Kirsner, Am. J. Digest. Dis.,
1941, 8, 160). It interferes, however, with the
absorption of phosphates from the intestine and in
the presence of a low phosphorus diet may cause
a deficiency (Fauley et al., Arch. Int. Med.,
1941, 67, 563). It is prescribed for this purpose
in the treatment of renal rickets, chronic uremia
and phosphatic renal calculi (Shorr and Carter,
1950, 144, 1549). Page and Page (Obstet. Gynec,
1953, 1, 94) relieved the muscular leg cramps
which occurred in about half of their well-fed
pregnant patients by prescribing 0.6 Gm. of alu-
minum hydroxide three times daily or by re-
ducing the consumption of milk, which provides
an excess of phosphorus in relation to calcium.
It appears not to interfere with absorption of
amino acids, ascorbic acid, glucose, and neutral
fat (Hoffman and Dyniewicz, Gastroenterology ,
1946, 6, 50). Some clinicians have claimed excel-
lent results in various forms of enteritis due to
its adsorbent oower. Eyerly and Breuhaus
(J.A.M.A., 1937, 109, 191) reported favorably
on the use of enemas of aluminum hydroxide gel
and kaolin in ulcerative colitis.

The most important medicinal use of aluminum
hydroxide is in the treatment of peptic ulcer, in
which the persistence of its antacid effect is of
especial importance, but it appears also to act as
a protecitve in these cases and to exercise some
other beneficial, perhaps astringent, action beyond
that of merely correcting the acidity; it is prob-
able that it has a protective action on the raw
surface. For literature on the use of this drug see
the report of the Council on Pharmacy, J.A.M.A.,
1941, 117, 1356. Collins (J.A.M.A., 1945, 127,
899) has reported the satisfactory use of alumi-
num hydroxide gel in the management of 3,000
patients with peptic ulcer over a period of many

Aluminum Hydroxide Gel

Part I

years (see also Rossett et al, Ann. Int. Med.,
1952, 36, 98). The more prolonged and effective
action of aluminum hydroxide enabled the ma-
jority of patients to follow a regimen compatible
with their occupations, although general hygienic
measures, diet and alleviation of mental tension
could not be neglected. Its constipating action
in some cases is undesirable; the simultaneous
use of laxatives may be required. The tendency
of the peptic ulcer patient to constipation is fa-
vored by the low-residue, bland diet usually
prescribed. Batterman and Ehrenfeld {Gastroen-
terology, 1947, 9, 141) reported the incidence
of constipation with various antacids as follows:
non-reactive aluminum hydroxide gels, 30 to 35
per cent; reactive aluminum hydroxide gels, 16
to 33 per cent; magnesium trisilicate. 14 to 15
per cent. Kirsner et al. (Ann. Int. Med., 1951,
35, 7S5) pointed out that no antacid in a single
dose was capable of neutralizing the night-time
hypersecretion of the duodenal ulcer patient.
For cases refractory- to usual medical man-
agement Winkelstein and Hollander (Surgery,
1945, 17, 696) and others employed with success
a continuous intragastric drip of aluminum hy-
droxide gel or a mixture of milk and sodium
bicarbonate. Woldman (Am. J. Digest. Dis.,
1941, 8, 39) reported that the continuous method
of administration was particularly beneficial in
bleeding peptic ulcer. In their most successful
management of the bleeding peptic ulcer patient,
Dunphy and Gray (Mod. Med., March 1, 1952,
p. 90) employed hourly feedings of 100 ml. of
warm milk and cream with 10 ml. of aluminum
hydroxide gel every hour during the day and
double these quantities even- 2 hours during
the night along with phenobarbital, atropine,
vitamins, and blood replacement, with operation
if shock was not corrected by transfusions. Binder
and Paul (Am. J. Digest. Dis., 1952, 19, 278)
reported good results in the bleeding case with a
similar medical management. Cantor et al. (Am.
J. Surg., 1950. 80, SS3) gave gelfoam and throm-
bin by mouth to form a clot in such cases and
used aluminum hydroxide gel to prevent diges-
tion of the thrombin and the clot.

Howard (U. S. Nov. M. Bull, 1945, 44, 1047)
reported prompt relief and rapid healing from
local application of aluminum hydroxide gel to
a variety of skin conditions, such as miliaria
rubra, tinea cruris or circinata, weeping eczema-
tous lesions, impetigo and epidermophytosis.
Friedman et al. (Am. J. Digest. Dis., 1948, 15,
57) effectively employed a paste in moist, but
not in dry. types of pruritus ani.

Aluminum hydroxide gel has been used as a
vehicle to increase the absorption of orally ad-
ministered penicillin (J. A.M. A., 1945, 128,' 845;
1945, 129, 315). Administration of aluminum
hydroxide with anticholinergic drugs, such as atro-
pine sulfate, given by mouth to animals, was
found by Seifter et al. (I. Pharmacol., 1952, 105,
96) to retard the absorption of the latter but to
prolong its action considerably. Clinical studies
by Berkowitz (Antibiot. Chemother., 1953. 3,
618) demonstrated that the addition of aluminum
hydroxide gel to a triple sulfonamide mixture
increased and prolonged the concentration of

sulfonamide in the blood. Simultaneous adminis-
tration of aluminum hydroxide with aminophyl-
line decreased the incidence of gastrointestinal
disturbances to such a degree that sufficient of
the latter compound could be given orally to at-
tain levels of theophylline in the blood which
are comparable to those obtained by intravenous
administration of aminophylline (Cronheim et al.,
Postgrad. Med., 1953, 13, 432); the aluminum
hydroxide appears not to alter the rate or the
degree of absorption of the aminophylline. With
chlortetracycline (Aureomycin > , aluminum hy-
droxide gel relieves the frequent gastrointestinal
disturbances but it also decreases the blood con-
centration of the antibiotic (Waisbren and others,
J.A.M.A., 1949, 141, 938; Boger et al, J. Phila.
Gen. Hosp., 1950, 1, 3) and changes its effect
on fecal urobilinogen and fecal bacterial flora
(Hayford and Waisbren. Surgery, 1952, 31, 361). S

Dose. — The usual dose of aluminum hydroxide
gel is 8 ml. (2 fluidrachms), with half a glass of
water, 3 to 6 times daily, about one hour after
meals and at bedtime. It may be taken as fre-
quently as every two hours. The range of dose is
4 to 30 ml.; generally not over 60 ml. is to be
taken in 24 hours.

Storage. — Preserve '"in tight containers and
avoid freezing/' U.S.P.

DRIED ALUMINUM HYDROXIDE
GEL. U.S.P.

Gelatum Alumini Hydroxidi Siccum

''Dried Aluminum Hydroxide Gel yields not
less than 50 per cent of aluminum oxide (AI2O3)."
U.S.P.

Sp. Hidrato de Aluminio Gclatinado Seco.

Dried aluminum hydroxide gel is prepared by
drying, at not too high temperature, the magma
of aluminum hydroxide obtained in preparing
the liquid gel (see preceding monograph) prior
to addition of glycerin or preservative. Products
on the market differ widely in bulk and rate of
solution because of variation in the temperature
and rate of drying, as well as variation in the
factors discussed under Aluminum Hydroxide Gel.

Description. — "Dried Aluminum Hydroxide
Gel is a white, odorless, tasteless, amorphous
powder. Dried Aluminum Hydroxide Gel is in-
soluble in water and in alcohol. It is soluble in
diluted mineral acids and in solutions of fixed
alkali hydroxides.'' U.S.P.

Standards and Tests. — Identification. — A so-
lution of 500 mg. of dried aluminum hydroxide
gel in 10 ml. of diluted hydrochloric acid responds
to tests for aluminum. Reaction. — The filtrate
from a suspension of 1 Gm. of dried gel in 25 ml.
of water is neutral to litmus paper. Acid-con-
suming capacity. — Each Gm. of dried aluminum
hydroxide gel requires not less than 250 ml. of
0.1 N hydrochloric acid (see this test under
Aluminum Hydroxide Gel). Chloride. — The limit
is 0.84 per cent. Sulfate. — The limit is 0.6 per
cent. Arsenic and heavy metals. — Dried aluminum
hydroxide gel meets the requirements of the cor-
responding tests under Aluminum Hydroxide Gel,
allowance being made for the difference in content
of AI2O3. U.S.P.

Part I

Aluminum Phosphate Gel 59

Assay. — A sample of about 400 mg. of dried
gel is assayed in a manner similar to that sum-
marized under the assay for Aluminum Hydroxide
Gel. U.S.P.

Uses. — In the form of tablets this is a con-
venient method of administering aluminum hy-
droxide gel. The following are proprietary names
for the tablets: Alugel (Cole), Amphojel
(Wyeth), Creamalin (Winthrop), Drydgel (Fair-
child), and Vanogel (Vanpelt & Brown). For an
account of its therapeutic uses see under Alumi-
num Hydroxide Gel. The antacid action of the
dry form is less rapid and efficient than that of
the gel. Tablets should probably be chewed for
best results.

The usual dose is 300 mg. (approximately 5
grains) 4 times daily; the range of dose is 300 mg.
to 2.4 Gm.

Storage. — Preserve "in tight containers."
U.S.P.

ALUMINUM PASTE. U.S.P.

"Aluminum Paste contains not less than 9 per
cent and not more than 10 per cent of Al." U.S.P.

Levigate 100 Gm. of aluminum, in very fine
powder, with 50 Gm. of liquid petrolatum to a
smooth paste and then incorporate this mixture
with 850 Gm. of zinc oxide ointment. U.S.P.

Assay. — A 1-Gm. portion of aluminum paste
is heated with a mixture of sulfuric and nitric
acids to oxidize as much of the fatty base as pos-
sible, while also dissolving the aluminum. The pH
of the liquid is adjusted to 2.5 and the zinc is
precipitated as sulfide. Aluminum in the filtrate
is precipitated as hydrous aluminum oxide by add-
ing ammonium hydroxide, and the precipitate is
finally weighed as AI2O3. The weight of Al in the
sample is calculated by multiplying the weight
of the oxide by 0.5292. U.S.P.

Use. — As mentioned in the article on alumi-
num, this paste is a convenient means of applying
the powdered metal around intestinal fistulae to
protect the surrounding skin against the digestive
action of the intestinal contents.

Storage. — Preserve "in well-closed containers,
and avoid prolonged exposure to temperatures
above 30°." U.S.P.

ALUMINUM PHOSPHATE GEL. U.S.P.

[Gelatum Alumini Phosphatis]

"Aluminum Phosphate Gel is a water suspen-
sion containing not less than 3.8 per cent and not
more than 4.5 per cent of aluminum phosphate
(AIPO4). It may contain peppermint oil, glycerin,
sorbitol, sucrose, saccharin, or other suitable
agents for flavoring purposes, and it may contain
sodium benzoate, benzoic acid, or other suitable
agents, in an amount not exceeding 0.5 per cent,
as a preservative." U.S.P.

Phosphaljel (Wyeth). Sp. Gel de Fosfato de Aluminio.

Aluminum phosphate gel may be prepared by
the interaction of an aluminum salt with a phos-
phate; the product, like aluminum hydroxide gel,
varies in viscosity and particle size depending on
the pH of the reaction mixture, the temperature,
and the concentration and the particular salts

used as the source of the interacting ions. After
precipitation of the aluminum phosphate the
product is dialyzed, mixed with one or more of
the substances officially permitted to be used for
stabilizing, preserving and flavoring purposes,
and passed through a colloid mill.

Description. — "Aluminum Phosphate Gel is
a white, viscous suspension from which small
amounts of water may separate on standing."
U.S.P.

Standards and Tests. — Identification. — (1)
A solution of the gel in hydrochloric acid responds
to tests for Aluminum. (2) A solution of the gel
in diluted nitric acid responds to tests for phos-
phate. pH — The pH of the gel, at 25°, is be-
tween 6.0 and 7.2. Reaction rate. — A mixture of
30 ml. of 0.1 N hydrochloric acid and 6 Gm. of
gel, heated at 37° for 15 minutes, has a pH be-
tween 2.0 and 2.5. Chloride. — Not over 0.16
per cent. Soluble phosphate. — Not over 700 parts
per million, calculated as PO-i. Sulfate. — Not
over 500 parts per million. Arsenic. — Not over
0.8 part per million. Heavy metals. — The limit is
5 parts per million. Acid-consuming capacity. —
About 250 mg. of the gel, accurately weighed, is
digested with 30 ml. of 0.1 N hydrochloric acid
at 37° for 30 minutes; the excess acid is titrated
with 0.1 A7 sodium hydroxide, using thymol blue
T.S. and titrating to a pH of 2.5. Each Gm. of gel
requires not less than 5 and not more than 9 ml.
of 0.1 A7 acid. U.S.P.

Assay. — A 20 Gm. portion of gel is dissolved
in nitric acid and diluted to 100 ml. with distilled
water. From a 10-ml. portion of this solution the
phosphate is precipitated as ammonium phos-
phomolybdate with ammonium molybdate T.S.
The precipitate is filtered, washed first with a
nitric acid solution, then with 1 per cent potas-
sium nitrate and dissolved in 50 ml. of 0.5 N
sodium hydroxide; the excess of alkali is titrated
with 0.5 N sulfuric acid, using phenolphthalein
T.S. as indicator. The reaction of ammonium
phosphomolybdate and sodium hydroxide may
be represented by the following equation:

(NH.4)3P04.12Mo03 + 23NaOH -*

llNa2Mo04 + (NH.4)2Mo04 +

NaNH.4HP04+ IIH2O

from which it is apparent that the equivalent
weight of AIPO4 is ^3 of its molecular weight,
one molecule of ammonium phosphomolybdate
being precipitated for each molecule of aluminum
phosphate undergoing reaction. Each ml. of
0.5 N sodium hydroxide represents 2.651 mg. of
AIPO4. U.S.P.

Uses. — Aluminum phosphate gel is employed
in the treatment of peptic ulcer and is particu-
larly advocated for the patient with postoperative,
jejunal (marginal) ulcer (Fauley et. al., Arch.
Int. Med., 1941, 67, 563; Collins, J. A.M. A.,
1945, 127, 899). Whereas aluminum hydroxide
failed to prevent the development of postoperative
jejunal ulcer in Mann-Williamson dogs in which
there is a relative deficiency of bile and pancreatic
juice, aluminum phosphate gel was shown to be
effective both as a preventive and a therapeutic
agent in such dogs. Clinical experience has con-
firmed the superiority of aluminum phosphate

Aluminum Phosphate Gel

Part I

over aluminum hydroxide in the management of
peptic ulcer in patients who have a deficiency of
pancreatic juice, a chronic diarrhea or a dietary
deficiency in phosphorus. Lichstein et al. (Am. J.
Digest. Dis., 1945, 12, 65) reported good results
in patients with uncomplicated peptic ulcer and
bleeding peptic ulcer.

The range of dose is 15 to 30 ml. (approxi-
mately 4 to 8 fluidrachms), alone or with a little
water, as frequently as even' 2 hours if necessary.
The total dose in 24 hours usually does not
exceed 100 ml.

Storage. — Preserve ''in tight containers."
U.S.P.

ALUMINUM SUBACETATE SOLU-
TION. U.S.P.

Liquor Alumini Subacetatis

"Aluminum Subacetate Solution yields, from
each 100 ml., not /less than 2.30 Gm. and not
more than 2.60 Gm. of aluminum oxide (AI2O3),
and not less than 5.43 Gm. and not more than
6.13 Gm. of acetic acid (C2H4O2)." U.S.P.

Liquor Aluminii Acetici (Ger., It.). Fr. Solution d'acetate
d'aluniinium. Ger. Aluminiumazetatlbsung. It. Acetato di
alluminio liquido.

Dissolve 160 Gm. of aluminum sulfate in 600
ml. of water, filter the solution, and gradually add
70 Gm. of precipitated calcium carbonate, in sev-
eral portions, with constant stirring. Now slowly
add 160 ml. of acetic acid, mix, and set the mix-
ture aside for 24 hours. Filter the mixture through
a Buchner funnel, wash the magma on the filter
with small portions of cold water until the filtrate
measures 1000 ml. The solution may be stabilized
(against precipitation) by the addition of not
more than 0.9 per cent of boric acid. Other
methods of producing the aluminum subacetate
may be used but the finished product must meet
the U.S.P. requirements. U.S.P.

Description. — ''Aluminum Subacetate Solu-
tion is a clear, colorless, or faintly yellow liquid,
having an acetous odor and an acid reaction to
litmus. It gradually becomes turbid on continued
standing, due to separation of a more basic salt."
U.S.P.

Standards and Tests. — Identification. —
Aluminum subacetate solution responds to tests
for aluminum and for acetate. Limit for boric
acid. — This test is performed as directed under
Aluminum Acetate Solution. U.S.P.

Assay. — The assay for aluminum oxide and
that for acetic acid are performed as directed
under Aluminum Acetate Solution. U.S.P.

Uses. — Aluminum subacetate solution is use-
ful as an astringent and antiseptic wash. Diluted
with 20 to 40 volumes of water it is employed as
a wet dressing in acute, vesicular and exudative
eczematous conditions of the skin; occasionally
somewhat stronger solutions are applied. It was
formerly used as a gargle for local treatment of
inflamed conditions of the throat.

Storage. — Preserve "in tight containers."
US.P.

Off. Prep. — Aluminum Acetate Solution,
US.P.

ALUMINUM SULFATE. U.S.P.

[Alumini Sulfas]

"Aluminum Sulfate contains an amount of
Ab(S04)3 equivalent to not less than 99.5 per
cent and not more than 112 per cent of
Al2(S04)3.18HoO." US.P.

Aluminium Sulfate; Concentrated Alum; Pearl or Pickle
Alum. Aluminium Sulfuricum; Sulfas Aluminicus; Alum-
inii Sulphas. Fr. Sulfate d'aluminium; Sulfate d'alumine
pur. Ger. Aluminiumsulfat ; Schwefelsaures Aluminium;
Schwefelsaure Tonerde. It. Solfato di alluminio. Up.
Sulfato de aluminio.

This salt may be manufactured by various
methods (see U.S.D., 19th ed.. p. 124) as, for ex-
ample, by dissolving aluminum hydroxide in sul-
furic acid, but is now obtained chiefly as one of
the by-products in the manufacture of soda from
cryolite or from bauxite.

Description. — "Aluminum Sulfate occurs as a
white crystalline powder, as shining plates, or as
crystalline fragments, and is stable in air. It is
odorless, and has a sweet taste, becoming mildly
astringent. Its solutions are acid to litmus. One
Gm. of Aluminum Sulfate dissolves in about 1 ml.
of water. It is insoluble in alcohol." US.P.

Standards and Tests. — Identification. — A 1
in 10 aqueous solution of aluminum sulfate re-
sponds to tests for aluminum and for sulfate.
pH. — The pH of a 1 in 20 solution is not less
than 2.9. Alkalies and alkaline earths. — Not over
0.4 per cent of residue is obtained on evaporating
the filtrate from a solution of aluminum sulfate
from which the aluminum has been precipitated
by ammonia T.S. Ammonium salts. — Ammonia is
not evolved on heating 1 Gm. of aluminum sulfate
with 10 ml. of sodium hydroxide T.S. Arsenic. —
Aluminum sulfate meets the requirements of the
test for arsenic. Heavy metals. — The limit is 40
parts per million. Iron. — A blue color is not pro-
duced immediately on adding 0.3 ml. of potassium
ferrocyanide T.S. to 20 ml. of a 1 in 150 solution
of aluminum sulfate. U.S.P.

Assay. — A sample of about 500 mg. of alumi-
num sulfate is assayed as explained under Alum.
Each Gm. of aluminum oxide represents 6.536
Gm. of Ai2(S04)3.18H20. N.F.

Uses. — Aluminum sulfate has medicinal prop-
erties very similar to those of alum. In 15 per
cent concentration it is used in perspiration-
inhibiting creams ; it may be used with aluminum
chloride in liquid deodorants. It has been em-
ployed in aqueous solution (about 4 or 5 per
cent) as an antiseptic, detergent application to
foul ulcers, and as an injection in fetid leukor-
rhea. In 10 per cent aqueous solution it was used
by Deuschle (Cincinnati M. J., 1943, 23, 578)
in sterilization of shallow dental cavities and the
alveolus after tooth extraction, the area being
packed and the solution dispersed by the passage
of a 2.5 milliampere galvanic current for 10 min-
utes through the saturated pack. Solution of
aluminum sulfate is capable of dissolving a con-
siderable quantity of freshly precipitated alumi-
num hydroxide. Such a solution, impregnated
with benzoin, has been used as a hemostatic and
as a vaginal douche in leukorrhea, under the
name of benzoinated solution of alumina (for

Part I

Aminacrine Hydrochloride 61

method of preparation see U.S.D. 24th ed., p. 58).
It resembles the styptic liquid of Pagliari.

Solutions of aluminum sulfate in water are
commonly used, by local application, in a con-
centration of 5 to 25 per cent, |v]

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep. — Aluminum Subacetate Solution,
U.S.P.

AMARANTH. U.S.P.

F.D. and C. Red No. 2, [Amaranthum]

Nq03S

N=N

S03Na

"Amaranth contains not less than 94 per cent
of C2oHnN2Na30ioS3, calculated on the dried
basis." U.S.P.

Amaranth Color; Azo Acid Rubin 2 B; Fast Red D;
Bordeaux S. Sp. Amaranto.

One of the products obtained in the sulfonation
of betanaphthol is 2-naphthol-3,6-disulfonic acid,
a dye intermediate known as R-acid, from the red-
dish color of its azo dye derivatives. By coupling
R-acid with the diazo derivative of naphthionic
acid (l-naphthylamine-4-sulfonic acid) there re-
sults the l-(4-sulfo-l-naphthylazo)-2-naphthol-
3,6-disulfonic acid, of which amaranth is the tri-
sodium salt.

Description. — "Amaranth occurs as a dark
red brown powder. One Gm. of Amaranth dis-
solves in about 15 ml. of water; it is very slightly
soluble in alcohol." U.S.P.

Standards and Tests. — Identification. — (1)
The color of a 1 in 100 solution of amaranth,
when viewed through a depth of 1 cm., is vivid
red; it is not appreciably changed on adding hy-
drochloric acid, but is intensified on adding sodium
hydroxide T.S. (2) About 50 mg. of amaranth
and 200 mg. of powdered sodium hydroxide is
fused by heating in a small test tube. On adding
0.5 ml. of water to the cooled residue, then a
moderate excess of diluted hydrochloric acid, and
warming, sulfur dioxide is evolved, which may be
recognized by its odor and also by testing the
vapor with starch iodate paper. Loss on drying. —
Not over 10 per cent, when dried at 120° to con-
stant weight. Water-insoluble substances. — Not
over 0.5 per cent. Metals precipitated by am-
monia, ammonium oxalate and phosphate. — Not
more than approximately 1 per cent. Ether-
extractable substances. — Not over 0.2 per cent.
U.S.P.

Assay. — About 350 mg. of amaranth is dis-
solved in water, sodium citrate is added, and the
solution is titrated with 0.1 N titanium trichlo-
ride, at boiling temperature, which reduces the
dye to a colorless or practically colorless deriva-

tive. Each ml. of 0.1 N titanium trichloride repre-
sents 15.11 mg. of C2oHuN2Na30ioS3. U.S.P.

Uses. — Amaranth is commonly used in the
dyeing of wool and silk, being an exceptionally
fast, light color. Because of its comparatively
innocuous character it is also included in the
U. S. Government list of certified colors for foods,
drugs, and cosmetics. It holds its color fairly well
in either acid or alkaline solutions. For studies of
its pharmaceutical uses see Pharm. J., 1936, 136,
233, 458, and /. A. Ph. A. Prac. Ed., 1941, 2, 398.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

AMARANTH SOLUTION. U.S.P.

Liquor Amaranthi

Dissolve 1 Gm. of amaranth in sufficient puri-
fied water to make 100 ml. U.S.P.

Description. — "Amaranth Solution is a clear,
vivid red liquid, having but a slight odor." U.S.P.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

COMPOUND AMARANTH SOLUTION.

N.F.

Dissolve 100 Gm. of caramel in 500 ml. of
purified water, add 90 ml. of amaranth solution,
250 ml. of alcohol, and enough purified water to
make the product measure 1000 ml.; mix well.
N.F.

Alcohol Content. — From 22 to 25 per cent,
by volume, of C2H5OH. N.F.

This solution is used as a color in several N.F.
preparations; it replaces the compound cudbear
tincture long used similarly but which varied to
some extent in tinctorial power.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

AMINACRINE HYDROCHLORIDE.
B.P.

Aminacrinae Hydrochloridum

HCI.H20

This antiseptic dye is referred to in the Ameri-
can literature as 9-aminoacridine hydrochloride,
but the B.P. describes it as 5-aminoacridine hydro-
chloride monohydrate, containing not less than
98.5 per cent of C13H10N2.HCI calculated with
reference to the substance dried to constant weight
at 100° at a pressure not exceeding 5 mm. of
mercury. The substance may be prepared by the
reaction of N-phenylanthranilic acid with phos-
phorus oxychloride, then reacting the product with
ammonium carbonate in phenol.

Description. — Aminacrine hydrochloride oc-
curs as a pale yellow, crystalline, odorless powder,
having a bitter taste. It is soluble in 300 parts of
water, at 20°; it is soluble in 90 per cent alcohol,
also in glycerin; at 20° it is soluble in 2000 parts
of isotonic sodium chloride solution; it is almost
insoluble in ether and in chloroform.

Aminacrine Hydrochloride

Part I

Standards and Tests. — Identification. — (1)
A saturated aqueous solution is pale yellow, ex-
hibiting a greenish-blue fluorescence; a very di-
lute solution has a powerful blue fluorescence.
(2) Aminacrine, liberated by the addition of alkali
to a solution of the salt and dried at 105° after
recrystallization from dilute alcohol, melts at
about 235°. (3) The salt responds to tests char-
acteristic of chlorides. Acidity. — The pH of a 0.2
per cent (w/v) solution is between 5.0 and 6.5.
Loss on drying. — Not more than 8.0 per cent.
Sulfated ash. — Not more than 0.2 per cent.

Assay. — The assay, using about 500 mg. of
sample, is identical with that specified for Pro-
flavine Hemisuljate. Each ml. of 0.1 M potassium
ferricyanide represnts 69.21 mg. of C13H10N2.-
HC1, this equivalent being based on the reaction
of three molecules of aminacrine hydrochloride
with one molecule of potassium ferricyanide.

Uses. — In vitro tests have demonstrated that
the bacteriostatic and bactericidal powers of
aminacrine hydrochloride are slightly greater than
those of proflavine; the toxicity, when injected
subcutaneously into mice, is midway between that
of proflavine and of acriflavine (Rubbo et al.,
Brit. J. Exp. Path., 1942, 23, 69). The same in-
vestigators concluded that it is only slightly more
toxic to human polymorphonuclear leukocytes
than is proflavine. Russell and Falconer {Lancet,
1943, 244, 580) showed that an isotonic 1:1000
solution, buffered at pH 6.2, was harmless when
applied to exposed rabbit's brain tissue, while the
same concentration of acriflavine caused hemor-
rhage and necrosis. After an intensive study of
the bacteriological and pharmacological proper-
ties, Ungar and Robinson {Lancet, 1943, 245,
285; /. Pharmacol., 1944, 80, 217) concluded that
it was an effective antiseptic having certain ad-
vantages over acriflavine and proflavine. The hy-
drochloride, in powder form, is the least inhibitory
to healing of wounds of any of the acridine anti-
septics, though Russell and Falconer (loc. cit.)
and Selbie and Mcintosh (/. Path. Bad., 1943,
55, 477) could not recommend the use, in powder
form, of any of the salts of acridine antiseptics
for prophylactic treatment of fresh wounds.

Poate {Lancet, 1944, 247, 238; Med. J. Aus-
tralia, 1944, 1, 242) controlled sepsis in wounds
in all but 5 out of 120 cases by irrigation with a
1:1000 solution, with an emulsion, or with a
powder containing 10 to 40 parts of sulfanilamide
to 1 part of the acridine compound. The solution
appeared to be particularly effective against hemo-
lytic staphylococci; against pyocyaneus infection
a 1:1000 solution in 2 per cent acetic acid was
used. Effective sterilization of skin, prior to sur-
gical operation, by application of a 1 per cent
solution in 50 per cent alcohol, was reported by
Bonney and Sandeman-Allen {Brit. M. J., 1944,
2, 210). Arden {Med. J. Australia, 1945, 32, 486)
preferred local application of 9-aminoacridine hy-
drochloride {Monocrine) to excision of contami-
nated wounds, even when brain tissue was in-
volved.

Nemir {Arch. Surg., 1951, 62, 493) employed
solutions containing 0.05 to 0.5 mg. per ml. in
peritoneal exudate following soiling with bowel
contents; the results were superior to those ob-

tained with 1 unit of penicillin and 10 units of
streptomycin per ml. or with 0.1 mg. of sulfa-
diazine per ml. In nontoxic concentrations amina-
crine hydrochloride inhibited CI. welchii, E. coli,
Staph, aureus, and some streptococci. As men-
tioned under Sulfanilamide, a vaginal cream con-
taining 0.2 per cent aminacrine hydrochloride, 15
per cent of sulfanilamide, 2 per cent of allantoin,
and lactose, in a water-miscible base buffered with
lactic acid to pH 4.5, has been used effectively in
bacterial cervicitis and vaginitis, Trichomonas
vaginalis vaginitis, and in some cases of monilial
vaginitis (Warner, N. Y. State J. Med., 1952, 52,
1029, and others).

Albert and Gledhill {Lancet, 1944, 1, 759)
found that absorbent dressings did not interfere
with the action of aminacrine.

AMINOACETIC ACID. N.F., LP.

Glycocoll, Glycine, [Acidum Aminoaceticum]
H2N.CH2.COOH

"Aminoacetic Acid, dried at 105° for 2 hours,
yields not less than 98.5 per cent and not more
than 101.5 per cent of C2H5NO2." N.F. The LP.
requires not less than 98.5 per cent of C2H5O2N,
calculated with reference to the substance dried
at 105° for 2 hours.

Ger. Aminoessigsaure; Glykokoll; Glycin; Sp. Acido
Aminoacetico.

Caution. — Glycine should not be confused with
glycin (/>-hydroxyphenyl-aminoacetic acid) , which
is a poisonous substance.

Aminoacetic acid, the simplest of the amino
acids, is found in bile in combination with cholic
acid. It is a constituent of many proteins and may
be obtained by the hydrolysis of glue, gelatin and
silk fibroin; Bergmann (/. Biol. Chem., 1938, 122,
577) found that it makes up one-half of the total
amino acids of the last-named substance.

Several processes for preparing aminoacetic acid
have been patented; these include hydrolysis of
glycine esters with organic acids, alkaline hy-
drolysis of glycine ethyl ester sulfate, hydrolysis
of methylene-aminoacetonitrile, electrolytic re-
duction of cyanoformic ester, as well as a method
involving hydrolysis of neck ligaments of cattle.
Large quantities of the acid may be conveniently
and economically prepared, however, by the reac-
tion of chloroacetic acid with excess ammonia at
room temperature or with ammonium carbonate
at a temperature of 60 to 65°. The excess of
ammonia is evaporated and the glycine crystallized
after addition of methyl alcohol; the product is
purified by recrystallization from methyl alcohol-
water solution. For other syntheses of amino-
acetic acid see Schmidt's Chemistry of the Amino
Acids and Proteins (Second Edition, 1944).

While the formula of aminoacetic acid is com-
monly written as H2N.CH2.COOH, various physi-
cal and chemical properties of the substance in-
dicate that it does not exist in this form. It is
now fairly certainly established that the tendency
of the carboxyl group to give up a proton (which
property is characteristic of acids) and the tend-
ency of the amino group to accept a proton
(which property is characteristic of bases) results

Part I

Aminoacetic Acid

in the migration of the proton (hydrogen ion)
from the carboxyl to the amino group, giving rise
to a neutral ion of the composition H3+N.CH2.-
COO~. Such an ion has been called a "zwitter-
ion" (meaning hybrid ion) but is better called
a "dipolar ion." The property of forming dipolar
ions is characteristic of amino acids. Notwith-
standing this internal neutralization of amino-
acetic acid, the substance is capable of acting as
an acid or a base, depending on the solvent
medium and whether or not another base or acid
is present to react with it. Thus, it forms a crys-
talline salt with hydrochloric acid, aminoacetic
acid hydrochloride, which may be used as a con-
venient means of administering the acid since in
the body the hydrochloric acid component is
released.

A suggested mechanism by which aminoacetic
acid enters into the building-up of proteins is
presented in the article on Amino Acids, Part II.

Description. — "Aminoacetic Acid occurs as a
white, odorless, crystalline powder, having a
sweetish taste. Its solution is acid to litmus paper.
One Gm. of Aminoacetic Acid dissolves in about
4 ml. of water. It is very slightly soluble in alco-
hol and in ether." N.F.

Standards and Tests. — Identification. — (1)
A vigorous evolution of colorless gas (nitrogen)
results when 5 drops of diluted hydrochloric acid
and 5 drops of a 1 in 2 solution of sodium nitrite
are added to 5 ml. of a 1 in 10 solution of amino-
acetic acid. (2) A deep wine color is produced
on adding 1 ml. of ferric chloride T.S. to 2 ml. of a

1 in 10 solution of aminoacetic acid; on adding an
excess of diluted hydrochloric acid the color dis-
appears, to reappear on adding stronger ammonia
T.S. in excess. (3) A blue color is produced on
adding 1 drop of liquefied phenol and 5 ml. of
sodium hypochlorite T.S. to 2 ml. of a 1 in 10
solution of aminoacetic acid. Loss on drying. —
Not over 0.2 per cent, when dried at 105° for

2 hours. Residue on ignition. — Not over 0.1 per
cent. Readily carbonizable substances. — A solu-
tion of 500 mg. of the acid in 5 ml. of sulfuric
acid is colorless. Chloride. — The limit is 70 parts
per million. Sulfate. — The limit is 65 parts per
million. Heavy metals. — The limit is 20 parts per
million. Hydrolyzable substances. — A 1 in 10
solution of aminoacetic acid which has been boiled
for 1 minute and then set aside for 2 hours is as
clear and mobile as the same solution which has
not been boiled. N.F.

For information on the solubility of amino-
acetic acid in mixtures of water and alcohol see
Dunn and co-workers (/. Biol. Chem., 1938, 125,
309).

Assay. — About 175 mg. of aminoacetic acid,
previously dried at 105° for 2 hours, is titrated
with 0.1 A7 sodium hydroxide in the presence of
formaldehyde. Each ml. of 0.1 N sodium hy-
droxide represents 7.507 mg. of C2H5NO2. N.F.
For an explanation of the assay see the following
monograph. The LP. employs the Kjeldahl method
of assay for nitrogen.

Incompatibilities. — The sparing solubility of
aminoacetic acid in alcoholic liquids may cause
its precipitation from aqueous solution on the
addition of alcohol. Ferric salts cause a wine-red

color, destroyed by acids; nitrites may react with
the liberation of nitrogen. Grill (/. A. Ph. A.,
1938, 27, 871) reported development of a brown
color in solutions of aminoacetic acid containing
low iso-alcoholic elixir.

Uses. — Glycine, as such, is not widely used in
therapeutics but in combination with other phar-
macologic agents it is important. In the metabo-
lism of the body, aminoacetic acid is involved in
the synthesis of body protein, creatine, glycocholic
acid, glutathione, uric acid, heme, etc. It converts
benzoic acid to its detoxified derivative hippuric
acid.

Myopathies. — The theory originally put forth
by Thomas in 1932 that glycine was the chief
source of the creatine of the muscles received
support from the studies of Bloch and Schoen-
heimer (/. Biol. Chem., 1940, 133, 633; 134,
785), but these authors showed further that
methionine and arginine are also converted into
creatine (/. Biol. Chem., 1941, 138, 167). More-
over, glycine is readily synthesized by man in
adequate amounts (Quick, /. Biol. Chem., 1931,
92, 65; Shemin and Rittenberg, /. Biol. Chem.,
1944, 153, 401) and it is not an essential amino
acid in the diet (Rose, Physiol. Rev., 1938, 18,
109). In normal men creatine does not appear in
the urine except after violent muscular exertion,
being excreted as a related compound creatinine.
In certain diseases of the voluntary muscles, how-
ever— notably so-called progressive muscular dys-
trophy— creatine does appear in the urine. Thomas
in 1932 tried glycine in this tragic disease. Since
then a number of clinicians reported favorably on
its effects, not only in progressive muscular dys-
trophy but also in myasthenia gravis (Boothby,
Proc. Mayo, 1932, 7, 447), poliomyelitis and
Addison's disease, but others failed to see any
marked benefit from the drug (J.A.M.A., 1939,
113, 559; and 1942, 119, 1506; 1951, 147, 1185).
Chaikelis (Am. J. Physiol., 1941, 133, 578) re-
ported that in normal men it increases muscular
power and delays appearance of muscle fatigue.
Maison, however (J. A.M. A., 1940, 115, 1439),
believes that the reported experiments dealing
with fatigue are open to criticism. In a well-
controlled study (J.A.M.A., 1942, 118, 594)
glycine failed to increase the work capacity of
human subjects. A high-protein diet seems prefer-
able to this unessential amino acid and also to
the incomplete protein, gelatin, which has been
employed as a dietary source of glycine (about
25 per cent).

Tracer Studies. — The ready incorporation of
glycine into so many essential compounds in the
body has made this amino acid, when labeled with
the isotope C14 (Rittenberg and Shemin, J. Biol.
Chem., 1950, 185, 103; Barnet and Wick, ibid.,
657) or N15 (Shemin and Rittenberg, ibid., 1945,
159, 567), most useful in the study of the inter-
mediary metabolism of tissue and serum protein,
hemoglobin, carbohydrate and other substances.
Rapid incorporation into serum and tissue pro-
tein has been observed. Only a small portion,
varying with the nutritional status and the pro-
tein intake, appears in the urine during the first
24 hours. Some of the carbon is excreted as
carbon dioxide by the lungs (Berlin et al., J. Clin.

Aminoacetic Acid

Part I

Inv., 1951, 30, 73). Labeled glycine has been
employed to study the life-span of erythrocytes
in circulating blood; the estimate of about 4
months made with immunological methods was
confirmed. Tracer studies show also that glycine
is converted to uric acid (Benedict et al., Me-
tabolism, 1952, 1, 3), creatinine (Shemin and
Rittenberg, /. Biol. Chem., 1947, 167, 875) and
other compounds. Since nitrogen excretion is in-
creased by the administration of cortisone, feeding
experiments with glycine labeled with N15 were
conducted by Clark (/. Biol. Chem., 1953, 200,
69) to determine the mechanism of this action;
the procedure used by Sprinnan and Rittenberg
(ibid., 1949, 180, 715) was used. It was found
that the increased nitrogen excretion during corti-
sone therapy resulted from interference with
protein synthesis in the tissues, with some ac-
cumulation of amino acids in the liver. Studies
with glycine labeled with both C14 and N15 have
been conducted (Chao et al., Fed. Proc, 1952,
11, 437). Isotope-labeled glycine has been em-
ployed to study the effect of steroid hormones on
the metabolism of the cells of the rat uterus.

Peripheral Vascular Insufficiency. — Gly-
cine possesses the metabolism-stimulating action
of protein (so-called Specific Dynamic Action)
which amounts to about 10 per cent of the basal
metabolic rate). Since this heat is dissipated by
an increase in peripheral blood flow, Gubner et al.
(Am. J. Med. Sc, 1947, 213, 46) and Gustafson
et al. (Surgery, 1949, 25, 539) prescribed 20 Gm.
of glycine dissolved in 200 ml. of water by
mouth three times daily as a vasodilator in cases
of thromboangiitis obliterans, Raynaud's phe-
nomenon, arteriosclerosis and other occlusive
peripheral vascular diseases; beneficial results
were obtained. The increase in peripheral blood
flow was greater than that obtainable with in-
gestion of ethyl alcohol. Collentine (/. Lab. Clin.
Med., 1948, 33, 1555) reported on the safety of
the intravenous administration of a 5 or 10 per
cent solution in isotonic sodium chloride solution
in a dose of 200 mg. per kilogram of body weight
in a period of 30 minutes. With double this dose,
warmth and tingling of the extremities, increased
salivation, nausea and lightheadedness were ex-
perienced for about 30 minutes following com-
pletion of the injection. In two cases of cirrhosis
of the liver, a maximum concentration of 32 mg.
per 100 ml. of blood (method of Christensen
et al, J. Biol. Chem., 1947, 168, 191) was found
at the end of the injection from an initial con-
centration of about 3 mg. per 100 ml.; the maxi-
mum urinary excretion occurred during the half
hour of the injection and the half hour afterward,
and the concentration in the blood returned al-
most to the initial level in 2>y2 hours.

Antacid. — A mixture of 30 per cent amino-
acetic acid and 70 per cent calcium carbonate
(Titralac, N.N.R., Schenley) produces an acid
neutralization curve similar to that of whole milk
(J.A.M.A., 1950, 152, 991); absence of systemic
alkalosis and acid "rebound" is claimed and the
product is recommended particularly for patients
with peptic ulcers who are unable to tolerate milk.
The dose is 1 to 2 tablets, each containing 150 mg.
glycine and 350 mg. calcium carbonate, taken

with water after meals or, in more severe cases,
every hour.

Dihydroxyaluminum Aminoacetate N.F. is a
basic aluminum salt of this amino acid which is
employed as an antacid. Its properties and uses
are described elsewhere in Part I.

Other Uses and Combinations. — Because of
the amphoteric nature of aminoacetic acid it may
be prepared in the form of aminoacetic acid hy-
drochloride, a crystalline solid, which may be used
as a source of hydrochloric acid for treatment of
achlorhydria gastrica. A dose of 200 mg. of amino-
acetic acid hydrochloride yields 0.6 ml. of diluted
hydrochloric acid, which is an average dose of the
latter. It is of interest in this connection that
aminoacetic acid hydrochloride contains 32.5
per cent of HC1 as compared with 19.9 per cent
of HC1 in glutamic acid hydrochloride, which is
widely used as a solid dosage form of hydro-
chloric acid.

Glycine esters of various phenols are used as
bactericides, fungicides, and insecticides (Smith
and Hansen, U. S. Patent 2,289,599, July 14,
1942). A water-soluble glycine derivative of ribo-
flavin has been prepared (Haas, U. S. Patent
2,398,706, April 16, 1946). A soluble, stable, and
less irritating form of theophylline is available
in the compound theophylline sodium glycinate
(q.v.). Martin and Thompson (U. S. Patent
2,376,795, May 22, 1945) used glycine to mini-
mize untoward effects of sulfapyridine. Amino-
acetic acid is used as an ingredient of S0rensen's
buffer mixtures, along with hydrochloric acid or
sodium hydroxide.

The dose of aminoacetic acid is from 4 to 30
Gm. (approximately 60 grains to 1 ounce), with
the total daily dose sometimes exceeding 60 Gm.

Storage. — Preserve "in well-closed contain-
ers." N.F.

AMINOACETIC ACID ELIXIR. N.F.

Glycine Elixir, Glycocoll Elixir, [Elixir Acidi
Aminoacetici]

"Aminoacetic Acid Elixir contains, in each 100
ml., not less than 12.1 Gm. and not more than
14.2 Gm. of C2H5NO2." N.F.

Dissolve 131.5 Gm. of aminoacetic acid in 700
ml. of purified water, add 60 ml. of syrup and 75
ml. of raspberry syrup, and mix well. Dissolve
2 Gm. of benzoic acid and 0.15 Gm. of vanillin
in 53 ml. of alcohol and 1.5 ml. of compound
orange spirit and add this solution to that of the
aminoacetic acid. Filter, if necessary, and add
sufficient water to the filtrate to make 1000 ml.
N.F.

Assay. — Exactly 25 ml. of aminoacetic acid
elixir is diluted to 100 ml. with water, the solu-
tion is decolorized with activated charcoal, filtered
and an aliquot portion of the filtrate neutralized
with 0.1 AT sodium hydroxide, using phenolphtha-
lein T.S. as indicator. The volume of alkali re-
quired is noted, but is not used as a quantitative
measure of the aminoacetic acid present because
of the amphoteric nature of the acid resulting
from the presence of the amino group; the alkali
consumed is required for the neutralization of
benzoic acid and acid in the raspberry syrup. To
another aliquot portion of the filtrate formalde-

Part I

Aminophylline 65

hyde T.S. is added, which converts the NH2.CH2.-
COOH to the methylene-imino compound CH2:-
N.CH2.COOH and permits titration of the car-
boxyl group with 0.1 N sodium hydroxide, using
phenolphthalein T.S. as indicator and titrating to
the same color as obtained in the first titration.
A blank titration to correct for the acidity of the
formaldehyde is performed and the correction
applied to the titration in which formaldehyde
was used. The difference between the titrations —
with and without formaldehyde, respectively —
represents the amount of alkali required to neu-
tralize the carboxyl group of the aminoacetic acid.
Each ml. of 0.1 N sodium hydroxide represents
7.507 mg. of C2H5NO2. N.F. This titration is a
modification of S0renson's Formol Method for
the estimation of amino acids. For further dis-
cussion of this assay see Green, Bull. N. F.
Comm., 1945, 13, 84.

Alcohol Content. — From 5 to 7 per cent, by
volume, of C2H5OH. N.F.

The average dose of this elixir is 15 ml. (ap-
proximately 4 fluidrachms), representing about 2
Gm. of aminoacetic acid.

Storage. — Preserve "in tight containers."
N.F.

AMINOPHYLLINE. U.S.P., B.P., LP.

Theophylline Ethylenediamine, [Aminophyllina]
(C7H8N402)2C2H4(NH2)2.2H20

"Aminophylline contains not less than 75 per
cent and not more than 82 per cent of anhydrous
theophylline (C7H8N4O2), and not less than 12.3
per cent and not more than 13.8 per cent of
ethylenediamine (C2H8N2)." U.S.P. The B.P.
and LP. requirements are identical with those
of the U.S.P.

The B.P. states that aminophylline may be
prepared by dissolving theophylline in ethylene-
diamine and evaporating the solution to dryness.
It is reported that the compound contains a mix-
ture of two double salts, the one consisting of
one molecule of theophylline combined with one
molecule of ethylenediamine, the other of one
molecule of theophylline combined with two
molecules of ethylenediamine.

Description. — "Aminophylline occurs as
white or slightly yellowish granules or powder,
possessing a slight ammoniacal odor and a bitter
taste. Upon exposure to air it gradually loses
ethylenediamine and absorbs carbon dioxide with
the liberation of free theophylline. Its solutions
are alkaline to litmus. One Gm. of Aminophylline
dissolves in about 5 ml. of water but owing to
hydrolysis separation of crystals of less aminated
theophylline begins in a few minutes, these crys-
tals dissolving on the addition of a small amount
of ethylenediamine. When, however, 1 Gm. is
dissolved in 25 ml. of water the solution remains
clear. It is insoluble in alcohol and in ether."
U.S.P.

Standards and Tests. — Identification. — To a
solution of 1 Gm. of aminophylline in 20 ml. of
water add, while stirring constantly, 1 ml. of
diluted hydrochloric acid; filter the precipitate,
wash it with small portions of cold water, and
dry it at 105° for 1 hour: the substance responds

to identification tests (1) and (2) under The-
ophylline and melts between 270° and 274°.
Residue on ignition. — Not over 0.15 per cent.
U.S.P.

Assay. — For theophylline. — A sample of
about 250 mg. of aminophylline is dissolved in
water containing ammonia, a measured excess of
0.1 N silver nitrate is added to precipitate silver
theophylline. The mixture is filtered through a
filtering crucible, the precipitate is washed with
water, and the excess of silver ion in the filtrate
is determined by titration with 0.1 iV ammonium
thiocyanate in the presence of nitric acid and
using ferric ammonium sulfate T.S. as indicator.
Each ml. of 0.1 N silver nitrate represents 18.02
mg. of C7H8N4O2. For ethylenediamine. — A solu-
tion of about 500 mg. of aminophylline is titrated
with 0.1 Af hydrochloric acid, using methyl orange
T.S. as indicator. Each ml. of 0.1 N acid repre-
sents 3.005 mg. of C2H8N2. U.S.P.

The B.P. assays for theophylline by dissolving
about 500 mg. of aminophylline in 20 ml. of
distilled water, neutralizing the solution with
0.5 N hydrochloric acid using bromocresol green
indicator and saturating the solution with sodium
chloride, then extracting the theophylline with a
mixture of 3 volumes of chloroform and 1 volume
of isopropyl alcohol. The solvent is evaporated,
and the residue is dried to constant weight at
105°. The assay for ethylenediamine is similar
to that of the U.S.P. The LP. assays are practi-
cally the same as those of the U.S.P.

Incompatibilities. — Alkaline in reaction,
aminophylline exhibits the incompatibilities of
alkalies. When in sufficiently concentrated solu-
tion the theophylline in this salt is precipitated
by acids. On exposure to air it gradually absorbs
carbon dioxide with liberation of theophylline.
With lactose, a yellow to brown color develops
on standing.

Uses. — Aminophylline has the general physio-
logical properties of theophylline. Its chief appli-
cations in clinical medicine depend upon its modi-
fication of blood flow, its relaxation of the
bronchial and other smooth musculature, its diu-
retic action and its ability to antagonize histamine.

Action. — It has been shown by Schack and
Waxier (/. Pharmacol., 1949, 97, 283) that the-
ophylline is restricted to blood plasma; it does
not penetrate the red cell membrane and is bound
only slightly to blood proteins. Further, it appears
to be bound only slightly to tissue proteins. They
concluded that its therapeutic effect is closely
related to the level in the blood. Based upon this
finding and because there is conflicting opinion as
to the therapeutic effectiveness of this drug,
Waxier and Schack (J.A.M.A., 1950, 143, 736)
studied the blood theophylline levels after admin-
istration of various doses of aminophylline by
the intravenous, intramuscular, oral and rectal
routes. Following intravenous injection of 250 mg.
of aminophylline the blood concentration falls
progressively to approximate zero after 9 hours.
Sustained blood levels followed intramuscular in-
jection of 500 mg., appreciable levels persisting
for 13 hours. They noted that this dosage given
intramuscularly produced values about twice as
high as a dose of 250 mg., persisted about twice

66 Aminophylline

Part I

as long, and was no more painful than the smaller
dose. Theophylline appeared in circulating blood
within 15 minutes after ingestion of an uncoated
tablet containing 200 mg., significant levels per-
sisting for 9 hours. There was a delay of 2 hours
after oral ingestion of enteric-coated tablets be-
fore the drug was demonstrable in the blood
plasma, significant levels persisting 7 hours after
a dose of 200 mg. and 10 hours with a 300 mg.
dose. Suppositories containing 500 mg. produced
widely varying values.

Wechsler et al. (J. Clin. Inv., 1950, 29, 28)
studied the cerebral circulation and metabolism
following intravenously administered aminophyl-
line and demonstrated conclusively that it results
in diminished cerebral blood flow due to increased
cerebrovascular resistance. There was a drop in
arterial carbon dioxide tension and a rise in arte-
rial pH. They were of the opinion that aminophyl-
line constricts the cerebral vessels, decreasing
cerebral blood flow, increasing carbon dioxide
tension of the brain, thus providing a stimulus
for hyperventilation, as reflected by the rising
pH. Moyer et al. (J. Clin. Inv., 1952, 31, 267)
pointed out that the arrest of Cheyne-Stokes
respiration after aminophylline cannot, therefore,
result from an increase of cerebral blood flow,
but is probably due either to a direct stimulating
effect on the respiratory center or an indirect
effect secondary to the depressed cerebral circu-
lation and resultant rise in tissue carbon dioxide
of the medulla. They found no difference in the
cerebral hemodynamic response to aminophylline
of patients in cardiac failure exhibiting Cheyne-
Stokes respiration and those with regular respi-
ration.

Leroy and Speer (/. Pharmacol., 1940, 69, 45)
found aminophylline to be twice as active as the-
ophylline sodium in dilating the coronary vessels.
Hanzlik and Moy (Standford M. Bull., 1945, 3,
127), in experiments on dogs, found that intrave-
nous aminophylline inhibits coronary constriction
produced by posterior pituitary solution, conclud-
ing that its effects are fundamentally vascular
rather than a direct stimulation of the myo-
cardium. Stewart (Cardiac Therapy, 19520 p. 27)
states that aminophylline induces its benefit in
pulmonary edema by increasing cardiac output,
probably by direct action on the heart muscle,
and by lowering the venous pressure. Escher
et al. (Fed. Proc, 1948, 7, 31, part I) demon-
strated that in normal human subjects rapid in-
travenous administration of aminophylline pro-
duced a significant increase in cardiac output
lasting 10 to 20 minutes, paralleling a brief in-
crease in renal plasma flow; glomerular filtration
rate remained high for as long as one hour despite
a fall in renal plasma flow to below control levels.
In chronic congestive heart failure it produces a
marked increase in cardiac output lasting as long
as one hour. It has been demonstrated by Segal
and associates (/. Clin. Inv., 1949, 28, 1190) that
aminophylline given intravenously provides im-
mediate protection against the bronchospastic ef-
fect of intravenously administered histamine or
methacholine. The drug is a gastric irritant and
it has been shown by Krasnow et al. (Proc. S.
Exp. Biol. Med., 1949, 71, 335) to stimulate

production of free hydrochloric acid in the stom-
ach after intravenous administration.

Therapeutic Uses. — Aminophylline is valuable
in treating bronchial asthma, particularly by the
intravenous route, and is often effective in cases
of status asthmaticus in patients who have become
refractory to epinephrine (see Herrmann and
Aynesworth, J. Lab. Clin. Med., 1937, 23, 135).
It is likewise beneficial in asthmatic bronchitis
and unresolved pneumonia. Barach (J. A.M. A.,
1945, 128, 589) has obtained relief of bronchial
spasm within 10 to 30 minutes following rectal
instillation of aminophylline solution. This mode
of administration is advantageous in that it may
be used by nurses or patients themselves. Accord-
ing to Waldbott (I.A.M.A., 1945, 128, 1205)
sensitivity to this drug has never been demon-
strated. Barach also found (I.A.M.A., 1951, 147,
730) that for palliative therapy in patients with
bronchial asthma or the bronchospastic type of
chronic hypertrophic pulmonary emphysema in
the absence of status asthmaticus, aminophylline
in doses of 200 to 300 mg. is the most satisfac-
tory oral medication for relief of bronchospasm.
For maximal effect it must be given when the
stomach is empty; if nausea results it may be
relieved by two teaspoonfuls of aluminum hy-
droxide gel. Whitfield et al. (Lancet, 1951, 260,
490) found it valueless in emphysema in the ab-
sence of bronchospasm. Kugelmass (J.A.M.A.,
1951, 147, 1240) used aminophylline to relax
the bronchial and esophageal musculature to dis-
lodge foreign bodies inspired or swallowed by
children, avoiding the need for endoscopy; he
gave 250 mg. in a solution instilled rectally.
Taplin et al. (Ann. Allergy, 1949, 7, 513) found
that aminophylline or theophylline-lactose powder,
in particle sizes of 0.5 to 5 n in diameter, when
given by inhalation in a dosage of 60 mg., will
relieve bronchial spasm in a majority of patients
almost immediately, but for a somewhat shorter
period than with intravenous administration. They
noted no systemic vasomotor, allergic or local
irritative effects.

The vasodilator action of aminophylline is
recommended in recent myocardial infarction by
Mikotoff and Katz (Am. Heart J., 1945, 30, 215).
Bakst et al. (ibid., 1948, 36, 527) found that
intravenous injection of 240 mg. of aminophyl-
line increases the capacity for effort without pain
in patients with angina of effort. It is widely
used in patients with coronary artery disease
in doses of 100 to 200 mg. 3 or 4 times daily by
mouth. Russek et al. (J.A.M.A., 1953, 153, 207)
compared the ability of various drugs to modify
the electrocardiographic response to standard exer-
cise (Master two-step test) in carefully selected
patients with coronary artery disease. They found
that aminophylline in doses of 500 mg. adminis-
tered intravenously or 400 mg. by the oral route
produced only a slight or insignificant effect. Its
use is recommended in treatment of pulmonary
edema, 250 or 500 mg. being injected by vein.
Similar amounts are used at bedtime to prevent
occurrence of nocturnal dyspnea. Suppositories
containing 500 mg. may be substituted for this
purpose. Kissin et al. (Angiology, 1951, 2, 217)
found an average improvement in exercise toler-

Part I

Aminophylline 67

ance of 42 per cent in subjects with intermittent
claudication due to obliterating arteriosclerosis,
following intravenous administration of a dose
of 240 mg. Rickles (/. Florida M. Assn., 1951,
38, 263) obtained relief of arterial spasm in simi-
lar cases by direct injection of aminophylline into
the femoral artery, with no untoward results.
Mover and associates (Am. J. Med. Sc, 1952,
224, 377) found the drug useful in relieving
hypertensive headaches, the dosage being 500
mg. intravenously. Mainzer (Schweiz. med.
Wchnschr., 1949, 79, 108) found intravenous
doses of 240 mg. to be of benefit in treatment
of cerebral hemorrhage.

Aminophylline was the only injectable diuretic
preparation prior to the introduction of the
organic mercurials. Vogl and Esserman {J. A.M. A.,
1951, 147, 625) called attention to the fact that
in addition to increasing the effective renal blood
flow and glomerular filtration rate it inhibits
renal tubular reabsorption, the latter being largely
responsible for its diuretic effect. Unlike the or-
ganic mercurial diuretics, however, it does not
produce demonstrable damage to the tubular
epithelium. They evolved a schedule using a mer-
curial injection intermittently every third day,
with multiple daily aminophylline injections to
potentiate and maintain diuresis in patients with
advanced congestive heart failure who are ap-
parently refractory to mercurial diuretics.

Cole (Am. J. Surg., 1946, 72, 719) reported
that intravenous administration of 500 mg. of
aminophylline produced in 9 out of 10 patients
relief from biliary colic within 5 to 7 minutes.
Seneque et al. (J. de Chirurgie, 1952, 68, 340)
found that it facilitates passage of residual biliary
calculi from the common bile duct following
biliary surgery and in conjunction with Pribam's
method of stimulating the flow of bile. Anderson
and Mclntyre (Nebr. State M. J., 1949, 34, 17)
found oral aminophylline useful in treating pri-
mary dysmenorrhea. Epstein (Arch. Dermat.
Syph., 1948, 58, 47) observed aminophylline, in-
travenously administered in a dose of 500 mg.
in 20 ml. of diluent, to give immediate relief in
patients with acute pruritic dermatoses.

Summary. — Aminophylline is used in treat-
ment of bronchial asthma and other bronchospas-
tic conditions, cardiac asthma and pulmonary
edema, coronary artery disease, obliterating arte-
riosclerosis, hypertensive headache and cerebral
hemorrhage, as a diuretic in congestive cardiac
failure either alone or to potentiate the effect of
mercurial diuretics, in biliary colic and in various
acute pruritic dermatoses. lYJ

Comparison of Routes of Administration.
— Rectal instillation of an aqueous solution of
aminophylline results in almost as rapid absorp-
tion as does intravenous injection (Barach, Bull.
N. Y. Acad. Med., 1944, 20, 538) ; rectal adminis-
tration avoids the infrequent but serious instances
of vascular collapse or fatal cardiac response
which may follow intravenous administration. Ab-
sorption from rectal suppositories is uncertain,
occasionally producing blood theophylline levels
comparable to those obtained by intravenous in-
jection of the same dose of aminophylline but
generally yielding low levels. Prigal et al. (J. Al-

lergy, 1946, 17, 172) found suppositories con-
taining aminophylline and pentobarbital sodium
to relieve asthma in about half the time required
for aminophylline alone. Oral administration of
aminophylline is less effective than when the
drug is given by the intravenous route or when
it is instilled rectally as an aqueous solution,
principally because the majority of patients de-
velop gastrointestinal disturbances after pro-
longed use. Enteric-coated tablets have been em-
ployed to overcome this disadvantage and, re-
cently, it has been observed that simultaneous
administration of aluminum hydroxide decreases
the incidence of gastrointestinal disturbances in
most patients to such a degree that sufficient
aminophylline may be given orally to produce
levels of theophylline in the blood which are
comparable to those obtained by intravenous ad-
ministration (Cronheim et. al., Postgrad. Med.,
1953, 13, 432); the aluminum hydroxide appears
not to alter the rate or the degree of absorption
of aminophylline, as compared with tablets of
aminophylline by itself.

Toxicology. — Scherf and Schlachman (Am.
J. Med. Sc, 1946, 212, 83) observed diminished
prothrombin time in patients to whom aminophyl-
line was administered intravenously. It has been
believed that this effect, shared by other methyl-
xanthines, may augment the risk of thrombosis
in certain patients receiving aminophylline or
kindred drugs. However, studies by Blood and
Patterson (Proc. S. Exp. Biol. Med., 1948, 69,
130) and by Holland and Gross (/. Iowa M. Soc,
38, 183) indicate that oral or intravenous admin-
istration of aminophylline produces no statisti-
cally significant changes in clotting time or plasma
prothrombin time. Studies by Overman and
Wright (Am. Heart J., 1950, 39, 65) of the ef-
fects of oral ingestion of the drug led them to
the same conclusion.

Intravenous injections must be given very
slowly, minimum time being 4 to 5 minutes, and
the solution should be warmed to body tempera-
ture before use. Rapid administration may lead
to peripheral vascular collapse. In at least 6 re-
ported instances (see Bresnick et al., J.A.M.A.,
1948, 136, 397) sudden death has followed in-
travenous administration. In each instance there
was evidence of myocardial disease and the sud-
denness of death suggested the probability that
cardiac standstill or ventricular fibrillation had
occurred. Excessive cerebral stimulation may re-
sult in wakefulness, vertigo, vomiting, hyperpnea
and even generalized convulsions.

Dose. — The usual oral dose of aminophylline
is 200 mg. (approximately 3 grains) 3 times daily,
with a range of 100 to 200 mg.; the maximum
safe dose is 200 mg. and the total dose in 24
hours should generally not exceed 600 mg. When
aluminum hydroxide is given simultaneously
larger doses of aminophylline may be tolerated;
Cronheim et al. (loc. cit.) found most of their
patients to tolerate doses of 1 to 1.6 Gm. (15 to
24 grains), which produced a reliable diuretic
effect, and some as much as 2.4 Gm. (36 grains)
of aminophylline per day when thus adminis-
tered. Per rectum, the usual dose is 500 mg.
(approximately lYz grains) 1 or 2 times daily,

68 Aminophylline

Part I

with a range of 250 to 500 mg.; the maximum
safe dose is 500 mg. and the total dose in 24
hours should not exceed 1 Gm. By intravenous
injection, the usual dose is 500 mg. (approxi-
mately lx/z grains) up to 3 times daily, with a
range of 250 to 500 mg.; the maximum safe dose
is 500 mg. and the total dose in 24 hours should
not exceed 1.5 Gm.

Storage. — Preserve "in tight containers."
U.S.P.

AMINOPHYLLINE INJECTION.
U.S.P. (B.P., LP.)

[Injectio Aminophyllinae]

"Aminophylline Injection is a sterile solution
of aminophylline in water for injection. It con-
tains not less than 93 per cent and not more
than 107 per cent of the labeled amount of
C16H24N10O4.2H2O. For the purpose of stabiliza-
tion, Aminophylline Injection may contain added
freshly distilled ethylenediamine solution amount-
ing to not more than 60 mg. of C2H8N2 for each
1 Gm. of aminophylline." U.S.P.

The B.P. defines Injection of Aminophylline as
a sterile solution of aminophylline in water for
injection free from carbon dioxide; ethylenedia-
mine may be added to aid solution, provided the
pH of the solution does not exceed 9.6. The solu-
tion is directed to be sterilized by heating in an
autoclave, or by filtration through a bacteria-
proof filter. The content of anhydrous theophyl-
line is not less than 71.0 per cent and not more
than 86.0 per cent of the labeled content of
aminophylline. The LP. limits for anhydrous
theophylline are 73.0 and 83.0 per cent, respec-
tively; for ethylenediamine (C2H8X2) the limits
are 12.3 and 19.8 per cent, respectively.

B.P. Injection of Aminophylline; Injectio Theophyl-
linae cum .SSthylenediamina. LP. Injection of Amino-
phylline; Injectio Aminophyllini. Sp. Inyeccion de
Aminofilina.

The U.S.P. permits an inordinate excess of
ethylenediamine (43 per cent above the upper
limit provided under Aminophylline) to be used
"for the purpose of stabilization." If the amino-
phylline and the injection are carefully prepared
so as to prevent absorption of carbon dioxide,
even the most concentrated injection employed
clinically may be made with at most only a frac-
tion of the permitted excess of ethylenediamine.

For uses and dose see under Aminophylline.

Storage. — Preserve "in single-dose contain-
ers, preferably of Type I glass." U.S.P.

Usual Sizes. — 2 ml. containing 500 mg. (ap-
proximately 7^2 grains) for intramuscular use;
10 ml. or 20 ml. containing respectively 250 mg.
or 500 mg. (approximately 4 or 7^ grains) for
intravenous use.

AMINOPHYLLINE SUPPOSITORIES.
U.S.P.

[Suppositoria Aminophyllinae]

"Aminophylline Suppositories contain not less
than 90 per cent and not more than 110 per cent
of the labeled amount of C16H24X10O4.2H2O."
U.S.P.

While the U.S.P. does not specify the supposi-

tory base which may be employed, a number of
the products on the market are stated to be made
with a Carbowax base; one such base may be
prepared by melting together 1 part of Carbowax
4000 (polyethylene glycol 4000, U.S.P. XV)
and 2 to 3 parts of Carbowax 1540. Such a base
will not melt at body temperature but will gradu-
ally release dispersed medication when sufficient
moisture is absorbed by the suppository, following
insertion in the rectum, to dissolve the base.

For uses and dose see under Aminophylline.

Storage. — Preserve "in well-closed containers
in a cold place." U.S.P.

Usual Size. — 500 mg. (approximately l1/*
grains) of aminophylline.

AMINOPHYLLINE TABLETS.
U.S.P. (B.P., LP.)

[Tabellae Aminophyllinae]

"Aminophylline Tablets contain not less than
93 per cent and not more than 107 per cent of
the labeled amount of C16H24X10O4.2H2O."
U.S.P. The B.P. requires the content of anhy-
drous theophylline to be not less than 67.5 per
cent and not more than 86.0 per cent, and the
content of ethylenediamine to be not less than
11.1 per cent and not more than 15.2 per cent, of
the labeled amount of aminophylline. The LP.
requires not less than 73.0 per cent and not more
than 84.0 per cent of anhydrous theophylline.

B.P. Tablets of Aminophylline; Tabellae Theophyllinae
cum iEthylenediamina. LP. Compressi Aminophyllini.
Sp. Tablet as de Aminofilina.

Storage. — Preserve "in tight containers."
U.S.P.

Usual Sizes. — 100 and 200 mg. (approxi-
mately \y2 and 3 grains), enteric coated tablets
or tablets containing aluminum hydroxide being
generally preferred to avoid gastric irritation.
Tablets containing aminophylline and phenobar-
bital are frequently prescribed.

AMINOPYRINE. X.F. (LP.)

Amidopyrine, [Aminopyrina]

CH,

lX3

(CH3)2N X0

The LP. defines Amidopyrine as 2 :3-dimethyl-
4-dimethylamino-l -phenyl- 5-pyrazoIone.

LP. Amidopyrine, Amidopyrinum. Pyramidon (.Win-
throp), Dimethylamino Antipyrine. Fr. Dimethylamino-
phenyldimethylpyrazolone. C-er. Dimethylamino-phenyldi-
methylpyrazolon. It. Fenil-dimetil-dimetilamido-isopira-
zolone. Sp. Aminoantipirina ; Aminopirina; Amidopirina.

This compound, first prepared in 1893, may be
regarded as a derivative of antipyrine in which a
hydrogen atom of the pyrazolone group is re-
placed by a dimethylamino or N(CHs)2 group.
It is designated as 1.5-dimethyl-4-dimethylamino-
2-phenyl-3-pyrazolone according to the standard
United States nomenclature. Aminopyrine is
manufactured by the reduction of isonitrosoanti-
pyrine with zinc and subsequent methylation of

Part I

Aminopyrine Elixir 69

the resulting 4-amino-antipyrine by means of
methyl iodide or dimethyl sulfate. Because of the
difficulty of directly methylating the aminoanti-
pyrine various means of indirectly accomplishing
this have been employed.

Description. — "Aminopyrine occurs as color-
less or white, small crystals, or as a white, crystal-
line powder. It is odorless and is stable in air
but is affected by light. Its solutions are alkaline
to litmus paper. One Gm. of Aminopyrine dis-
solves in 18 ml. of water, in 1.5 ml. of alcohol,
in 1 ml. of chloroform, and in 13 ml. of ether.
Aminopyrine melts between 106.5° and 109°."
N.F.

Standards and Tests. — Identification. — (1)
A bluish violet color develops on adding 3 drops
of diluted hydrochloric acid and 1 ml. of ferric
chloride T.S. to 5 ml. of a 1 in 25 solution of
aminopyrine; the color changes to violet red on
adding a few drops of diluted sulfuric acid. (2)
A deep violet color, changing to a grayish black
precipitate of silver, is formed on adding 5 drops
of silver nitrate T.S. to 5 ml. of a 1 in 25 solu-
tion of aminopyrine. (3) A dark blue color or
precipitate is immediately formed when a 1 in 25
solution of aminopyrine is added to a freshly pre-
pared potassium ferricyanide T.S. containing
some ferric chloride (difference from antipyrine).
Loss on drying. — Not over 1 per cent, when dried
at 60° for 2 hours. Residue on ignition. — Not
over 0. 1 5 per cent. Chloride. — A purple color, but
no turbidity, is immediately produced on adding
silver nitrate T.S. to a solution of aminopyrine
acidified with nitric acid. Heavy metals. — The
limit is 20 parts per million. Readily carbonizable
substances. — A solution of 100 mg. of aminopy-
rine in 1 ml. of sulfuric acid is colorless. Anti-
pyrine.— A mixture of 100 mg. of aminopyrine,
100 mg. vanillin, 5 ml. of water and 2 ml. of
sulfuric acid, heated to boiling, has no more
color than a mixture of 5 ml. of water, 2 ml. of
sulfuric acid, and 100 mg. of vanillin, also heated
to boiling. N.F.

Incompatibilities. — Aminopyrine has incom-
patibilities very similar to those of antipyrine. It
is precipitated by many alkaloidal reagents includ-
ing iodine, tannic acid and Mayer's reagent.
Oxidizing agents produce a blue to violet color;
these include ferric chloride, silver nitrate, nitric
acid, nitrites, iodine, and certain enzymes. Calo-
mel and mercury bichloride are reduced. Aspirin
and salol are discolored and become moist when
mixed with it, as do citric, tartaric, and salicylic
acids, phenol, and chloral hydrate. Solutions of
aminopyrine when mixed with acacia show a color
change from violet, through yellow to brown.
This is due to the oxidase of acacia and may be
prevented by previously heating the mucilage on
a water bath for 30 minutes.

Uses. — Aminopyrine is one of the most power-
ful analgesics of the "coal-tar group" but because
of its frequent incrimination in cases of agranulo-
cytosis its use in this country has been largely
discontinued. Its effect on the threshold for pain,
produced by radiant heat on the normal skin, was
no different than that of the equivalent dose of
acetanilid or acetylsalicylic acid (Wolff, Hardy
and Goodell, /. Clin. Inv., 1941, 20, 63). It

will relieve neuralgic headaches, dysmenorrhea,
rheumatism and similar painful conditions. In
rheumatic fever it causes diminution of fever
and relieves the joint pain as effectively as do
the salicylates; small doses, such as 300 mg.
three to six times daily, are adequate (McEwen,
Bull. N. Y. Acad. Med., 1943, 19, 679). A few
authors believe it has a specific curative effect on
the progress of the disease. (Bodenstab, Deutsches
Arch. klin. Med., 1928, 159, 129). Contrary to
some reports Borafski and Steigmann (J.A.M.A.,
1933, 100, 1859) found its effects in measles to
be not essentially different from those of other
coal-tar antipyretics. In 1932 Scherf reported
symptomatic relief in diabetes insipidus; this was
confirmed by Kahn (J.A.M.A., 1933, 100, 1593).
Large doses of the drug intravenously will cause
a great reduction in the output of urine for 6 or 8
hours, but when used repeatedly it loses its anti-
diuretic power. In healthy persons Weitzman
(Ztschr. klin. Med., 1940, 137, 429) reported
that it caused increased rather than decreased
diuresis following the ingestion of a large amount
of water.

Toxicology. — The most dangerous outcome
from the use of aminopyrine is the agranulocy-
tosis which develops in some patients; this con-
sists of a very low leukocyte count in the blood
(as low as a few hundred per cu. mm.), an almost
total absence of granulocytes (neutrophils), a
maturation arrest of myeloblasts in the bone mar-
row, fever, malaise, necrotic ulcerations of the
throat and other mucous membranes, prostration
and death in as high as 70 per cent of cases
(Kracke and Parker, J. A.M. A., 1938, 111, 1255,
and FitzHugh, ibid., p. 1643). Since agranulocy-
tosis is so often fatal, and since other effective
analgesic drugs are available, the use of amino-
pyrine has been largely discontinued, [v]

The analgesic dose of aminopyrine is from 130
to 300 mg. (approximately 2 to 5 grains) ; a
maximum single dose of 600 mg. and maximum
total doses of 1 to 3 Gm. in a period of 24 hours
are recorded, which latter dose is hardly to be
considered safe.

Storage. — Preserve "in well-closed, light-
resistant containers." N.F.

AMINOPYRINE ELIXIR. N.F.

Amidopyrine Elixir, [Elixir Aminopyrinae]

"Aminopyrine Elixir contains, in each 100 ml.,
not less than 3.7 Gm. and not more than 4.3 Gm.
of C13H17N3O." N.F.

Dissolve 40 Gm. of aminopyrine in 200 ml. of
alcohol, add 3 ml. of compound orange spirit, 10
ml. of compound amaranth solution, 60 ml. of
glycerin, 400 ml. of syrup, and enough purified
water to make the product measure 1000 ml. Mix
well and filter, if necessary, to produce a clear
liquid. N.F.

Assay. — A sample of 5 ml. of elixir is alka-
linized with ammonia and the aminopyrine ex-
tracted with successive portions of chloroform.
After washing the chloroform solution with water,
the former is filtered into a tared beaker, the
solvent is evaporated and the residue of amino-

Aminopyrine Elixir

Part I

pyrine dried at 60° for 2 hours, cooled, and
weighed. N.F.

Alcohol Content. — From 17 to 20 per cent,
by volume, of C2H5OH. N.F.

This preparation is an acceptable dosage form
for aminopyrine, but it should be used cautiously
in view of the potential harmful effect of the
active ingredient. The N.F. gives the usual dose
as 4 ml. (approximately 1 fluidrachm). which
represents about 160 mg. (approximately 2y2
grains) of aminopyrine.

Storage. — Preserve "in tight containers." N.F.

AMINOPYRINE TABLETS. X.F. (LP.)

Amidopyrine Tablets, [Tabellae Aminopyrinae]

"Aminopyrine Tablets contain not less than 94
per cent and not more than 106 per cent of the
labeled amount of C13H17N3O." N.F. The LP.
limits are 93.0 and 107.0 per cent, respectively.

I. P. Tablets of Amidopyrine; Compressi Amidopyrini.

Assay. — A representative sample of tablets,
equivalent to 1 Gm. of aminopyrine. is dissolved
in 1 N hydrochloric acid. After filtering to re-
move insoluble matter an aliquot portion of the
filtrate is rendered alkaline with ammonia T.S.
and the aminopyrine extracted with chloroform.
The chloroform is evaporated and the residue of
aminopyrine dried at 60° for 2 hours, cooled and
weighed. N.F.

Usual Size. — 5 grains (approximately 300
mg.).

AMINOSALICYLIC ACID. U.S.P., (LP.)

Para-aminosalicylic Acid, PAS

COOH

"Aminosalicylic Acid contains not less than
98.5 per cent of C7H7NO3. calculated on the dried
basis." U.S.P. The LP. requires not less than 97.0
per cent of the active component, referred to the
substance as it is found.

"Caution. — Prepare solutions of Aminosalicylic
Acid within 24 hours of administration. Under no
circumstances use a solution if its color is darker
than that of a freshly prepared solution." U.S.P.

LP. Para-aminosalicylic Acid; Acidum Para-amino-
salicylicum. Pamisyl {Parke-Davis). 4-Aminosalicylic Acid;
4-Amino-2-hydroxybenzoic Acid.

This tuberculostatic agent may be synthesized
by several processes, as by carboxylation of m-
aminophenol, reduction of />-nitrosalicylic acid,
or by a 4-step synthesis starting with 4-nitro-2-
aminotoluene (J.A.Ph.A., 1949, 38, 9). Besides
the acid, the calcium and sodium salts are official.

Description. — "Aminosalicylic Acid is a white
or nearly white, bulky powder, darkening on
exposure to fight and air. It is odorless or has a
slight acetous odor. One Gm. of Aminosalicylic
Acid dissolves in about 500 ml. of water and in
about 21 ml. of alcohol. It is slightly soluble in
ether and practically insoluble in benzene." U.S.P.

Standards and Tests. — Identification. — (1)
.The diacetyl derivative melts at about 191°. (2)

On adding ferric chloride T.S. to a saturated solu-
tion a violet color is produced. (3) The acid
melts rapidly, with evolution of carbon dioxide,
between 145° and 150°. pH — The pH of a satu-
rated solution is between 3.0 and 3.7. Water. —
Not over 0.5 per cent, when determined by the
Karl Fischer method. Residue on ignition. — Not
over 0.1 per cent. Clarity and color of solution. —
1 Gm. dissolves in 10 ml. of 1 in 10 sodium bicar-
bonate solution to give a clear solution which has
no more than a faint yellow color. Chloride. —
The limit is 140 parts per million. Arsenic. — The
limit is 10 parts per million. Heavy metals. — The
limit is 30 parts per million, m- Amino phenol. —
Not over 0.2 per cent. U.S.P.

Assay. — About 300 mg. of aminosalicylic acid
is dissolved in glacial acetic acid, after which cold
water, ice, and hydrochloric acid are added and
the solution is titrated with 0.1 M sodium nitrite
until it produces with starch iodide paste a blue
color immediately. In this assay the amino group
is quantitatively diazotized. with one molecule of
aminosalicylic acid reacting with one molecule of
sodium nitrite. Each ml. of 0.1 M sodium nitrite
represents 15.31 mg. of C7H7NO3. U.S.P. In the
LP. assay about 300 mg. of the acid is dissolved
in 5 ml. of acetone and titrated with 0.1 A7 sodium
hydroxide, using bromothymol blue as indicator.
Each ml. of 0.1 N sodium hvdroxide represents
15.31 mg. of C7H7NO3.

Stability. — Oberweger et al. {Quart. J. P.,
194S, 21, 292) investigated the stability of both
the acid and its sodium salt. Dry aminosalicylic
acid evolves carbon dioxide at temperatures above
100° C, melting during the decomposition; the
sodium salt is quite stable even when heated at
150° C. for an hour and may be sterilized in the
dry state by this procedure, after first dehydrating
the dihydrate at 100° to 110° for 1.5 hour's. Aque-
ous solutions of the acid are relatively unstable,
particularly at elevated temperatures; the acid
decomposes to w-aminophenol. with liberation of
carbon dioxide. Explosions due to the accumulated
pressure of the gas formed in acid solutions of
aminosalicylic acid have been reported (Bulletin
of the American Society of Hospital Pharmacists,
Jan. -Feb., 1950, page 21). The sodium salt is con-
siderably more stable in aqueous solution and can
be boiled without marked decarboxylation; steri-
lization by autoclaving results in appreciable de-
composition (15 per cent in a 1 to 5 solution
according to Oberweger et al.). Solutions of the
sodium salt develop a yellow to brown color;
color formation may be delayed if not avoided
entirely by dissolving 0.1 per cent of sodium
metabisulfite in the solution. Solutions of the so-
dium salt for oral use may be prepared from
anhydrous aminosalicylic acid by the reaction, in
water, of 153 parts of the acid with 84 parts of
sodium bicarbonate, i.e., in the proportion of the
molecular weights of the two substances.

Uses. — Aminosalicylic acid has been used in
the treatment of human tuberculosis since Leh-
mann's observation (Lancet, 1946, 250, 15) that
it possesses bacteriostatic activity against tubercle
bacilli.

Action. — The acid is rapidly absorbed from
the gastrointestinal tract and diffuses generally

Part I

Ammonia

throughout the tissues, the highest concentrations
being found in the kidney, lung and liver; it is
also found in cerebrospinal fluid. While a concen-
tration of 0.15 mg. per 100 ml. is bacteriostatic
when tested against tubercle bacilli, in vitro (Leh-
mann, loc. cit.), the blood levels when thera-
peutic doses are given are of the order of 2 to 11
mg. per 100 ml. and even higher. Aminosalicylic
acid must be given at intervals of 2.5 to 3 hours
to maintain continuously elevated blood levels.
Almost all of it is excreted in the urine within
10 hours (McClosky et al, J. Pharmacol., 1948,
92, 447; Way et al, ibid., 1948, 93, 368; Venka-
taraman et al, J. Biol. Chem., 1948, 173, 641).
The acid is bacteriostatic rather than bactericidal
but the exact metabolic function altered to inhibit
growth is undetermined.

Tuberculosis. — Bogen (Am. Rev. Tuberc,
1950, 61, 226), in an extensively annotated re-
view, reported that most investigators found early
marked symptomatic improvement, with less
cough and sputum, increased appetite, slowing of
pulse and respiration, and a drop in temperature
especially in fever due to tuberculous pneumonia
or pleurisy, following use of aminosalicylic acid.
When used alone, however, the acid has proved
to be less effective than streptomycin (Tempel,
J.A.M.A., 1952, 150, 1165). Aminosalicylic acid
may be given by itself in the treatment of infec-
tions due to streptomycin-resistant tubercle ba-
cilli (American Trudeau Society, Am. Rev.
Tuberc, 1951, 63, 617). Its use in conjunction
with isonicotinic acid hydrazide is being investi-
gated (Trans. 12th Conf. Chemoth. Tbc, 1953).
Some authorities recommend aminosalicylic acid
alone during the long-range preparation of pa-
tients for resectional operation. Others use it for
symptomatic relief of protracted, incurable tuber-
culosis.

The concomitant administration of aminosali-
cylic acid and streptomycin markedly delays the
emergence of streptomycin-resistant strains of
tubercle bacilli and thus prolongs the therapeutic
effect of the antibiotic. On a 120-day regimen of
12 Gm. of aminosalicylic acid daily and 1 Gm. of
streptomycin twice a week, resistance to 10 micro-
grams per ml. of the latter was reduced from 82
per cent to less than 20 per cent (Report, Council
on Pharm. & Chem., J.A.M.A., 1951, 147, 253).
This significant reduction in bacterial resistance
has been accomplished without any sacrifice in
therapeutic efficacy. In fact, pulmonary, miliary,
meningeal, and other forms of tuberculosis have
all shown clinical improvement on the combined
regimen.

Toxicology. — Gastrointestinal disturbances,
consisting of nausea, vomiting, and diarrhea, are
rather frequent early in the course of treatment
but may subside with continued therapy. Reduc-
tion in gastrointestinal irritation has been re-
ported to be obtained by use of enteric-coated
tablets or granules, by dispersion in a flavored
effervescent drink, by oral or intravenous adminis-
tration of a solution of the sodium salt or by
oral use of the potassium salt in solution. Serious
toxic reactions are rare. A few allergic reactions,
including dermatitis and drug fever, have been
reported. Muri (Nor disk Med., 1952, 47, 141)

reported a case of fatal aminosalicylic acid intoxi-
cation and Steininger et al. (Am. Rev. Tuberc,
1954, 69, 451) reported a fatal allergic reaction
from a 5.5-Gm. dose of sodium aminosalicylate.
Several reports of thyroid enlargement occurring
during therapy with aminosalicylic acid have ap-
peared (Brinkman and Coates, ibid., 1954, 69,
458). Purpura and a mild hypoprothrombinemia
have been observed. Patients with impaired he-
patic or renal function should be given aminosali-
cylic acid with caution.

Dose. — The usual dose is 3 Gm. (approxi-
mately 45 grains) 4 times daily by mouth, with a
range of 2 to 4 Gm. The maximum safe dose is
4 Gm. and the total dose in 24 hours should not
exceed 16 Gm. To minimize the gastrointestinal
disturbances, which are frequent, the dose should
be administered with meals ; simultaneous use of 5
to 10 ml. of aluminum hydroxide gel is recom-
mended. Enteric-coated granules are used to mini-
mize discomfort. Most patients tolerate the so-
dium salt better and this salt is used for parenteral
administration. The calcium salt is also official.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

AMINOSALICYLIC ACID TABLETS.

U.S.P.

"Aminosalicylic Acid Tablets contain not less
than 95 per cent and not more than 105 per cent
of the labeled amount of C7H7NO3." U.S.P.

Usual Size. — 500 mg.

AMMONIA

Fr. Ammoniac (gaz). Ger. Ammoniak; Ammoniakgas.

One of the most important compounds of nitro-
gen is ammonia, NH3, a transparent and colorless
gas possessing an acrid taste and an exceedingly
pungent odor. From its alkaline reaction and
gaseous nature it was called the volatile alkali by
the earlier chemists. Ammonia is the simplest
form of the class of bodies described as amines,
and is the prototype of nitrogenous organic bases,
which may be considered as substituted ammonias.
The word "ammonia" originated from the fact
that it was near the temple of the Egyptian deity
Ammon that the earliest sal ammoniac was found
as a product originating from camels' urine. Solu-
tions of ammonia have been known and used
from very early cimes. The substance itself was
first recognized by Priestley, who heated the aque-
ous solution of ammonia and collected the gas
over mercury. Its components and the proportion
in which they are combined were determined by
Berthollet and by Austin.

Ammonia, either as such or in the form of am-
monium salts, is found in small quantities in the
air and in most natural waters; it is a constituent
in plant and animal fluids and in a few minerals.
It is formed during the decay of nitrogenous
organic materials and is an important factor in
plant nutrition.

Ammonium compounds are sometimes found in
sufficient quantity to afford a satisfactory natural
source. Some of the guano deposits in South
America contain a considerable proportion of
ammonium carbonate and have been used as a

Ammonia

Part I

source of ammonia. Volcanic areas frequently
contain quantities of ammonium chloride and sul-
fate. However, only a small proportion of the
commercial supply is obtained from natural
sources. A considerable quantity of ammonia is
obtained in the manufacture of illuminating gas,
power gases, or coke from coal and in the pro-
duction of shale oil from shale. Some ammonia is
obtained from the destructive distillation of bones
and other animal and vegetable wastes. But the
most important commercial source of ammonia
today is that of the synthesis of ammonia from
its constituent elements, nitrogen and hydrogen.
The techniques of manufacture vary consider-
ably, but in general the processes consist of a re-
action between three volumes of hydrogen and
one volume of nitrogen at pressures between 100
and 1000 atmospheres and at temperatures rang-
ing from 400° to 550°, while in contact with a
promoted iron catalyst. Nitrogen for the reaction
may be obtained by the distillation of liquid air
or from the manufacture of producer gas. Hydro-
gen may be derived from the reaction of natural
gas with steam in the presence of a nickel catalyst,
from the electrolysis of brine, or from coke and
steam by way of the water-gas reaction. The
German chemist Haber was the first to develop
a process for synthesis of ammonia from its ele-
ments as a result of which the method is gener-
ally designated as the Haber synthetic ammonia
process. Ammonia may also be obtained from the
compounds formed by fixation of atmospheric
nitrogen; thus calcium cyanamide may be made
to vield it in accordance wath the following reac-
tion: CaNCN + 3H20 -> CaCOa + 2NH3.

Ammonia has a specific gravity of 0.597
(air =1). The gas may be liquefied or solidified;
the solid melts at — 85°, the liquid boils at
— 33.4°. It is very soluble in water, a portion
combining with the water to form ammonium hy-
droxide. It is easily liquefied by compression. In
the latter form it is available on the market in
cylinders. It combines with acids to form salts
containing the ammonium ion, NH4+, which was
named by Berzelius. Ammonium ion acts in many
respects in a manner analogous to the ions of the
alkaline metals.

In addition to ammonium salts, ammonia forms
an interesting series of addition compounds with
many metallic salts. For instance, the familiar
deep blue solution obtained when aqueous am-
monia is added to a cupric salt contains such an
addition compound. Among the salts which com-
bine in this manner with ammonia are those of
silver, zinc, copper, chromium, nickel, cobalt, and
the platinum metals. Usually two, four, or six
molecules of ammonia are bound to the metallic
ion. These compounds were extensively investi-
gated by Werner; they are known as metal-am-
monia complexes, Werner's complexes, or ammines
(not amines, which are organic derivatives).

The largest peace-time use of ammonia is in
the manufacture of fertilizers; indeed, ammonia
is in some areas applied directly to the soil as a
fertilizer. Ammonia also enters into the manufac-
ture of many chemicals and such substances as
rubber, plastics, various synthetic textile fibers,
. lacquers, etc. It is also employed as a refrigerant.

In the steel industry it is used to harden steel by
virtue of its forming a nitride. In time of war
ammonia is of commanding importance because
it is the starting point for the manufacture of
almost all military explosives.

Physiological Action. — Ammonia is an irre-
spirable gas; it is so irritant that the instant it
comes in contact with the glottis is causes imme-
diate spasm of that orific and inhibition of res-
piration. Continued exposure to high concentra-
tions, however, may be sufficiently irritating to
produce pulmonary edema. Repeated or long-
continued exposure to low concentrations of the
gas will cause chronic pulmonary irritation, but
less than 250 parts per million of the vapor are
probably harmless. Exposure of the skin to the
concentrated gas leads to vesicle formation. Its
only therapeutic value lies in its local irritant
effects, for it cannot circulate in the blood stream,
being there converted into ammonium salts.
Remedial effects of ammonia water or aromatic
ammonia spirit are due to the evolution of am-
monia gas which irritates the nasal mucous mem-
brane, and reflexly stimulates the respiratory and
vasomotor centers.

For description of ammonia poisoning, see
under Diluted Ammonia Solution. For account of
physiologic properties of ammonium ion see under
Ammonium Carbonate.

DILUTED AMMONIA SOLUTION.
U.S.P. (B.P.)

Ammonia Water, Diluted Ammonium Hydroxide
Solution, Liquor Ammonia; Dilutus

"Diluted Ammonia Solution is a solution of
NH3 containing, in each 100 ml., not less than

9 Gm. and not more than 10 Gm. of NH3. Upon
exposure to air it loses ammonia rapidly." U.S.P.
The B.P. Dilute Solution of Ammonia contains

10 per cent w/w (limits, 9.5 to 10.5) of NH3.

B.P. Dilute Solution of Ammonia. Solution of Ammonia.
Liquor Ammonii Hydroxidi ; Liquor Ammonii Caustici
(Ger.); Ammonia Caustica Diluta. Fr. Ammoniaque offi-
cinale diluee; Solution aqueuse, au dixieme.de gaz am-
moniac. Ger. Ammoniakfliissigkeit. It. Soluzione di am-
moniaca. Sp. Solution de Amoniaco Diluida.

Diluted ammonia solution may be prepared by
diluting 398 ml. of strong ammonia solution with
sufficient purified water to make 1000 ml. U.S.P.

Description. — "Diluted Ammonia Solution is
a colorless, transparent liquid, having a very
pungent, characteristic odor. It is alkaline to
litmus. Its specific gravity is about 0.96." U.S.P.

Standards and Tests. — Identification. —
Dense, white fumes are produced when a glass rod
wet with hydrochloric acid is held near diluted
ammonia solution. Non-volatile substances. — Not
over 2 mg. of residue is obtained on evaporating
10 ml. of diluted ammonia solution and drying at
105° for 1 hour. Heavy metals. — The limit is 5
parts per million. Readily oxidizable substances.
— The pink color of a mixture of 10 ml. of diluted
ammonia solution with a slight excess of diluted
sulfuric acid and 0.1 ml. of 0.1 N potassium per-
manganate does not completely disappear in 10
minutes. U.S.P.

The B.P. provides a test for limit of tarry mat-
ter in which 6 Gm. of powdered citric acid is dis-

Part I

Ammonia Solution, Strong 73

solved in 15 ml. of dilute solution of ammonia:
no tarry odor is perceptible. The arsenic and
lead limits are 0.1 and 0.3 part per million,
respectively.

Assay. — A portion of 5 ml. of diluted ammonia
solution is mixed with water and titrated with 1 N
sulfuric acid, using methyl red T.S. as indicator.
Each ml. of 1 N sulfuric acid represents 17.03 mg.
of NH3. U.S.P. In the B.P. assay the ammonia
solution is weighed into a measured excess of 1 N
hydrochloric acid; the excess of acid is titrated
with 1 N sodium hydroxide using methyl red as
indicator.

Composition. — Water is capable of dissolving
large amounts of ammonia; one volume of water
at 0° and 1 atmosphere dissolves 1298 volumes
of the gas, and at 20° it dissolves 710 volumes.
To a large extent the ammonia dissolves as such;
a portion of it combines chemically with water to
form the weak base, ammonium hydroxide, which
dissociates slightly into ammonium and hydroxyl
ions. Some hydrates of NH3 are also present.

Incompatibilities. — Ammonium hydroxide re-
acts with acids to form the corresponding am-
monium salts and with many metals forms a pre-
cipitate. Alkaloids are precipitated from solutions
of their salts. Free iodine may form nitrogen
iodide which is explosive when dry.

Uses. — When brought into contact with living
tissue, ammonia solution acts as a stimulant, irri-
tant, or caustic according to the concentration of
the solution. The official diluted ammonia solu-
tion, if applied for a short time to the skin, pro-
duces burning pain and redness; if contact is pro-
longed it is capable of destroying the whole
dermal tissue. When injected into the circulation,
diluted ammonia solution produces the character-
istic effects of ammonium salts but for reasons
pointed out elsewhere (see under Ammonium
Carbonate) it cannot be absorbed from the stom-
ach in sufficient quantity to exercise any direct
influence upon the general system. It is widely
used for sudden syncope of nervous origin. By
the mouth, the effects are due to reflex stimula-
tion of the vasomotor center from irritation of
the gastric mucous membrane. Still more marked
action of the same nature follows smelling of
ammonia vapor, as from ammonia water (see also
under Ammonia). If injected hypodermically, the
resulting pain is a powerful reflex stimulant to
circulation and respiration. It may cause necrosis
at the injection site. Although it is an alkali, it is
too irritant to be useful as a gastric antacid.

Ammonia water is used as an ingredient of
stimulating liniments, especially when combined
with olive or other oil. Under the title Ammonia
Liniment the N.F. IX recognized a preparation
made by mixing 10 ml. of oleic acid with 740 ml.
of sesame oil, adding 250 ml. of diluted ammonia
solution and agitating until a uniform mixture
resulted, [v]

Toxicology. — The symptoms of poisoning by
ammonia are solely those of local irritation : pain
in the mouth, throat, and epigastrium; vomiting
and collapse from the severity of the gastritis.
Conjunctivitis is common. The conjunctiva should
be rinsed with water or isotonic sodium chloride
solution. In some cases the irritation of the throat

is so severe as to produce an acute edema of the
glottis which may mechanically obstruct respira-
tion and cause rapid death from asphyxia. In the
treatment of the condition, passage of the stom-
ach tube or the use of emetics is contraindicated
because of the danger of perforation. Diluted
acetic acid in the form of vinegar may be used
as an antidote; olive oil or some other fatty sub-
stance is useful not only because it combines
with the caustic alkali to form a comparatively
nonirritant soap, but also by virtue of its local
soothing action upon the inflamed mucosa. Mor-
phine sulfate hypodermically may be used safely
to relieve pain. In case of edema of the larynx,
tracheotomy is indicated; it should be realized
that this condition may not develop for an hour
or two after the ingestion of the poison and the
physician should remain ready for immediate
operation if necessary. The subsequent treatment
is purely symptomatic.

Dose, from 0.6 to 2 ml. (approximately 10 to
30 minims), largely diluted.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 30°." U.S.P.

Off. Prep. — Aromatic Ammonia Spirit, U.S.P.;
Bismuth Magma; Senega Syrup; Washed Sulfur,
N.F.

STRONG AMMONIA SOLUTION.
U.S.P. (B.P.)

Stronger Ammonia Water, Stronger Ammonium
Hydroxide Solution, Liquor Ammonias Fortis

"Strong Ammonia Solution is a solution of
NH3, containing not less than 27 per cent and not
more than 30 per cent of NH3. Upon exposure to
air it loses ammonia rapidly. Caution. — Great care
should be used in handling Strong Ammonia Solu-
tion because of the caustic and irritating proper-
ties of its vapor. Before the container is opened it
should be well cooled and the closure covered
with a towel before removal. Strong Ammonia
Solution must never be tasted nor its vapor in-
haled." U.S.P.

The B.P. Strong Solution of Ammonia is more
concentrated than the U.S.P. solution. It contains
32.5 per cent w/w of NH3 (limits 31.5 to 33.5).

B.P. Strong Solution of Ammonia. Sp. Solution de
Amoniaco Fuerte.

Strong ammonia solution may be obtained by
dissolving ammonia gas in water. The solution is a
complex preparation, containing NH3, hydrates
of the latter, some NH4OH and small amounts
of NH4+ and OH-.

Description. — "Strong Solution of Ammonia
is a colorless, transparent liquid, having an ex-
ceedingly pungent, characteristic odor. It is
strongly alkaline to litmus. Its specific gravity is
about 0.90." U.S.P.

Standards and Tests. — Strong ammonia solu-
tion, diluted with one and one-half volumes of
water, meets the requirements of the tests for
non-volatile substances, heavy metals, and readily
oxidizable substances under Diluted Ammonia So-
lution. U.S.P. The B.P. has a test for limit of
tarry matter (see under Diluted Ammonia Solu-
tion), and sets the limits of arsenic and lead at
0.4 and 1 part per million, respectively.

74 Ammonia Solution, Strong

Part I

Assay. — About 2 ml. of strong ammonia solu-
tion is weighed accurately in a glass-stoppered
flask containing water and titrated with 1 N sul-
furic acid, using methyl red T.S. as indicator.
Each ml. of 1 AT sulfuric acid represents 17.03 mg.
of NH3. U.S.P. In the B.P. assay the ammonia
solution is weighed in a flask containing a meas-
ured excess of 1 N hydrochloric acid; the excess
of acid is titrated with 1 N sodium hydroxide.

Great care should be exercised in opening
bottles containing strong ammonia solution. It is
safer, if the solution has been kept in a warm
room, to cool it with ice before attempting to
withdraw the stopper, as the liberated gas, when
warm, frequently is forced out under considerable
pressure, and accidents which have resulted in
injury to the sight of the operator are recorded.

Uses. — Strong ammonia solution is too potent
for medicinal use in its original concentration but
provides a convenient solution for dilution to the
strength of ordinary ammonia water. Sufficiently
diluted with camphor and rosemary spirits, it was
formerly employed as an irritant lotion for
alopecia. The inadvertent inhalation of the gas
escaping from strong ammonia solution may cause
inflammation of the upper respiratory tract. The
best antidote, under these circumstances, is the
inhalation of vapors of vinegar or acetic acid.
(For toxicology, see under Diluted Ammonia
Solution.) E

Dose, 0.2 to 0.4 ml. (approximately 3 to 6
minims), largely diluted.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 25°." U.S.P.

Off. Prep.— Diluted Ammonia Solution, U.S.P.,
B.P.; Ammoniacal Silver Nitrate Solution, N.F.;
Ammoniated Liniment of Camphor; Aromatic
Spirit of Ammonia, B.P.

AROMATIC AMMONIA SPIRIT.
U.S.P. (B.P.)

[Spiritus Ammoniac Aromaticus]

"Aromatic Ammonia Spirit contains, in each
100 ml., not less than 1.7 Gm. and not more than
2.1 Gm. of total NH3, and ammonium carbonate,
corresponding to not less than 3.5 Gm. and not
more than 4.5 Gm. of (NH^COa." U.S.P.

The B.P. Aromatic Spirit of Ammonia con-
tains 1.185 per cent w/v of free ammonia (limits,
1.12 to 1.25), calculated as NH3, and 3.0 per cent
w/v of ammonium carbonate (limits, 2.76 to
3.24), calculated as (NH4)2C03.

B.P. Aromatic Spirit of Ammonia. "Aromatics"; Spirit
of Sal Volatile. Sp. Espiritu Aromatico de Amoniaco.

Dissolve 34 Gm. of translucent ammonium car-
bonate in 90 ml. of diluted ammonia solution and
140 ml. of purified water by gentle agitation, and
allow the solution to stand for 12 hours. Dissolve
10 ml. of lemon oil, 1 ml. of lavender oil and 1 ml.
of myristica oil in 700 ml. of alcohol contained
in a graduated bottle or cylinder, and add gradu-
ally the ammonium carbonate solution along with
enough purified water to make 1000 ml. Set the
mixture aside in a cool place for 24 hours, agi-
tating it occasionally, and then filter, using a
covered funnel. US.P.

The B.P. prepares aromatic spirit of ammonia

by distilling a mixture of alcohol, water, lemon
oil and nutmeg oil, collecting two portions of
distillate, the first and larger portion containing
most of the alcohol and oils, and the second por-
tion representing largely water saturated with
oils; the ammonium bicarbonate and stronger
ammonia water are dissolved in the aqueous frac-
tion of the distillate and then mixed with the
distillate representing the hydroalcoholic solution
of the oils. The B.P. preparation is slightly
stronger in ammonia water and slightly weaker
in ammonium carbonate.

Under ammonium carbonate it was pointed out
that this substance is a mixture of ammonium
carbamate and ammonium bicarbonate. In the
hydroalcoholic medium of aromatic ammonia
spirit the carbamate dissolves completely and is
converted by water to carbonate; the bicarbonate,
however, because of its insolubility in alcohol,
would be largely precipitated if ammonia were not
included to convert it to carbonate. This need for
ammonia is all the more necessary because am-
monium carbonate which has been exposed to the
air for a long time will have been in considerable
part converted to ammonium bicarbonate by loss
of ammonia; in the presence of ammonia the
bicarbonate is converted again to carbonate. But
even with the inclusion of ammonia it is impera-
tive that translucent pieces af ammonium car-
bonate be used, for the amount of ammonia may
be inadequate to convert a large amount of bi-
carbonate to carbonate, with the result that a
part of the bicarbonate remains insoluble. The
U.S.P. allows 12 hours for the reaction between
ammonia and the components of ammonium car-
bonate to become completed. If directions are
followed in every detail, the precipitation (of
ammonium bicarbonate) sometimes observed will
not occur.

Description. — "Aromatic Ammonia Spirit is a
nearly colorless liquid when recently prepared, but
gradually acquires a yellow color on standing. It
has the taste of ammonia, has an aromatic and
pungent odor, and is affected by light. Its specific
gravity is about 0.90." US.P.

The yellow color acquired by the spirit, on
standing, is due either to alteration of the volatile
oils, or to a reaction of aldehydes in alcohol in
the presence of alkali. Despite the change in color,
the spirit retains its therapeutic activity.

Assay. — For total ammonia. — A 10-ml. por-
tion of spirit is diluted with water, mixed with
30 ml. of 0.5 N sulfuric acid, and the mixture
boiled until a clear solution results, after which
the excess of acid is titrated with 0.5 N sodium
hydroxide, using methyl red T.S. as indicator.
Each ml. of 0.5 N acid represents 8.516 mg. of
XH3. For ammonium carbonate. — A second 10-ml.
portion of spirit is mixed with 30 ml. of 0.5 N
sodium hydroxide, the mixture boiled until the
ammonia is expelled and an amount of sodium
carbonate equivalent to the ammonium carbonate
originally present is formed, and the solution
neutralized with 0.5 N sulfuric acid, first to
phenolphthalein T.S., and then to methyl orange
T.S. Each ml. of 0.5 N acid consumed in the
presence of methyl orange represents 48.05 mg.
of (NH4)2C03. This equivalent is based on the

Part I

Ammonium Acetate, Strong Solution of 75

fact that at the phenolphthalein endpoint the
carbonate has been converted to bicarbonate, and
that it is only the latter which is neutralized in
the presence of methyl orange.

The B.P. assays for free ammonia by essen-
tially the same method that the U.S. P. employs
for total ammonia, except that from the amount
of acid required to neutralize both free and com-
bined ammonia is subtracted the amount equiva-
lent to the ammonium carbonate present. In the
assay for ammonium carbonate the following
steps are performed: the sample of spirit is
treated with a solution of barium chloride to pre-
cipitate barium carbonate and form an equivalent
amount of ammonium chloride; simultaneously a
measured excess of 1 ^ sodium hydroxide is
added, which reacts with the ammonium chloride
to form sodium chloride and ammonia; the am-
monia from this reaction, as well as that present
in the spirit initially, is reacted with formaldehyde
to convert it to methenamine; finally, the excess
of the sodium hydroxide solution is titrated with
1 N hydrochloric acid, using thymol blue indi-
cator. Each ml. of 1 N sodium hydroxide repre-
sents 48.05 mg. of (NEU)2C03.

Alcohol Content. — From 62 to 68 per cent,
by volume, of C2H5OH. U.S.P.

Uses. — Aromatic ammonia spirit is used as a
mild stimulant in syncope and other forms of
circulatory weakness. Its action is purely reflex,
resulting from irritation of the mucous membrane
of the alimentary tract. Although ammonia is a
stimulant to the circulation it can act only when
injected hypodermically. Aromatic ammonia spirit
has been used for "sick headache." H

The usual dose is 2 ml. (approximately 30
minims), well diluted with water. The maximum
safe dose is usually 4 ml. and the total dose in 24
hours should seldom exceed 10 ml.

Storage. — Preserve "in tight, light-resistant
containers, preferably at a temperature not above
30°." U.S.P.

AMMONIUM ACETATE SOLUTION.
N.F. (B.P.)

[Liquor Ammonii Acetatis]

"Ammonium Acetate Solution contains, in each
100 ml., not less than 6.5 Gm. and not more
than 7.5 Gm. of CH3COONH4, with small
amounts of acetic and carbonic acids. Note. —
Dispense only recently prepared Ammonium
Acetate Solution." N.F. The B.P. limits of am-
monium acetate for this solution are from 6.9 to
7.5 per cent w/v.

B.P. Dilute Solution of Ammonium Acetate, Liquor
Ammonii Acetatis Dilutus. Spirit of Mindererus. Am-
monium Aceticum Solutum; Ammonii Acetas Liquidus;
Liquor Ammonii Acetici. Fr. Acetate d'ammonium dis-
sous; Solution officinale d'acetate d'ammonium; Acetate
d'ammonium liquide. Ger. Ammoniumacetatlosung. It.
Soluzione di acetato di ammonio. Sp. Acetato de amonio
liquido; Acetato amonico liquido; Espiritu de minderero.

Dissolve 50 Gm. of ammonium carbonate, in
hard, translucent pieces, in sufficient diluted
acetic acid to make 1000 ml. of solution. Avoid
strong agitation of the solution during its prepara-
tion. The solution may also be prepared by mix-
ing equal volumes of the following solutions:
Solution No. 1. — Dissolve 100 Gm. of ammonium

carbonate, in hard, translucent pieces, in suffi-
cient purified water to make 1000 ml. Solution
No. 2. — Mix 320 ml. of acetic acid with sufficient
purified water to make 1000 ml. of solution. N.F.

The B.P. equivalent of this preparation is made
by diluting the stronger solution (q.v.) with seven
parts of distilled water.

The palatability and compatibility of this solu-
tion are enhanced by having in it a slight excess
of acetic acid and carbon dioxide; it is, there-
fore, important that the ammonium carbonate be
not decomposed and that the acetic acid be of
specified strength. Particularly to insure having
carbon dioxide in the solution as it is dispensed, it
should be prepared as required for immediate use.

Description. — "Ammonium Acetate Solution
is a clear, colorless liquid, free from empyreu-
matic odor. It has a mildly salty, acid taste, and
an acid reaction to litmus." N.F.

Standards and Tests. — Identification. — Am-
monium acetate solution responds to tests for
ammonium and for acetate. Residue on ignition. —
The residue from 20 ml. of solution does not
exceed 3 mg. N.F.

Assay. — A portion of 25 ml. is diluted with
water, made alkaline with sodium hydroxide T.S.
and the ammonia distilled out of the mixture into
50 ml. of 1 N sulfuric acid; the excess acid is
titrated with 1 N sodium hydroxide using methyl
red T.S. as indicator. Each ml. of 1 A7 sulfuric
acid represents 77.08 mg. of CH3COONH4. N.F.
The B.P. assay is explained under Strong Solution
of Ammonium Acetate.

Uses. — Ammonium acetate solution is used as
a saline diaphoretic and diuretic, especially in
febrile conditions, [Yl

Dose, from 15 to 30 ml. (approximately Yi to 1
fluidounce) every two or three hours, mixed with
water and sweetened.

Storage. — Preserve "in tight containers." N.F.

Off. Prep. — Iron and Ammonium Acetate So-
lution, N.F.

STRONG SOLUTION OF AMMONIUM
ACETATE. B.P.

Liquor Ammonii Acetatis Fortis

This solution contains about 57.5 per cent
w/v of ammonium acetate (limits, 55.0 to 60.0
per cent) and is prepared by the interaction in an
aqueous solution of glacial acetic acid, ammonium
bicarbonate and sufficient strong ammonia solu-
tion to make the pH of the solution, when a
portion of it is diluted with 10 volumes of water,
between 7 and 8 (the test being based on the
production of a full blue color with bromothymol
blue solution and a full yellow color with thymol
blue solution).

Description and Standards. — The solution
is described as a thin syrupy liquid having an odor
of ammonia as well as of acetic acid; the weight
per ml., at 20°, is about 1.094 Gm. Arsenic and
lead limits of 4 p.p.m. and 5 p.p.m., respectively,
are prescribed.

Assay. — A sample of 5 ml. of solution is
diluted with water, formaldehyde neutralized to
phenolphthalein is added, and the solution titrated
with 1 N sodium hydroxide, using phenolphthalein

76 Ammonium Acetate, Strong Solution of

Part I

solution as indicator. Each ml. of I N sodium hy-
droxide represents 77.08 mg. of ammonium ace-
tate. This assay is based on the fact that hydroly-
sis of ammonium acetate to ammonia and acetic
acid may be made complete by having formalde-
hyde present to react with ammonia, forming
methenamine, and leaving acetic acid to be ti-
trated with alkalki.

Dose, from 1 to 4 ml. (approximately 15 to 60
minims).

Storage. — Preserve in a bottle made of lead-
free glass. B.P.

Off. Prep. — Dilute Solution of Ammonium
Acetate, B.P.

AMMONIUM BICARBONATE. B.P.

Ammonii Bicarbonas

Ammonium Bicarbonate contains not less than
98.0 per cent of NH4HCO3. B.P.

Fr. Carbonate acide d'ammonium. Gcr Ammoniumbicar-
bonat; Doppeltkohlensaures Ammonium. Sp. Bicarbonato
amonico.

Ammonium bicarbonate may be prepared by a
number of methods. One of these consists in sub-
liming so-called "ammonium carbonate" (really
a mixture of ammonium bicarbonate and am-
monium carbamate; see Ammonium Carbonate)
in the presence of a little water, a white fibrous
mass of ammonium bicarbonate, somewhat con-
taminated with the carbamate, being obtained. By
washing the mass with alcohol the carbamate is
dissolved while the bicarbonate remains insoluble.
Ammonium bicarbonate may also be prepared by
passing carbon dioxide into an aqueous solution
of ammonia or by treating "ammonium carbonate''
with alcohol in order to remove the carbamate.

Description and Standards. — Ammonium
bicarbonate occurs as colorless crystals or a white
crystalline powder. It is slightly hygroscopic, dis-
solves in 5 parts of water (at 20°) but is in-
soluble in alcohol. It volatilizes slowly at room
temperatures. At 60° it rapidly dissociates into
ammonia, carbon dioxide and water. It gives the
characteristic reactions of the ammonium salts
and of the bicarbonates.

Pure ammonium bicarbonate does not possess
the irritant odor of ammonia, but because the
commercial preparations often contain traces of
carbamate, ammonia is produced in consequence
of the dissociation of the latter. According to
Whittet (Pkarm. J., 1949, 162, 24), solutions of
ammonium bicarbonate are stable for at least 6
months if stored in glass-stoppered bottles; ex-
posed to air the solutions steadily decompose be-
cause of the release of ammonia and carbon
dioxide.

The B.P. includes tests for limits of tarry mat-
ter, chlorides, sulfates, arsenic, lead and iron. It
may be assayed by dissolving 2 Gm. in 40 ml. of
1 N hydrochloric acid, boiling the solution to
expel carbon dioxide, cooling, and finally titrating
the excess of acid with 1 N sodium hydroxide
solution, using methyl red as the indicator.

Uses. — This drug is very similar in its thera-
peutic range to the so-called ammonium carbonate
which is. as a matter of fact, largely composed
of the bicarbonate. It is somewhat less irritating

than the older salt since it does not form the basic
carbonate. It has been used as an expectorant and
a carminative.

Externally, ammonium bicarbonate has been
applied in 0.5 to 2 per cent aqueous solution for
periodic irrigation of suppurating wounds before
granulations fill in the wound (see Berezin, Am.
Rev. Soviet Med., 1945, 2, 230).

The dose is from 300 to 600 mg. (approxi-
mately 5 to 10 grains).

AMMONIUM BROMIDE. N.F.

[Ammonii Bromidum]

"Ammonium Bromide, dried at 105° for 2
hours, contains not less than 99 per cent of
NHiBr." N.F.

Ammonium Bromatum; Ammonium Bromuretum; Am-
monium Hydrobromicum. Fr. Bromure d'ammonium ;
Bromhydrate d'ammoniaque. Ger. Ammoniumbromid;
Bromammonium. It. Bromuro di ammonio; Bromidrato di
aniinoni.ua. Sp. Bromuro de amonio.

Formerly this salt was prepared by dissolving
bromine in ammonia water, the hypobromite pro-
duced being reduced to bromide by means of
hydrogen sulfide. An early pharmacopeial process
directed preparation of the salt by the interaction
of ferrous bromide and ammonia water, the re-
sulting ferrous hydroxide being oxidized to ferric
hydroxide and filtered off, and the ammonium
bromide obtained by evaporation of the filtrate. A
present-day commercial method of preparing the
salt involves reaction between boiling solutions
of ammonium sulfate and potassium bromide; on
cooling, the potassium sulfate precipitates in part,
with the remainder separating on concentration of
the liquid, aided by addition of alcohol. The am-
monium bromide is obtained from the residual
liquid by concentrating it to crystallize' the salt.

Description. — "Ammonium Bromide occurs
as colorless crystals, or as a yellowish white crys-
talline powder, having no odor. It is somewhat
hygroscopic. One Gm. of Ammonium Bromide
dissolves in about 1.3 ml. of water and in about
12 ml. of alcohol." N.F.

Standards and Tests. — Identification. — A 1
in 10 solution of ammonium bromide responds to
tests for ammonium and for bromide. Residue
on ignition. — Not over 0.05 per cent. Acidity. —
Not more than 0.05 ml. of 0.1 N sodium hy-
droxide is required to neutralize 2 Gm. of ammo-
nium bromide in 20 ml. of water, using methyl
red T.S. as indicator. Chloride. — In the assay,
each Gm. of ammonium bromide requires not less
than 101.1 ml. and not more than 103.0 ml. of
0.1 N silver nitrate in the assay. Sulfate. — No tur-
bidity is produced in 1 minute on adding barium
chloride T.S. to a 1 in 20 solution of ammonium
bromide, acidulated with hydrochloric acid. Ba-
rium.— No turbidity is produced in 5 minutes on
adding potassium sulfate T.S. to a 1 in 20 solution
of ammonium bromide, acidulated with hydro-
chloric acid. Heavy metals. — The limit is 20 parts
per million. Iron. — No blue color is produced im-
mediately on adding potassium ferrocyanide T.S.
to a 1 in 150 solution of ammonium bromide.
Bromate. — No yellow color is produced immedi-
ately on adding diluted sulfuric acid to powdered
ammonium bromide. Iodide. — Not even a tran-

Part I

Ammonium Carbonate

sient violet color is seen in the chloroform layer
of a mixture of a 1 in 20 ammonium bromide
solution, ferric chloride T.S., and chloroform.
N.F.

Assay. — A sample of about 400 mg. of ammo-
nium bromide, previously dried at 105° for 2
hours, is assayed by the Volhard method, in
which a measured excess of 0.1 AT silver nitrate
is employed; the excess silver ion is determined
by titration with 0.1 N ammonium thiocyanate,
using ferric ammonium sulfate T.S. as indicator.
Each ml. of 0.1 N silver nitrate represents
9.796 mg. of NH4Br. N.F.

Uses. — Ammonium bromide is useful chiefly
for the action of bromide ion (see under Potas-
sium Bromide). It has a disagreeable taste and
may cause digestive disturbances. According to
Dressier {Clinical Cardiology, 1942, p. 186) it is
preferable to ammonium chloride in treatment
of edema of cardiac origin, being better tolerated
and having the two-fold action of being sedative
to the central nervous system and producing aci-
dosis as an adjuvant to mercurial diuresis. For
such purpose it is administered in doses of 1 Gm.
four times a day for two days before injection
of the mercurial.

Dose, 0.6 to 2 Gm. (approximately 10 to 30
grains) well diluted.

Storage. — Preserve "in tight containers."
N.F.

Off. Prep. — Five Bromides Elixir; Bromides
Syrup; Three Bromides Elixir; Three Bromides
Tablets, N.F.

AMMONIUM CARBONATE.

[Ammonii Carbonas]

U.S.P.

"Ammonium Carbonate consists of ammonium
acid carbonate (NH4HCO3) and ammonium car-
bamate (NH2.COO.NH4) in varying proportions,
and yields not less than 30 per cent and not more
than 33 per cent of NH3." U.S.P.

Ammonia Crystal; Sal Volatile. Ammoniae Carbonas; Am-
monium Carbonicum; Ammonium Sesquicarbonicum. Fr.
Carbonate d'ammonium officinal; Sesquicarbonate d'am-
moniaque; Alcali volatil concret. Ger. Ammoniumkarbonat ;
Kohlensaures Ammonium; Hirschhornsalz; Fluchtiges Salz.
It. Carbonato di ammonio. Sp. Carbonato de amonio.

As is apparent from the official definition, "am-
monium carbonate" is in reality a mixture of am-
monium bicarbonate and ammonium carbamate.
The salt is prepared by heating a mixture of am-
monium chloride and calcium carbonate in iron
pots or retorts; the "ammonium carbonate" vapor
is condensed and the ammonium vapor is con-
ducted into an acid solution. The reaction may be
represented as follows:

4NH4C1 + 2CaCOs -> NH4HCO3.NH2COONH4
+ NH3 + 2CaCl2 + H2O

Ammonium carbonate can also be prepared by
direct reaction of ammonia, carbon dioxide and
steam.

Description. — "Ammonium Carbonate occurs
as a white powder or as hard, white or translucent
masses, having a strong odor of ammonia, with-
out empyreuma, and with a sharp, ammoniacal
taste. Its solutions are alkaline to litmus. On ex-
posure to air, it loses ammonia and carbon dioxide,

becoming opaque, and is finally converted into
friable, porous lumps or a white powder of am-
monium bicarbonate. One Gm. of Ammonium
Carbonate dissolves very slowly in about 4 ml.
of water. It is decomposed by hot water." U.S.P.

Standards and Tests. — Identification. — Am-
monium carbonate volatilizes without charring
when heated; the vapor is strongly alkaline to
moistened litmus paper. Solutions of ammonium
carbonate effervesce with acids. Residue on igni-
tion.— Not over 0.05 per cent. Chloride. — The
limit is 35 parts per million. Sulfate. — The limit
is 50 parts per million. Heavy metals. — The limit
is 10 parts per million. Emypreumatic matter. —
A colorless, odorless residue is obtained on evapo-
rating to dryness on a water bath a nitric acid
solution of 1 Gm. of ammonium carbonate. U.S.P.

If official ammonium carbonate is treated with
90 per cent alcohol, it is resolved into the two
salts of which it is composed, ammonium car-
bamate going into solution while the acid ammo-
nium carbonate remains undissolved. The latter
compound also remains undissolved when the com-
mercial carbonate is treated with an amount of
water insufficient for complete solution. Upon
complete solution of the salt in water there re-
sults a mixture of acid and neutral carbonates,
the carbamate having undergone hydrolysis ac-
cording to the equation:

NH2.COO.NH4 + H2O -» (NHO2CO3

Boiling the aqueous solution results in decomposi-
tion of the compound into ammonia and carbon
dioxide.

Exposed to air, ammonium carbonate is gradu-
ally converted into bicarbonate, becoming opaque
and friable, and changing to powder form.

Assay. — A sample of about 2 Gm. of am-
monium carbonate is dissolved in 50 ml. of 1 N
sulfuric acid, and the excess of acid is titrated
with 1 AT sodium hydroxide, using methyl orange
T.S. as indicator. Each ml. of 1 A7 sulfuric acid
represents 17.03 mg. of NH3. U.S.P.

Uses. — Locally ammonium carbonate is an
active irritant capable of causing gastritis. Sys-
temically its action is that of its ammonium
radical. When injected intravenously, in experi-
mental studies (since it is not injected in thera-
peutics), the blood pressure increases, partly from
an effect on the cardiac muscles, and probably
also in part from a stimulation of the vasomotor
center in the medulla: the pressure returns to
normal in a very few minutes. After toxic doses
the rise may be followed by a fall to a point below
normal. There is an increase in the rapidity of
breathing due to an action upon the respiratory
center. The action upon the spinal cord is shown
by increased activity of reflexes; in sufficient
doses it is capable of causing tetanic convulsions.
These effects are caused only when ammonium
carbonate is injected rapidly. When the drug is
taken by mouth, the ammonium ion is so rapidly
destroyed in the system that it is scarcely possi-
ble for a sufficient quantity to be absorbed through
the mucous membrane of the alimentary tract.
It is oxidized in the liver and appears in the
urine chiefly as urea (see also under Ammonium
Chloride) .

Ammonium Carbonate

Part I

Ammonium carbonate has been used as a car-
minative in "sick headache." It is also employed
as an expectorant in the same type of bronchitis
in which ammonium chloride is used; the car-
bonate will obviously be converted to chloride in
the stomach and its action will therefore be that
of the chloride. Coarsely pulverized and mixed
with half its bulk of stronger ammonia water, and
usually scented with oil of lavender, it constitutes
the common smelling salts so frequently held
under the nostrils as stimulant in syncope and
nervous collapse. It is unlikely that sufficient am-
monia can be absorbed through the mucous mem-
brane to exert any physiological action, and as
the gas is irrespirable it cannot be inhaled. The
beneficial action, which undoubtedly occurs in
many patients, is probably due to a reflex effect
from irritation of the nasal mucous membrane.
Acetic acid vapors are used for the same purpose.
A similar result is obtained by swallowing a solu-
tion of ammonium carbonate, as in the popular
aromatic ammonia spirit, although in this case
the reflex comes from irritation of the stomach
instead of the nose. EO

Ammonium carbonate, under the name baker's
ammonia, is sometimes used as a leavening agent,
replacing sodium bicarbonate.

The usual dose is 300 nig. (approximately 5
grains) in dilute solution. The maximum safe dose
is usually 600 mg. and the total dose in 24 hours
should seldom exceed 2 Gm.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 30°, protected
from' light." U.S.P.

Off. Prep. — Aromatic Ammonia Spirit, U.S.P.,
Ammonium Acetate Solution; Bismuth Magma;
Expectorant Mixture, N.F.

AMMONIUM CHLORIDE. U.S.P., B.P.

[Ammonii Chloridum]

"Ammonium Chloride, dried over sulfuric acid
for 4 hours, contains not less than 99.5 per cent
of NH4CI." U.S.P. The B.P. requires not less
than 99.5 per cent of NH4CI, calculated with
reference to the substance dried in a vacuum
desiccator over sulfuric acid for 24 hours.

Muriate of Ammonia. Ammonium Muriaticum; Am-
monium Chloratum; Ammonium Chloruretum; Ammonium
Hydrochloricum; Chlorhydras Ammoniac; Ammonii Chlor-
urum. Fr. Chlorure d'ammoniurn; Chlorhydrate d'am-
moniaque; Sel ammoniac. Ger. Ammoniumchlorid; Salmiak.
It. Cloruro di ammonio. Sp. Cloruro de amonio.

Ammonium chloride originally came from
Egypt, where it was obtained by sublimation
from the soot resulting from the burning of
camels' dung, which was used in that country for
fuel. The name sal ammoniac, by which it was
first known, is derived from the fact that it was
largely obtained in the Libyan desert near the
temple of Jupiter Ammon. Ammonium chloride
has long been known in China, where it is obtained
from the water of certain volcanic springs. It is
found in the fumaroles of Vesuvius, Etna, Hecla,
and other volcanoes, and in the cracks and fissures
in recent lava streams.

Ammonium chloride is commonly prepared by
passing ammonia into hydrochloric acid. Chief
source of the ammonia is ammoniacal gas liquor

(see Ammonia), from which a reasonably pure
ammonia may be distilled after treatment with
lime. Purification of the ammonium chloride
may be effected by subliming the salt. Ammonium
chloride may also be prepared by the interaction
of ammonia and hydrogen chloride vapors in the
presence of some water. For other methods which
have been used see U.S.D., 23rd edition.

Description. — "Ammonium Chloride occurs
as colorless crystals or as a white, fine or coarse,
crystalline powder. It has a cool, saline taste,
and is somewhat hygroscopic. One Gm. of Ammo-
nium Chloride dissolves in 2.6 ml. of water, in
about 100 ml. of alcohol, and in about 8 ml. of
glycerin. One Gm. of it dissolves in 1.4 ml. of
boiling water." U.S.P.

Standards and Tests. — Identification. — A 1
in 10 solution of ammonium chloride responds to
tests for ammonium and for chloride. Loss on
drying. — Not over 0.5 per cent, when dried over
sulfuric acid for 4 hours. Residue on ignition. —
Not over 0.1 per cent, on igniting a mixture of 1
ml. of sulfuric acid and 2 Gm. of ammonium
chloride. Acidity. — Not more than 0.05 ml. of
0.1 N sodium hydroxide is required to neutralize
2 Gm. of ammonium chloride in 20 ml. of water,
using methyl red T.S. as indicator. Thiocyanate.
— Addition of a few drops of ferric chloride T.S.
to a 1 in 10 solution of ammonium chloride, acidu-
lated with hydrochloric acid, does not produce
a red color. Heavy metals. — The limit is 10 parts
per million. U.S.P. The B.P. limits loss on drying
to 1.0 per cent, arsenic to 4 parts per million,
and lead to 5 parts per million.

Assay. — About 200 mg. of ammonium chlo-
ride, previously dried over sulfuric acid for 4
hours, is assayed by a modification of the Volhard
method in which an excess of 0.1 N silver nitrate
is added, and the excess of silver ion titrated
directly, without filtering off the silver chloride,
with 0.1 N ammonium thiocyanate, using ferric
ammonium sulfate T.S. as indicator. The modifi-
cation consists in adding 3 ml. of nitrobenzene
prior to the titration with ammonium thiocyanate
solution; the former coats the particles of silver
chloride so that they will not react with the
thiocyanate (see Caldwell and Moyer, Ind. Eng.
Chem., Anal. Ed., 1935, 7, 38). Each ml. of 0.1 AT
silver nitrate represents 5.350 mg. of NH4CI.
U.S.P.

The B.P. utilizes the classical Volhard assay,
the silver chloride being removed by filtration
before titrating with thiocyanate.

Incompatibilities. — Ammonium chloride is
incompatible with lead and silver salts, producing
precipitates respectively of lead and silver chlo-
rides. With alkalis, as well as with substances
which in aqueous solution produce an alkaline
reaction, ammonia is liberated. This incompati-
bility is shared by all ammonium salts.

Uses. — Ammonium chloride is most commonly
used as an expectorant and as a diuretic; it is an
excellent systemic acidifying agent. It possesses
the stimulant qualities of its basic ion and re-
sembles the carbonate in its physiologic action.

Acidifying and Diuretic Actions. — Systemic
effects of ammonium chloride depend upon the
ability of the liver to convert ammonium ion into

Part I

Ammonium Chloride

urea, thus liberating the anion into the blood
stream and into extracellular fluids. For this rea-
son all the inorganic salts of ammonium increase
the acidity of the urine. One gram of ammonium
chloride is as effective as a urinary acidifier as
2.5 Gm. of sodium acid phosphate (see J. A.M. A.,
1951, 147, 207). It is used, therefore, in those
types of urinary tract infection where a low uri-
nary pH is desired, in doses of 6 to 8 Gm. (ap-
proximately V/i to 2 drachms) daily. It is some-
times administered in conjunction with methena-
mine.

According to Cornbleet (J.A.M.A., 1951, 146,
1116), the excess chloride that is liberated filters
through the kidney glomeruli, which the tubules
refuse to reabsorb from the filtrate. Some of the
chloride is neutralized by sodium, potassium and
calcium. Compensatory factors acting through the
posterior lobe of the pituitary body and the
adrenal cortex cause an equivalent amount of
water to leave with the sodium, increasing urine
formation and promoting diuresis. Grollman states
that the acidosis produced by ammonium chloride
causes the passage of intracellular salts and water
into the extracellular spaces, with elimination of
this tissue fluid by the kidney (see Modern Medi-
cine, June 1, 1951, p. 59).

One of the uses of the acidifying quality of this
drug is based on the observation of Aub, Minot
and Reznikoff (Medicine, 1925, 4, 1) that diminu-
tion of the pH of the circulating blood renders
calcium more soluble, thus promoting decalcifica-
tion. In lead poisoning the stored lead accom-
panies calcium. It is possible, therefore, to "de-
lead" a patient with lead poisoning by the admin-
istration of ammonium chloride in 1 Gm. (ap-
proximately 15 grains) doses each hour 8 to 10
times daily, together with a diet poor in calcium
and rich in phosphorus. It has been noted by
Brown, Kolmer and Rule (Am. J. Syph., 1943,
27, 501) that stored bismuth, resulting from its
injection for the treatment of syphilis, may be
similarly mobilized, but toxic reactions may be
encountered.

A frequent use of ammonium chloride is to
promote diuresis in many conditions characterized
by edema, as in the nephrotic syndrome, portal
cirrhosis of liver, and congestive heart failure.
Dosage is 4 to 12 Gm. (approximately 1 to 3
drachms) daily, in divided quantities, with meals,
usually as enteric-coated tablets. It is ordinarily
given in courses of 3 days, with equal rest periods
to minimize gastric irritation and diarrhea. In
the edema of congestive heart failure it is popu-
larly administered for 48 to 72 hours prior to
giving a mercurial diuretic to enhance the effect
of the latter (Etheridge, Arch. Int. Med., 1936,
57, 514). Stock et al. (Circulation, 1951, 4, 54)
state that its synergistic effect when so used is
probably due to its ability to prevent or counter-
act alkalosis. Schroeder (J.A.M.A., 1951, 147,
1109) attributes the synergism to the fact that the
acidic salts cause osmotic tubular diuresis as well
as increasing the renal excretion of bases, includ-
ing sodium. It has been found by Greiner and
Gold (JAM. A., 1953, 152, 1130) that even in a
dose of 16 Gm. ammonium chloride is less effec-
tive as a diuretic than are orally administered

theophylline salts and organic mercurials. Addi-
tional diuretic indications for ammonium chloride
include treatment of premenstrual tension, ther-
apy of Meniere's syndrome in conjunction with a
neutral diet (Furstenburg et al, Ann. Otol. Rhin.
Laryng., 1934, 43, 1035), and in certain alcoholic
states. Cornbleet (loc. cit.) treated bromide intoxi-
cation successfully with ammonium chloride, since
this salt furnishes chloride to displace the bromide
and is simultaneously a diuretic.

Zintel, Rhoads and Ravelin (Surgery, 1943, 14,
728) reported intravenous use of ammonium
chloride in alkalosis. They used a 2 per cent
solution in normal saline or in 5 per cent dextrose,
the maximum rate of injection being 1 liter in
2 hours. A 1-Gm. dose is said to reduce the serum
carbon dioxide-combining power in a 150-pound
adult by 1.1 volume per cent. The solution in
saline may be autoclaved for 20 minutes at 15
pounds pressure. No serious reaction is reported
although there may be chill or fever.

Expectorant Action. — Ammonium chloride is
widely prescribed as an expectorant. Being non-
volatile it is not exhaled through the pulmonary
alveoli. It is believed that reflex stimulation of
the bronchial mucous glands results from irrita-
tion of the gastric mucosa. Perry and Boyd
(/. Pharmacol., 1941, 73, 65) demonstrated an
increase in bronchial secretion by reflex action
from the stomach, there being no response to
introduction of ammonium chloride after severing
branches of the vagus nerve supplying the
stomach. Banyai states (J.A.M.A., 1952, 148,
501) that, in addition to reducing viscosity and
pH and increasing fluidity of the bronchial secre-
tions, the drug stimulates the ciliary function of
the mucosa. A dose of 300 mg. every 2 hours is
used in a syrup; tablets should not be enteric-
coated. Flavored lozenges containing the drug are
sometimes prescribed in pharyngitis and laryngitis
to secure both a local effect and an effect from
the medicated saliva that is swallowed.

Local Anesthetic Action. — A new use for
ammonium chloride has been described by Judo-
vich, Bates and Bishop (Anesth., 1944, 5, 341),
based on earlier investigation of a preparation of
the pitcher plant, Sarracenia purpurea, made by
distillation of the powdered rhizome in the pres-
ence of caustic alkali and used in the relief of
neuralgic pain. Neutralization of the distillate
with hydrochloric or sulfuric acid yields salts
found to be identical with ammonium chloride
and ammonium sulfate, respectively (see Stewart
et al, Am. J. Physiol, 1940, 129, 474; Walti,
J.A.C.S., 1945, 67, 2271). Following preliminary
sedation of the patient with morphine, atropine
and amytal, from 3 to 5 ml. of a 6 per cent solu-
tion of ammonium chloride, adjusted to pH 7.2
by means of sodium hydroxide, is mixed with
50 ml. of cerebrospinal fluid and injected intra-
spinally. Such administration is limited to patients
with root pain of metastatic origin.

Toxicology. — Among the more severe toxic
reactions to ammonium chloride, acidosis has
been reported by Sleisinger and Freedberg (Circu-
lation, 1951, 3, 837), during its administration
as a diuretic. They believed the severe acidosis
to be related to intrinsic renal disease and the

Ammonium Chloride

Part I

inability of the kidneys to prevent continued loss
through the urine of fixed base with chloride. The
drug may also precipitate uremia when used in
the presence of renal disease.

According to Purdum (7. A. Ph. A., 1942, 31,
298) syrups of glycyrrhiza, raspberry, orange
flowers, citric acid and tolu balsam are the most
effective masking vehicles for the disagreeable
salty taste of ammonium chloride. An aromatic
syrup of ammonium chloride, prepared by Sorg
and Kuever (/. A. Ph. A., Pract. Ed., 1942, 3,
262) especially for use in Furstenberg's treatment
of Meniere's disease, has the following composi-
tion: Ammonium chloride, 200 Gm.; soluble sac-
charin, 10 Gm.; menthol, 1 Gm.; alcohol, 30 ml.;
glycerin, 100 ml.; compound syrup of sarsaparilla,
400 ml.; distilled water, to 1000 ml. (3

The usual dose is 1 Gm. (approximately 15
grains), by mouth, 4 times a day, with a range
of 300 mg. to 2 Gm.; the maximum safe dose is
2 Gm., and the total dose in 24 hours exceeds
8 Gm. only under certain conditions (v.s.). As
an expectorant, 300 mg. (approximately 5 grains)
is used as frequently as every two hours.

Storage. — Preserve "in tight containers."
U.S.P.

AMMONIUM CHLORIDE CAPSULES

U.S.P.

[Capsulse Ammonii Chloridi]

"Ammonium Chloride Capsules contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of NH4CI." U.S.P.

Sp. Cdpsulas de Cloruro de Amonxo.

Assay. — The contents of not less than 20 cap-
sules are transferred to a 500-ml. volumetric
flask, the emptied capsules being washed with
water and this solution filtered into the same
volumetric flask. After diluting to 500 ml. an
aliquot portion, equivalent to about 200 mg. of
ammonium chloride, is transferred to a distilling
flask, alkalinized with 10 per cent sodium hydrox-
ide solution, and the ammonia distilled into a
boric acid solution. The ammonia in this solution
is titrated with 0.1 N sulfuric acid, using methyl
red T.S. as indicator. A blank test is performed
on the reagents and any necessary correction ap-
plied. Each ml. of 0.1 N sulfuric acid represents
5.350 mg. of NH4CI. U.S.P.

Storage. — Preserve "in tight containers."
U.S.P.

Usual Sizes. — 5 and ll/z grains (approxi-
mately 300 and 500 mg.).

AMMONIUM CHLORIDE TABLETS.
N.F.

[Tabellae Ammonii Chloridi]

"Ammonium Chloride Tablets contain not less
than 94 per cent and not more than 106 per cent
of the labeled amount of NH4CI for tablets of
300 mg. or more, and not less than 92.5 per cent
and not more than 107.5 per cent for tablets of
less than 300 mg." N.F.

Usual Sizes. — 5 and lYz grains (approxi-
mately 300 and 500 mg.), frequently enteric
coated.

AMMONIUM IODIDE. N.F.

[Ammonii Iodidum]

"Ammonium Iodide dried at 105° for 2 hours
contains not less than 98 per cent of NH4I. It
may contain not more than one per cent of am-
monium hypophosphite as a stabilizing agent."
N.P.

Ammonium Jodatum; Jodetum Ammonicum; Ammonium
Hydrojodicum. Fr. Jodure d'ammonium. Ger. Ammonium-
jodid; Jodammonium. It. Joduro di amnionic Sp. Voduro
de amonio.

Several methods of preparing ammonium iodide
are available. The one probably most often em-
ployed is that involving the interaction of am-
monium sulfate and potassium iodide; the potas-
sium sulfate precipitates on cooling the mixture
and adding some alcohol to it, and the ammonium
iodide is obtained on evaporating the liquid phase.
Other methods of making ammonium iodide in-
volve neutralization of hydriodic acid by am-
monia, interaction between ferrous iodide and
ammonium carbonate, or between potassium
iodide and ammonium bitartrate.

Description. — "Ammonium Iodide occurs as
minute, colorless, cubic crystals, or as a white,
granular powder. It is odorless, and has a sharp,
salty taste. Ammonium Iodide is very hygro-
scopic, and soon becomes yellow or yellowish
brown on exposure to air and light, owing to the
loss of ammonia and the liberation of iodine, if no
stabilizing agent is added. Its solutions are neutral
or acid to litmus paper. One Gm. of Ammonium
Iodide dissolves in about 0.6 ml. of water, in
about 3.7 ml. of alcohol, and in about 1.5 ml. of
glycerin, at 25°. One Gm. also dissolves in about
0.5 ml. of boiling water." N.F.

Standards and Tests. — Identification. — A 1
in 20 solution of ammonium iodide responds to
tests for ammonium and for iodide. Loss on dry-
ing.— Not over 5 per cent, when dried at 105° for
2 hours. Residue on ignition. — Not over 0.5 per
cent (strong heating decomposes the salt with
evolution of iodine vapor and volatilization with-
out fusing). Chloride. — In the assay, each Gm. of
ammonium iodide consumes not less than 67.6 ml.
and not more than 69.0 ml. of 0.1 N silver nitrate.
Free iodine. — Not even a transient violet color
appears in chloroform when it is shaken with
5 volumes of 1 in 150 solution of ammonium
iodide. Barium. — No turbidity is produced in 5
minutes on adding a 1 in 10 solution of sodium
sulfate to 5 volumes of a 1 in 20 solution of am-
monium iodide which has been acidulated with
hydrochloric acid. Heavy metals. — The limit is
20 parts per million. N.F.

Assay. — The Volhard method is employed in
assaying ammonium iodide; an excess of 0.1 N
silver nitrate is added to about 500 mg. of am-
monium iodide, previously dried at 105° for 2
hours, the mixture heated until the precipitate
has a yellow color and, after cooling, the residual
silver nitrate is estimated by titration with 0.1 N
ammonium thiocyanate using ferric ammonium
sulfate T.S. as indicator. Each ml. of 0.1 N silver
nitrate represents 14.50 mg. of NH4I. N.F.

Uses. — Ammonium iodide has been used like
potassium iodide (see Potassium Iodide, also

Part I

Amobarbital

Iodine). It was especially recommended in chronic
bronchitis and in asthma, with the thought of
combining the resolvent action of the iodide and
the expectorant effect of ammonium. Pennock
used it in cases of lepra and psoriasis, in the form
of a 4 to 12 per cent ointment. As the iodide is
decomposed by air, the ointment should be kept
in well-stoppered bottles. |v]

Dose, from 200 to 600 mg. (approximately 3 to
10 grains).

Storage. — Preserve "in tight, light-resistant
containers." N.F.

AMMONIUM SALICYLATE. N.F.

[Ammonii Salicylas]

"Ammonium Salicylate, dried over sulfuric
acid for 4 hours, contains not less than 98
per cent of C7H5NH4O3." N.F.

Ammonium Salicylicum. Fr. Salicylate d'ammonium.
Ger. Ammoniumsalicylat; Salicylsaures Ammonium. It.
Salicilato di ammonio. Sp. Salicilato de amonio.

This salt may be made by adding salicylic
acid to ammonia water until the acid is in slight
excess, then evaporating the solution and crystal-
lizing. Contamination with iron gives the product
a pinkish or reddish tinge; overheating results in
the salt having a phenol-like odor.

Description. — "Ammonium Salicylate occurs
as colorless, lustrous prisms, or plates, or as a
white crystalline powder having a faint pink
tinge. It is odorless, and has at first a slightly
salty, bitter taste, with a sweet aftertaste. It is
stable in dry air, but is affected by light. One
Gm. of Ammonium Salicylate dissolves in about
1 ml. of water and in about 3 ml. of alcohol." N.F.

Standards and Tests. — Identification. — Am-
monium salicylate responds to tests for ammonium
and for salicylate. Acidity. — Not more than 0.4
ml. of 0.1 N sodium hydroxide is required to
neutralize 1 Gm. of ammonium salicylate, using
methyl red T.S. as indicator. Residue on ignition.
— Not over 0.05 per cent. Heavy metals. — The
limit is 10 parts per million. N.F.

Assay. — About 500 mg. of ammonium salicyl-
ate, previously dried over sulfuric acid for 4
hours, is titrated with 0.1 iV hydrochloric acid in
the presence of ether. The acid displaces sali-
cylic acid which dissolves in the ether layer; an
equivalent amount of ammonium chloride is
formed in the aqueous phase. Because a small
amount of salicylic acid remains dissolved in the
aqueous phase it is necessary, when the first
end-point is reached, to replace the ether layer
by a fresh portion of ether to extract the salicylic
acid in the aqueous layer; the titration is con-
tinued until the bromophenol blue indicator shows
a permanent pale green color in the aqueous layer.
Each ml. of 0.1 N hydrochloric acid represents
15.52 mg. of C7H5NH4O3. N.F.

Uses. — Ammonium salicylate was at one time
thought to be one of the best forms of adminis-
tering salicylic acid internally but it is seldom
used at present. For discussion of its uses, see
under Acetylsalicylic Acid and Sodium Salicylate.

Dose, from 0.6 to 1.3 Gm. (approximately 10
to 20 grains).

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." N.F.

AMOBARBITAL. U.S.P.

5-Ethyl-5-isoamylbarbituric Acid, [Amobarbitalum]

HN
HN

y~\ws

^/^CHgCHgCHtCH^j

Amylobarbitone, B.P.C. Amytal (Lilly).

Amobarbital may be prepared by the general
procedure for producing barbiturates, namely, by
condensation of the proper substituted malonic
ester with urea; in this instance the ester is
isoamylethylmalonic ester. Condensation is ef-
fected in an autoclave in the presence of sodium
ethylate (see Shonle and Moment, J.A.C.S., 1923,
45, 243; U. S. Patent 1,514,573, November 4,
1924).

Description. — "Amobarbital occurs as a
white crystalline powder. It is odorless and has a
bitter taste. Its solutions are acid to litmus paper.
One Gm. of Amobarbital dissolves in about
1300 ml. of water, in 5 ml. of alcohol, in about
17 ml. of chloroform, and in 6 ml. of ether. It is
soluble in solutions of fixed alkali hydroxides and
carbonates. Amobarbital melts between 156° and
158.5°. U.S.P.

Standards and Tests. — Identification. — (1)
Ammonia is evolved on heating amobarbital with
sodium hydroxide T.S. (2) The />-nitrobenzyl
derivative melts between 151° and 154°. Loss
on drying. — Not over 1 per cent, when dried over
sulfuric acid for 4 hours. Residue on ignition. —
Not over 0.1 per cent. Readily carbonizable sub-
stances.— A solution of 500 mg. of amobarbital
in 5 ml. sulfuric acid has no more color than
matching fluid A. U.S.P.

Uses. — Amobarbital, introduced as Amytal, is
a barbiturate of moderate duration of action. It
has the advantage over barbital and phenobarbi-
tal of being destroyed in the body and since its
elimination does not depend on the kidneys amo-
barbital is preferable to the two other barbitu-
rates for administration to patients with kidney
disease. For a comparison of duration of action
and metabolism of amobarbital see the mono-
graph on Barbiturates, in Part II.

For parenteral administration the water-soluble
sodium derivative, in sterile form, is employed;
the latter may also be given orally and, some-
times, rectally. Amobarbital sodium is the drug
of choice when a longer period of action is de-
sired during the gradual induction of narcosis
in a patient to be interviewed by the technique
of "narcosynthesis" or "narcoanalysis" (see also
under Thiopental Sodium) ; for a review of this
use of amobarbital sodium see Lipton {American
Practitioner, 1950, 1, 148). According to Miller
{Arch. Neurol. Psychiat., 1952, 67, 620) simulta-
neous use of ethyl alcohol improves the incidence
of success in narcoanalysis by decreasing somno-
lence and increasing talkativeness while also
decreasing the dose of amobarbital sodium re-

Amobarbital

Part I

quired; from 120 to 300 mg. of amobarbital
sodium, depending on the weight of the patient,
is dissolved in 20 to 25 ml. of isotonic sodium
chloride solution containing 10 to 15 per cent
of alcohol and the solution administered intrave-
nously over a period of 2 to 4 minutes.

Its moderate vasodepressor effect seems to be
useful for the purpose of diagnosing phenochro-
mocytoma (Anderson et al., Am. Heart J., 1952,
43, 252).

Administered intravenously (230 to 500 mg.),
amobarbital sodium produced a significant de-
pression of oxygen uptake by the brain, a lower-
ing of blood flow, and a mild depression of mean
arterial pressure in the eclamptic patient; this
may be an advantage in the preeclamptic patient
for the prevention of seizures but may add to the
depression produced by convulsions in the ad-
vanced case (McCall and Tavlor, J.A.M.A., 1952,
149, 51).

Combined with amphetamine, amobarbital has
been reported to neutralize extremes of moods,
giving the depressed patient a more normal out-
look and behavior (Grahn, American Practitioner ,
1950, 1, 795).

The usual dose of amobarbital is 100 mg. (ap-
proximately iy2 grains) once or twice daily, by
mouth, with a range of 20 to 300 mg. The maxi-
mum safe dose is usually 500 mg.. and the total
dose during 24 hours should seldom exceed 1 Gm.
When used as a sedative it is given in doses of
20 to 50 mg.; as a hypnotic the dose is 100 to
300 mg.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

AMOBARBITAL ELIXIR. N.F.

[Elixir Amobarbitali]

"Amobarbital Elixir contains, in each 100 ml.,
not less than 417 mg. and not more than 462 mg.
of CiiHi8N203." N.F.

Dissolve 4.4 Gm. of amobarbital, 1 Gm. of sac-
charin sodium, 0.26 ml. of orange oil, 0.15 ml.
of lemon oil, 0.03 ml. of cinnamon oil, 0.006 ml. of
caraway oil, 0.0018 ml. of coriander oil, 0.02 ml.
of anise oil, and 0.02 ml. of sassafras oil in 300
ml. of alcohol. To this solution add 310 ml. of
propylene glycol, 4.4 Gm. of methenamine, 11.25
ml. of caramel, and enough purified water to
make 1000 ml. Mix well, allow the product to
stand 24 hours, and filter until it is clear. N.F.
The purpose of the methenamine is to increase
the solubility of the amobarbital.

Assay. — A 25-ml. portion of elixir is alkalin-
ized with sodium hydroxide T.S. and shaken with
petroleum benzin to remove the flavoring oils;
after washing the petroleum benzin with water
it is discarded. The alkaline solution is acidified
with hydrochloric acid and the amobarbital ex-
tracted with several portions of ether. The
washed ether extraction is evaporated to dryness,
dried at 105°. and weighed. N.F.

Alcohol Content. — From 27 to 33 per cent,
by volume, of C2H5OH. N.F.

The N.F. gives the usual dose as 4 ml. (ap-
proximately 1 fluidrachm), representing 17.6 mg.
(approximately l/i grain) of amobarbital.

Storage. — Preserve "in tight containers."
N.F.

AMOBARBITAL TABLETS. U.S.P.

"Amobarbital Tablets contain not less than 94
per cent and not more than 106 per cent of the
labeled amount of C11H18N2O3." U.S.P.

The tablets are assayed by a modification of
the procedure described under Barbital Tablets.

Usual Sizes.— 8, 15, 30, 50, and 100 mg. (l/s,
lA, y2, Ya and \Vz grains).

AMOBARBITAL SODIUM. U.S.P.

[Amobarbitalum Sodicum]

"Amobarbital Sodium contains not less than
98.5 per cent of CiiHi7N2Na03, calculated on
the dried basis." U.S.P.

Amylobarbitone Sodium, B.P.C. Sodium Isoamylethyl-
barbiturate. Amytal Sodium (Lilly).

The sodium derivative of amobarbital may be
obtained by the interaction of sodium hydroxide
or sodium carbonate with amobarbital.

Description. — "Amobarbital Sodium occurs
as a white, friable, granular powder. It is odorless,
has a bitter taste, and is hygroscopic. Its solutions
are alkaline to litmus and to phenolphthalein.
Amobarbital Sodium is very soluble in water,
soluble in alcohol, but practically insoluble in
ether and in chloroform." U.S.P.

Standards and Tests. — Identification. — (1)
The amobarbital obtained in the assay melts be-
tween 156° and 158.5° and responds to the iden-
tification tests under Amobarbital. (2) The resi-
due from the ignition of amobarbital sodium ef-
fervesces with acids and responds to the tests for
sodium. Loss on drying. — Not over 1 per cent,
when determined by drying at 105° for 4 hours.
Heavy metals. — The limit is 30 parts per million.
Free amobarbital. — Not over 0.5 per cent, the
amobarbital being extracted with benzene and the
residue after evaporation of the benzene dried at
105° for 30 minutes. U.S.P.

Assay. — A solution of 1 Gm. of amobarbital
sodium in 15 ml. of water is acidified with hydro-
chloric acid and the liberated amobarbital is
extracted with chloroform. The chloroform ex-
tract is filtered, evaporated to dryness, and the
residue of amobarbital is dried at 105° for 30
minutes and weighed. The weight of the residue,
multiplied by 1.097, represents CnHuNaNaOs.
U.S.P.

Uses. — Amobarbital sodium, being soluble in
water, is the form in which the barbiturate is
administered parenterally; it may also be given
orally. For parenteral use the sterile powder, sup-
plied in ampuls, is used to make the solution and
this must be prepared immediately before use in
order to avoid hydrolytic decomposition of the
barbiturate. A rectal suppository, containing
200 mg. of amobarbital sodium, is also available.
The uses are discussed under Amobarbital.

Dose. — The usual dose is 100 mg. (approxi-
mately 1^2 grains) once or twice daily by mouth
or per rectum or, in a 5 or 10 per cent solution,
intramuscularly or subcutaneousiy. The range of
dose is 20 to 500 mg. The maximum safe dose

Part I

Amodiaquine Hydrochloride 83

is usually 500 mg. and a total dose of 1 Gm. is
seldom exceeded in a 24-hour period. When used
as a preanesthetic sedative as much as 600 mg.
(approximately 9 grains) may be given. As an
anticonvulsant in tetanus 800 mg. (approximately
12 grains) may be required. In emergencies it is
given intravenously with great caution (not over
1 ml. per minute of a 5 or 10 per cent solution).
Storage. — Preserve "in tight containers."
U.S.P.

AMOBARBITAL SODIUM CAPSULES.
U.S.P.

"Amobarbital Sodium Capsules contain not
less than 90 per cent and not more than 105 per
cent of the labeled amount of CnHi7N2Na03."
c7-SJP-

Usual Sizes.— 60 and 200 mg. (1 and 3
grains).

STERILE AMOBARBITAL SODIUM.
U.S.P.

"Sterile Amobarbital Sodium contains not less
than 98.5 per cent of CuHn^NaOs, calculated
on the dried basis." U.S.P.

This is the sterile powder from which injectable
solutions of amobarbital sodium are prepared by
addition of water for injection.

Usual Sizes.— 65, 125, 250, 500, and 750 mg.,
and 1 Gm.

AMODIAQUINE HYDROCHLORIDE.
LP.

Amodiaquini Hydrochloridum
C20H22ON3Cl.2HCl.2H2O

Amodiaquine Hydrochloride is 7-chloro-4-(3'-
diethylaminomethyl - 4' - hydroxyanilino)quinoline
dihydrochloride clihydrate. It contains not less
than 98.0 per cent and not more than the equiv-
alent of 100.0 per cent of C20H22ON3CI.2HCL-
2H20. LP.

Camoquin Hydrochloride (Parke, Davis). Miaquin.
CAM-AQ1. SN 10,751.

This antimalarial agent is of the 4-aminoquino-
line type (see article on Antimalarial Agents, in
Part II) and hence is related to chloroquine. It
may be prepared from 4,7-dichloroquinoline and
4-acetamido-a-diethylamino-o-cresol; for details
of synthesis see Burckhalter et al. (J.A.C.S., 1948,
70, 1363), also U. S. Patents 2,474,819 and
2,474,821 (1949).

Description. — Amodiaquine Hydrochloride oc-
curs as a yellow, crystalline powder; it is odorless
and has a better taste. It is soluble in about 22
parts of water; soluble in alcohol. It melts be-
tween 154° and 157°, with decomposition. LP.

Standards and Tests. — Identification. — (1)
The amodiaquine base obtained in the assay melts
between 205° and 209°, with decomposition. (2)
Amodiaquine hydrochloride responds to tests for
chlorides. Residue on ignition. — Not over 0.2 per
cent. LP.

Assay. — About 300 mg. of amodiaquine hy-
drochloride is dissolved in water, the solution is
made alkaline with ammonia T.S. and, after the

mixture has been allowed to stand for not less
than 30 minutes, the precipitated amodiaquine
base is collected in a glass filtering crucible, dried
at 110° for 3 hours, and weighed. LP.

Uses. — Amodiaquine hydrochloride is a sup-
pressive antimalarial drug with action similar to
that of chloroquine (see Chloroquine Phosphate) ;
it has the advantages of increased effectiveness in
a single dose and of lesser toxicity. It is rapidly
absorbed from the gastrointestinal tract. A thera-
peutic concentration is attained in the blood
within 1 hour of its ingestion. As with chloroquine,
the highest concentration of the drug is found in
the liver. Erythrocytes contain twice the concen-
tration in blood plasma, which latter is about 190
micrograms per liter on a dose of 300 mg. daily.
It remains in the tissues for at least a week after
a single dose. Less than 5 per cent is excreted in
the urine. In the form of a 5 per cent aqueous
solution it may be given intramuscularly with
only slight induration resulting (Payne et al., Am.
J. Trop. Med., 1949, 29, 353) or intravenously
(Payne et al, ibid., 1951, 31, 698). After slow in-
jection intravenously of 150 or 300 mg. of the
dihydrochloride only a trivial decrease in blood
pressure was observed.

Antimalarial Action. — Amodiaquine is an
effective suppressive drug (Coggeshall, Am. J.
Trop. Med. Hyg., 1952, 1, 124) and it rapidly
controls fever and parasitemia in patients infected
with P. falciparum, P. vivax, or P. malariae
(Chaudhuri, Indian Med. Gaz., 1948, 83, 225;
Singh and Kalyanum, Brit. M. J., 1952, 2, 312;
Hoekenga, J. A.M. A., 1952, 149, 1369; Love et
al, Am. J. Med. Sc, 1953, 225, 26). It does not
affect the gametocytes of P. falciparum or the
tissue stage of P. vivax, but its tendency to re-
main in the body for some time delays the relapse
in P. vivax infestations, particularly in partially
immune persons. Its efficacy in a single dose and
the rarity of toxic manifestations are its chief
advantages. Reports of its value have appeared
from all parts of the world. Doses have varied
widely but 10 mg. per Kg. of body weight, or an
average of 600 mg. for an adult in a single dose,
seems to be adequate. Several studies indicate
that a single dose is more effective than the same
quantity in divided doses over a period of 24 to
120 hours (Chaudhuri and Chakravarty, Indian
J. Malariol, 1948, 2, 115; Patel and Mehta, In-
dian J. Med. Set., 1948, 2, 675; Khan et al,
Indian Med. Gaz., 1951, 86, 293). A dose of 5
or of 7.5 mg. per Kg. was reported to be insuffi-
cient (Simeons and Chhatre, Indian Med. Gaz.,
1947, 82, 255). A single dose of 150 mg. intra-
muscularly, or 150 to 300 mg. (according to the
size of the patient and the severity of the symp-
toms) intravenously controlled the malarial par-
oxysm (Payne et al, loc. cit.).

In experimental amebic hepatitis in hamsters,
Thompson and Reinertson (Am. J. Trop. Med.,
1951, 31, 707) reported that Camoquin and chlo-
roquine by mouth, and emetine intramuscularly,
were equally effective, whereas carbarsone, chlo-
ramphenicol, chlortetracycline, penicillin and di-
hydrostreptomycin showed little effect.

Toxicology. — In therapeutically effective
doses, amodioquine is less toxic than chloroquine

Amodiaquine Hydrochloride

Part I

(Hoekenga, loo. cit.). On a dose of 300 mg. daily,
which is much larger than is needed for therapy
or suppression, weakness, insomnia, nausea, vom-
iting, diarrhea, tenesmus, headache, palpitation,
and fainting have been reported (Berliner et al.,
J. Clin. Invest., 1948, 27, Suppl., 98).

Dose. — The dose is 10 mg. of the base per Kg.
of body weight or 400 to 800 mg. (6 to 12 grains),
according to the size of the patient, in a single
dose by mouth to control the malarial paroxysm
or as a weekly suppressive dose. It will not pre-
vent relapse in P. vivax malaria as it does not act
on the tissue stage of the parasite. The dose for
the infant and child should be calculated on the
basis of 10 mg. per Kg. of body weight. A dose
of 150 to 300 mg. may be given slowly intrave-
nously as a 5 per cent aqueous solution. Camoquin
hydrochloride is supplied in tablets representing
200 mg. of the base; the drug is included in
N.N.R.

Storage. — Preserve in a well-closed container.
LP.

AMPHETAMINE. B.P., LP.

Amphetaminum

C6H5.CH2.CH(NH2).CH3

The B.P. defines Amphetamine as (±)-2-ami-
nopropylbenzene and specifies that it contain not
less than 98.0 per cent of C9H13N. The LP. indi-
cates it to be (±)-2-amino-l-phenylpropane and
requires not less than 97.0 per cent of C9H13N.
Amphetamine was official in U.S.P. XIV.

Racemic Amphetamine. l-Phenyl-2-aminopropane. d,l-
Alphamethylphenethylamine. Racemic Desoxynorephedrine.
Isomyn. Benzedrine (Smith, Kline & French Labs.).

Amphetamine may be synthesized in several
ways. One method starts with phenylacetic acid,
CeHsCHsCOOH, which is heated with acetic an-
hydride and sodium acetate to form methyl benzyl
ketone (phenylacetone), C6H5CH2.CO.CH3; this
is heated with formamide, HCONH2, yielding the
formyl derivative of the ketone, CoHsCtb.CH-
(NHCHO).CH3, which on hydrolysis with acid
and subsequent alkalinization yields the mixture
of racemic bases known as amphetamine. Alter-
natively the methyl benzyl ketone may be con-
verted to the oxime, which on reduction yields
amphetamine.

Description. — Amphetamine is a colorless,
mobile liquid, having a slight and characteristic
odor, an acrid taste, and volatilizing slowly at
ordinary temperatures. It is slightly soluble in
water; freely soluble in alcohol, in ether, and in
chloroform; soluble in fixed oils and in volatile
oils; readily soluble in acids. An aqueous solution
of amphetamine is alkaline to litmus. The weight
per ml. of amphetamine, at 20°, is between 0.930
and 0.935 Gm. B.P., LP. Amphetamine readily
absorbs carbon dioxide from the air.

Standards and Tests. — Identification. — (1)
Amphetamine distils at about 200° with decompo-
sition. (2) The benzoyl derivative of ampheta-
mine, twice recrystallized from 50 per cent
alcohol, melts at about 135°. Water. — No turbid-
ity is produced on dissolving 1 ml. of ampheta-
mine in 10 ml. of anhydrous liquid paraffin.

Non-volatile matter. — Not over 2.5 mg. of residue
remains when 500 mg. of amphetamine is heated
on a water bath for 1 hour and dried to constant
weight at 105°. Residue on ignition. — Not over
0.1 per cent. B.P., LP.

Assay. — The B.P. directs that 250 mg. of
amphetamine be dissolved in 25 ml. of 0.1 N
hydrochloric acid and the excess of acid titrated
with 0.1 N sodium hydroxide, using methyl red
as indicator. Each ml. of 0.1 N acid is equiva-
lent to 13.52 mg. of C9H13N. The LP. directs
solution of about 250 mg. of amphetamine in
10 ml. of alcohol and direct titration with 0.1 N
hydrochloric acid, using methyl red as indicator.

Uses. — Amphetamine and its salts belong to
the general class of sympathomimetic agents (see
monograph on this subject in Part II). A distinc-
tion is made between the racemic preparation,
which is referred to simply as amphetamine, and
the dextrorotatory isomer, called d-amphetamine
or dextro-amphetamine (Dexedrine, Smith, Kline
& French). The actions of amphetamine are
similar to those of ephedrine and methampheta-
mine.

Amphetamine and its carbonate, being volatile,
were formerly used in inhalers to permit appli-
cation of the vapor to nasal mucosa, thereby
effecting shrinkage of swollen and congested
nasal structures in head colds, sinusitis, vaso-
motor rhinitis, and hay fever. One or two inhala-
tions through each nostril, at hourly intervals,
was recommended. Simpson and Simon (Am. J.
Pharm., 1937, 109, 343) found that ordinarily
the patient would inhale into the lungs approxi-
mately 0.05 mg. per inhalation, which seemed un-
likely to render any constitutional effect. Swine-
ford (/. Allergy, 1938, 9, 572) found, however,
that it was possible by very deep inhalations to
carry sufficient amphetamine into the bronchi to
cause blanching of the mucosa. Although unto-
ward effects were infrequent with proper use, the
convenience and simplicity of the inhaler facili-
tated excessive dosage with resultant undesirable
symptoms, especially in susceptible individuals.
Such overdosage paralyzed ciliary action of the
respiratory mucous membranes, caused abnormal
dryness, and actually aggravated rather than cor-
rected swelling and congestion, with the possi-
bility of development of atrophic rhinitis (Kully,
J.A.M.A., 1945, 127, 307). Restlessness and in-
somnia were the most frequent untoward effects.
Inhalations were contraindicated in patients with
cardiovascular disease or marked sensitivity to the
drug. Inhalers containing amphetamine were
withdrawn from the market in the United States
because of their misuse to produce a "Benzedrine
jag" by soaking the medicated fabric inside the
inhaler with water or beverage and drinking the
solution. Propylhexedrine (Benzedrex) replaced
the amphetamine (Benzedrine) in these inhalers.
Oil solutions of amphetamine are sometimes used
for topical application.

Amphetamine sulfate is administered orally in
the treatment of narcolepsy, postencephalitic
parkinsonism, mental depression, alcoholism,
obesity and spastic conditions of the gastrointes-
tinal tract. Its pharmacology was reviewed by
Ivy and Krasno (War Med., 1941, 1, 15).

Part I

Amphetamine 85

Cardiorespiratory Action. — In sufficient dose,
amphetamine causes a marked rise in the blood
pressure which comes on rather slowly and lasts
for a prolonged time. Beyer (/. Pharmacol., 1939,
66, 318) found that 33 mg. of the drug caused,
in humans, an average rise in the blood pressure
of about 25 mm. of mercury which lasted for
more than seven hours. According to Tainter et al.
(J. Pharmacol., 1936, 57, 152; 1938, 64, 190;
1939, 66, 146), it does not dilate the bronchi but
it has a depressant effect on the muscles of the
gastrointestinal tract. Beyer showed that in man
it causes a distinct rise in the metabolic rate
which lasts for more than nine hours. In many
persons it causes a loss of appetite, perhaps from
the delayed emptying of the stomach (Beyer and
Meek, Ann. Int. Med., 1939, 63, 752). The most
valuable property of this drug is its stimulating
effect on cerebral, respiratory and vasomotor
activity which exceeds that of any other drug of
the sympathomimetic group (Warren and Werner,
/. Pharmacol., 1945, 85, 119). Handley and
Ensberg (Anesth., 1945, 6, 561) found it to be
the most effective and the most rapidly acting
stimulant to antagonize respiratory depression due
to morphine; the other drugs studied were nik-
ethamide, ephedrine, pentylenetetrazol, and caf-
feine.

Central Nervous System Effects. — The
effects of amphetamine and its salts on the cere-
brum have led to its widespread use in the treat-
ment of conditions of mental depression, exhaus-
tion and even aberrations. Grant (Air Force, 1944,
March) described the use of amphetamine to
avoid sleepiness in aviators and this use of the
drug by ground troops was discussed in Circular
Letter No. 58, issued by the United States War
Department, February 23, 1943. For mental weari-
ness, 5 mg. every 3 hours was advised; for physi-
cal fatigue, 10 mg. every 6 hours. The total dose
should not exceed 30 mg. per week and adequate
rest must be obtained at the end of each period
of overexertion. It is valuable in the treatment
not only of acute alcoholism but also of the alco-
holic psychoses (Reifenstein and Davidoff,
J. A.M. A., 1938, 10, 1811; Miller, ibid., 1942,
120, 271). The effect of amphetamine on higher
nervous activity in the human has been compared
with that of alcohol by Finkelstein et al. {Bull.
Johns Hopkins Hosp., 1945, 76, 61). Ampheta-
mine improved the response to conditioned and
unconditioned stimuli, whereas alcohol decreased
the response. Amphetamine has been employed
with more or less temporary benefit in the treat-
ment of various depressive insanities and is often
of service in narcolepsy (Prinzmetal et al.,
J.A.M.A., 1935, 105, 25) and catalepsy. Combined
with amobarbital it is claimed to moderate ex-
tremes of mood and to give the depressed patient
a more normal outlook and behavior (Grahn,
American Practitioner, 1950, 1, 795). In post-
encephalitic parkinsonism it causes not only im-
provement in the mental attitude but also lessens
rigidity and tremor. It is most effective in combi-
nation with stramonium or scopolamine (Mat-
thews, Am. J. Med. Sc, 1938, 195, 448). Myerson
and Loman (Arch. Neurol. Psychiat., 1942, 48,

823) reported successful treatment of spasmodic
torticollis with amphetamine sulfate.

Amphetamine sulfate has been used effectively
in the treatment of barbiturate poisoning (Myer-
son et al., New Eng. J. Med., 1939, 221, 1015;
Kornblau, Anesth. & Analg., 1948, 27, 116;
Nabarro, Brit. M. J., 1950, 2, 924; Dick, Am. J.
Med. Sc, 1952, 224, 281); in the depression
associated with the withdrawal of morphine from
addicts (Duckworth, Brit. M. J., 1940, 2, 628);
for the exhaustion and lassitude of roentgen ill-
ness (Jenkinson and Brown, Am. J. Roentgen.,
1944, 51, 496); in hypotension (Peoples and
Guttmann, Lancet, 1936, 1, 1107); in various
combinations, as with phenobarbital, in the treat-
ment of petit mal epilepsy (Livingston and Kajidi,
J.A.M.A., 1945, 129, 1071); with belladonna and
a barbiturate in seasickness (Hill, Brit. M. J.,
1937, 2, 1109). Burrill et al. (J. Dent. Research,
1944, 23, 337) found that amphetamine sulfate
increased the analgesic effect of acetophenetidin.
Hindes (Ind. Med., 1946, 15, 262) reported bene-
fit in 96 per cent of dysmenorrhea cases.

Antispasmodic Uses. — Amphetamine sulfate
has also been used to lessen spasm of the alimen-
tary tract, gall bladder or ureters to facilitate
roentgenography of the intestinal tract. Rosen-
berg et al. (J. A.M. A., 1938, 110, 1944) found
that spastic colon was not relieved. Indeed, its
use as an intestinal antispasmodic agent is quite
limited, being overshadowed by its effects on the
cardiovascular and the central nervous system.

Use in Obesity. — Amphetamine sulfate is
employed for the reduction of body weight (Al-
brecht, Ann. Int. Med., 1944, 21, 983; Pelner,
ibid., 1945, 22, 201), its effect being due probably
to a combination of increased metabolism and
decreased appetite (see Harris et al., J. A.M. A.,
1947, 134, 1468; Goetzl and Stone, Gastro-
enterology, 1948, 10, 1948; Roberts, Ann. Int.
Med., 1951, 34, 1324; Freed and Mizel, ibid.,
1952, 36, 1492).

Toxicology. — The widespread use of ampheta-
mine sulfate to counteract depression, the result
of fatigue or alcoholism, is greatly to be depre-
cated for three reasons: (1) the tendency toward
habit formation, (2) the almost certain rise in
blood pressure, and (3) the fact that under some
circumstances not understood it may produce
dangerous circulatory collapse. Smith (J. A.M. A.,
1939, 113, 1022) reported a case of collapse
terminating fatally. Apfelberg (ibid., 1938, 110,
575), Hertzog and Karlstrom (ibid., 1943, 121,
256), and Gericke (ibid., 1945, 128, 1098) also
reported cases of poisoning. However, the inci-
dence of untoward effects has been surprisingly
low and the symptoms of headache, restlessness,
insomnia, irritability, palpitation and disturbance
in bowel habit have usually been mild and have
disappeared rapidly on discontinuance of the drug
(Pelner, N. Y. State J. Med., 1944, 44, 2596).
Daily doses as large as 30 to 50 mg. have been
long continued without ill effects (Myerson, Am.
J. Med. Sc, 1940, 199, 729) and Bakst (U. S.
Nav. M. Bull., 1944, 43, 1228) reported absence
of untoward effects or withdrawal manifestations
after daily use during nine years. Shorvon (Brit.
M. /., 1945, 2, 285) discussed the problem of

86 Amphetamine

Part I

addiction in psychopathic patients; withdrawal of
the drug from a patient accustomed to consuming
daily for many months twenty-five to thirty 5 mg.
tablets indicated mental but not physical depend-
ence. Clinical experience has been that certain
types of psychopaths can well tolerate and benefit
from large doses of amphetamine. In general,
untoward effects have been due to overdosage or
improper dosage. El

Dose. — Amphetamine base is used only by
inhalation (see above) ; its salts are used orally or
parenterally. The usual dose of amphetamine sul-
fate is 10 mg. (approximately % grain) twice a day
by mouth, with a range of 2.5 to 10 mg. The
maximum safe dose is usually 20 mg. and the
maximum dose in 24 hours should seldom exceed
100 mg. Because of variation in individual sus-
ceptibility, treatment with amphetamine sulfate
should be started with a test dose of 2.5 to 5 mg.
(approximately }4s to V12 grain). To avoid in-
somnia, the drug is best given during the morn-
ing and preferably not later than midafternoon.
The average doses for its common uses are as fol-
lows: depressive states, 5 to 10 mg. twice daily;
alcoholism, 5 to 15 mg. twice daily; postencepha-
litic parkinsonism, 10 to 20 mg. twice daily;
narcolepsy, 10 to 40 mg. two or three times daily
as required; obesity, 2.5 to 5 mg. twice daily
about one-half hour before meals. In barbiturate
poisoning, the initial dose is 20 to 50 mg. intra-
venously in a 2 per cent solution; subsequently
50 to 100 mg. may be given intramuscularly, every
hour if necessary, to counteract the hypnosis and
depression of the central nervous system.

AMPHETAMINE PHOSPHATE. N.F.

Racemic Amphetamine Phosphate, rf/-Monobasic
Amphetamine Phosphate, d/-Amphetaminium Phosphate

C9H13N.H3PO4

"Amphetamine Phosphate, dried at 105° for 2
hours, contains not less than 98 per cent of
C9H13N.H3PO4." N.F.

Profetamine Phosphate (Clark & Clark) ; Raphetamine
Phosphate (Strasenburgh) .

This salt differs from amphetamine sulfate in
being a salt of phosphoric acid in which one of
the three hydrogen atoms of the latter is neu-
tralized by amphetamine base.

Description. — "Amphetamine Phosphate oc-
curs as a white, odorless, crystalline powder. It
has a bitter taste. Amphetamine Phosphate i»
freely soluble in water, and slightly soluble in alco-
hol. It is practically insoluble in benzene, in chloro-
form, and in ether. The pH of a solution of
Amphetamine Phosphate (1 in 20) is between
4 and 5." N.F.

The standards, tests and assay are identical
with those for amphetamine sulfate, except for
the difference in the identification of the cation;
also, the residue on ignition of amphetamine phos-
phate is 0.1 per cent.

Uses. — Amphetamine phosphate is used for
the same purposes as amphetamine sulfate. Be-
cause of the lower content of amphetamine base
in the phosphate, as compared with the sulfate, it
may be calculated that 12.6 mg. of the phosphate
is equivalent to 10 mg. of the sulfate, so that

doses of amphetamine phosphate would have to
be approximately 25 per cent greater than those
of amphetamine sulfate for equivalent effect. For
most purposes, however, amphetamine phosphate
is actually used in the same dose as amphetamine
sulfate. As an analeptic amphetamine phosphate
is administered intravenously or intramuscularly
in doses of 20 to 50 mg. every 30 to 60 minutes
until consciousness is restored; the solution em-
ployed commonly contains 10 mg. per ml. and is
preserved with 0.5 per cent chlorobutanol. The
N.F. gives the usual dose as 5 mg.

Storage. — Preserve "in well-closed contain-
ers." N.F.

AMPHETAMINE PHOSPHATE
INJECTION. N.F.

"Amphetamine Phosphate Injection is a sterile
solution of amphetamine phosphate in water for
injection. It contains not less than 95 per cent
and not more than 105 per cent of the labeled
amount of C9H13N.H3PO4." N.F.

Storage. — Preserve "in single-dose or mul-
tiple-dose containers, preferably of Type I glass."
N.F.

Usual Size. — 100 mg. in 10 ml.

AMPHETAMINE PHOSPHATE
TABLETS. N.F.

"Amphetamine Phosphate Tablets contain not
less than 90 per cent and not more than 110 per
cent of the labeled amount of C9H13N.H3PO4."
N.F.

Usual Size. — 5 mg. (approximately Vn grain).

DIBASIC AMPHETAMINE
PHOSPHATE. N.F.

Racemic Dibasic Amphetamine Phosphate, rf/Dibasic

Amphetamine Phosphate, ^'/-Dibasic Amphetaminium

Phosphate

(C9Hi3N)2.H3P04

"Dibasic Amphetamine Phosphate, dried at
105° for 2 hours, contains not less than 98 per
cent of (C9H13N)2.H3P04." N.F.

This salt differs from amphetamine phosphate
in that two of the hydrogen atoms of phosphoric
acid are neutralized by amphetamine base.

Description. — "Dibasic Amphetamine Phos-
phate occurs as a white, odorless, crystalline pow-
der. It has a slightly bitter taste. One Gm. of
Dibasic Amphetamine Phosphate dissolves in
about 20 ml. of water, and in about 650 ml. of
alcohol. It is insoluble in ether. The pH of a solu-
tion of Dibasic Amphetamine Phosphate (1 in
20) is between 7 and 8.5." N.F.

Uses. — This salt differs from amphetamine
phosphate in containing approximately 25 per
cent more of amphetamine base and thus it is
equivalent to amphetamine sulfate when equal
weights of the two are compared. Dibasic am-
phetamine phosphate is neutral in aqueous solu-
tion, while the monobasic phosphate is acid; this
difference, however, is of no significance in the
use of the two salts. The dose of dibasic ampheta-
mine phosphate is exactly the same as that of
amphetamine sulfate. The N.F. gives the usual
dose as 5 mg.

Part I

Amphetamine Sulfate 87

Storage. — Preserve "in well-closed containers."
N.F.

DIBASIC AMPHETAMINE
PHOSPHATE TABLETS. N.F.

"Dibasic Amphetamine Phosphate Tablets con-
tain not less than 90 per cent and not more
than 110 per cent of the labeled amount of
(C9Hi3N)2.H3P04." N.F.

Usual Size. — 5 mg. (approximately Yi2 grain).

DEXTRO-AMPHETAMINE
PHOSPHATE. N.F.

Monobasic Dextro-amphetamine Phosphate, Dextro-
amphetaminium Phosphate

C9H13N.H3PO4

"Dextro-amphetamine Phosphate, dried at 105°
for 2 hours, contains not less than 98.5 per cent of
C9H13N.H3PO4." N.F.

This salt has the same relationship to ampheta-
mine phosphate as dextro-amphetamine sulfate
has to amphetamine sulfate.

Description. — "Dextro-amphetamine Phos-
phate occurs as a white, odorless, crystalline pow-
der. It has a bitter taste. One Gm. of Dextro-
amphetamine Phosphate dissolves in 20 ml. of
water. It is slightly soluble in alcohol and is prac-
tically insoluble in benzene, in chloroform, and in
ether. The pH of a solution of Dextro-ampheta-
mine Phosphate (1 in 10) is between 4 and 5."
N.F.

Uses. — Dextro-amphetamine phosphate has the
same actions and uses as amphetamine sulfate
but, as with the dextro form of amphetamine
sulfate, the dextro isomer of amphetamine phos-
phate is about twice as active in its central stimu-
lant effects as the racemic form of amphetamine
phosphate. Accordingly the usual dose of the dex-
tro isomer should be about half that of racemic
monobasic amphetamine phosphate; however, the
N.F. gives the usual dose as 5 mg.

Storage. — Preserve "in well-closed containers."
N.F.

DEXTRO-AMPHETAMINE
PHOSPHATE TABLETS. N.F.

"Dextro-amphetamine Phosphate Tablets con-
tain not less than 90 per cent and not more
than 110 per cent of the labeled amount of
C9H13N.H3PO4." N.F.

Usual Size. — 5 mg.

DIBASIC DEXTRO-AMPHETAMINE
PHOSPHATE. N.F.

Dibasic Dextro-amphetaminium Phosphate

(C9Hi3N)2.H3P04

"Dibasic Dextro-amphetamine Phosphate, dried
at 105° for 2 hours, contains not less than 98 per
cent of (C9Hi3N)2.H3P04." N.F.

This salt corresponds to the dextro isomer of
amphetamine sulfate in containing, by a coinci-
dence of molecular weights, the same proportion
of amphetamine. It differs from dextro-ampheta-
mine phosphate in that two of the hydrogen
atoms of phosphoric acid are neutralized by am-

phetamine, thereby making the salt less acid than
dextro-amphetamine phosphate.

Description. — "Dibasic Dextro-amphetamine
Phosphate occurs as a white, odorless, crystalline
powder. It has a slightly bitter taste. One Gm. of
Dibasic Dextro-amphetamine Phosphate dissolves
in about 20 ml. of water, and in about 650 ml. of
alcohol. It is insoluble in ether. The pH of a solu-
tion of Dibasic Dextro-amphetamine Phosphate
(1 in 20) is between 6.0 and 7.5." N.F.

Uses. — The uses of this dextro isomer are
qualitatively the same as amphetamine sulfate;
the dose is theoretically and actually the same as
for dextro-amphetamine sulfate, since both dextro
salts contain the same proportion of active base.
The N.F. gives the usual dose as 5 mg.

Storage. — Preserve "in well-closed containers."
N.F.

DIBASIC DEXTRO-AMPHETAMINE
PHOSPHATE TABLETS. N.F.

"Dibasic Dextro-amphetamine Phosphate Tab-
lets contain not less than 90 per cent and not
more than 110 per cent of the labeled amount of
(C9Hi3N)2.H3P04." N.F.

Usual Size. — 5 mg.

AMPHETAMINE SULFATE.
U.S.P., B.P., LP.

Amphetaminium Sulfate, d/-l-Phenyl-2-aminopropane
Sulfate, [Amphetaminae Sulfas]

ch,chch, so;

NH3

"Amphetamine Sulfate, dried at 105° for 2
hours, contains not less than 98 per cent and not
more than 100.5 per cent of (C9Hi3N)2.H.2S04."
U.S. P. The B.P. defines Amphetamine Sulphate as
(±)-2-aminopropylbenzene sulfate, and requires
not less than 99.0 per cent of (CgHi3N)2.H2S04,
calculated with reference to the substance dried
to constant weight at 105°. The LP. defines it as
(±)-2-amino-l-phenylpropane sulfate, and re-
quires not less than 98.0 per cent of (CgHi3N)2.-
H2SO4, the substance not being dried prior to
assay.

B.P. Amphetamine Sulphate. LP. Amphetamini Sulfas.
Racemic Amphetamine Sulfate. d/-a-Methylphenethylamine
Sulfate. Benzedrine Sulfate (Smith, Kline & French Labs.).

The B.P. states that this salt may be prepared
by neutralizing an alcoholic solution of ampheta-
mine base with sulfuric acid.

Description. — "Amphetamine Sulfate occurs
as a white, odorless, crystalline powder. It has a
slightly bitter taste. Its solutions are acid to
litmus, having a pH of 5 to 6. One Gm. of
Amphetamine Sulfate dissolves in about 9 ml. of
water, and in about 500 ml. of alcohol. It is in-
soluble in ether." U.S.P.

Standards and Tests. — Identification. — (1)
The benzoyl derivative of amphetamine melts be-
tween 131° and 135°. (2) A solution of ampheta-
mine sulfate responds to tests for sulfate. Water.
— Not over 1 per cent when dried at 105° for
2 hours. Residue on ignition. — Not over 0.2 per

88 Amphetamine Sulfate

Part I

cent. Dextroamphetamine. — A 1 in SO solution
of amphetamine sulfate is optically inactive.
U.S.P.

Assay. — A sample of 300 mg. of dried am-
phetamine sulfate is dissolved in water, made
alkaline with sodium hydroxide, and the ampheta-
mine base extracted with ether. The ether is
evaporated to a volume of about 10 ml., 20 ml.
of 0.1 N sulfuric acid is added and. after evapo-
ration of the remainder of the ether, the excess
of acid is titrated with 0.1 A* sodium hydroxide,
using methyl red T.S. as indicator. Each ml. of
0.1 A7 sulfuric acid represents 18.43 mg. of
(C9Hi3N)2.H2S04. U.S.P.

For uses and dose of amphetamine sulfate see
under Amphetamine, [v]

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

AMPHETAMINE SULFATE
TABLETS. U.S.P. (LP.)

"Amphetamine Sulfate Tablets contain not less
ihan 90 per cent and not more than 110 per cent
of the labeled amount of (C9Hi3N)2.H2S04."
U.S.P. The corresponding LP. limits are 92.0 to
108.0 per cent.

LP. Tablets of Amphetamine Sulfate; Compressi Am-
pbetamini Sulfatis.

Usual Sizes. — 5 and 10 mg.

DEXTRO AMPHETAMINE
SULFATE. U.S.P.

d-Amphetaminium Sulfate, d-l-Phenyl-2-amino-
propane Sulfate

"Dextro Amphetamine Sulfate, the dextrorota-
tory isomer of amphetamine sulfate, dried at 105°
for 2 hours, contains not less than 98 per cent and
not more than 100.5 per cent of (C9Hi3N)2.-
H2SO4." U.S.P.

Dexedrine Sulfate (.Smith, Kline & French Labs.).

Dextro amphetamine sulfate is obtained by
resolution of the racemic variety, which is official
as Amphetamine Sulfate.

Description. — "Dextro Amphetamine Sulfate
occurs as a white, odorless, crystalline powder.
Its 1 in 20 solution is acid to litmus, having a pH
of 5 to 6.3. One Gm. of Dextro Amphetamine
Sulfate dissolves in about 10 ml. of water and in
about 800 ml. of alcohol. It is insoluble in ether."
U.S.P.

Standards and Tests. — Identification. — (1)
The benzoyl derivative melts between 155° and
158°. (2) A 1 in 10 solution of dextro amphet-
amine sulfate responds to tests for sulfate. Spe-
cific rotation. — Not less than +20° and not more
than +23. 5°, when determined in a solution con-
taining 400 mg. of dried dextro amphetamine sul-
fate in each 10 ml. Loss on drying. — Not over
1 per cent, when dried at 105° for 2 hours. Resi-
due on ignition. — Not over 0.1 per cent. U.S.P.

Assay. — The assay is performed as described
under Amphetamine Sulfate. U.S.P.

Uses. — The dextrorotatory form of amphet-
amine was observed bv Prinzmetal and Alles
(Proc. S. Exp. Bio. Med., 1939, 42, 206) to have
a substantially greater central nervous stimulating

effect than the racemic form; also, the levorota-
tory form was found to be relatively devoid of
this euphoriant action. Otherwise the actions of
the optically active and racemic forms of the
compound are pharmacodynamically similar. The
general clinical pharmacology of amphetamine
has been discussed in the monograph on Amphet-
amine; for further information see Reifenstein
and Davidoff (N. Y. State J. Med., 1939, 39, 42).
Confirming the initial observations of Prinzmetal
and Alles, Davidoff (Med. Rec, 1943, 156, 422)
reported racemic amphetamine to be distinctly
weaker in its stimulation of motor and intellectual
function than either d-amphetamine or desoxy-
ephedrine (methamphetamine). Similarly, Novelli
and Tainter (/. Pharmacol., 1943, 77, 325) re-
ported that dextro amphetamine was at least twice
as active as the racemic form in its effects on the
motor activity of rats. This effect on the sensorium
and motor phenomena is attributable to an inher-
ent activity of the compound which is unique,
for usually the levo-form of biologically active
agents having one asymmetric carbon atom is
more active than the dextro form.

Beyer and Skinner (ibid., 1940, 68, 419) stud-
ied the detoxication and excretion of racemic
amphetamine and its optically active forms in
man. They found essentially no difference in the
absorption and excretion of the three forms, al-
though the greater effect of the dextro form on
the sensorium was quite evident. Thus, up to 64
per cent of either active form of amphetamine
was excreted during a period of 24 hours.

As a generalization, dextro amphetamine tends
to be used in place of the racemic form in those
conditions where stimulation of the sensorium is
indicated, as in certain depressive states, in post-
encephalitic parkinsonism, and in narcolepsy. In
a study of comparative therapeutic effects of the
two forms on humans, Freed (West. J. Surg.
Obst. Gyn., 1949, 57, 67) found the racemic salt
to be equal, in appetite-curbing effect, to the
dextro salt when the latter is used in half the
dose of the former. He received the clinical im-
pression that the individual who requires large
doses of most drugs for a therapeutic effect re-
sponds more satisfactorily to racemic amphet-
amine sulfate than to the dextro isomer; the high-
strung, hypersensitive individual who is prone to
drug intolerance and who responds to small doses
of drugs in general seems to prefer the dextro
isomer. In anhedonic individuals the levo form
of amphetamine, which is present in the racemic
drug, produces through its stronger adrenergic
action a satiation to food at lower dosage levels;
the hypersensitive individual, on the other hand,
does not tolerate too well the adrenergic effect of
the levo isomer and therefore prefers dextro
amphetamine sulfate.

Toxicology. — The undesirable effects of the
drug following overdosage are excessive excite-
ment, loquaciousness, headache and insomnia, as
observed also with racemic amphetamine. Since
the drug is slowly excreted and metabolized these
effects may persist for 24 to 48 hours when the
dose is excessive. According to Freed (loc. cit.)
there is considerably less incidence of side reac-
tions with dextro amphetamine sulfate than with

Part I

Amyl Nitrite 89

the racemic salt. Since the peripheral vascular
action of the dextro and racemic salts is believed
to be quantitatively the same, it is apparent that
the lower dosage required in the case of the dextro
compound is less likely to elicit peripheral vascu-
lar complications. Dextro amphetamine sulfate is
usually not indicated in cases of severe hyper-
tension, angina pectoris, hyperthyroidism, and
Raynaud's disease.

Dose. — The usual adult dose of dextro amphet-
amine sulfate in simple depressed states, obesity,
alcoholism, hyperemesis gravidarum, or drowsi-
ness is 5 mg. twice a day, with a range of dose
of 2.5 to 5 mg. The last dose should precede the
anticipated bedtime by at least 4 hours; other-
wise, the stimulating effect of the drug will inter-
fere with sleep, in which case it may be necessary
to counteract the effect with barbiturate hypnotics.
The dose for control of narcolepsy or the depres-
sion of parkinsonism may be 25 mg. a day or
more, symptomatically. The maximum safe dose
in 24 hours seldom exceeds 50 mg. Dexedrine
Sulfate Spanstdes contain 15 mg. of the dextro
salt in the form of tiny pellets, of which there
are over a hundred in each capsule, having vary-
ing disintegration times so as to release the drug
uniformly over a period of 8 to 10 hours; for use
in weight reduction one such capsule, taken in
the morning, curbs appetite throughout the day.

Storage. — Preserve "in well-closed containers."
U.S.P.

DEXTRO AMPHETAMINE SULFATE
TABLETS. U.S.P.

"Dextro Amphetamine Sulfate Tablets contain
not less than 90 per cent and not more than 110
per cent of the labeled amount of (C,9Hi3N)2.H2-
S04." U.S.P.

Usual Sizes. — 5 and 10 mg.

AMYL NITRITE. U.S.P., B.P., LP.

Isoamyl Nitrite, [Amylis Nitris]

CH3.CH(CH3) .CH2.CH2.ONO

"Amyl Nitrite contains not less than 90 per
cent of C5H11NO2. Caution. — Amyl Nitrite is
very flammable. Do not use where it may be
ignited." U.S.P.

The B.P. states that Amyl Nitrite consists
chiefly of the nitrites of 3-methylbutanol, (013)2-
CH.CH2.CH2.OH, and 2-methylbutanol, (C2H5)
(CH3)CH.CH2.0H; it is required to contain not
less than 90.0 per cent w/w of nitrites, calculated
as CsHuCteN. The LP. indicates it to be a mix-
ture of the nitrite of 3-methylbutanol- 1 with a
small quantity of the nitrite of 2-methylbutanol-l
and other nitrites of the homologous series; the
purity rubric is the same as that of the U.S.P.
and B.P.

Araylium Nitrosum; Nitris Amylicus. Ft. Azotite d'amyle.
Ger. Amylnitrit; Salpetrigsaureamylester. It. Nitrito
d'amile; Nitrito d'isoamile. Sp. Nitrito de amilo; Ester
isoamilnitroso.

This substance, discovered by Balard in 1844,
is the product of esterifi cation of amyl alcohol
and nitrous acid. A convenient method for pre-
paring the ester by the interaction of amyl alcohol,

sulfuric acid and sodium nitrite is described by
Noyes (J.A.C.S., 1933, 55, 3888). Other methods
of preparation are described in the U.S.D., 20th
ed., p. 140.

The amyl alcohol used in the preparation of
amyl nitrite is frequently a mixture of isomeric
alcohols; as a result, the product may likewise
be a mixture of two or more isomers. Usually,
it consists chiefly of isoamyl nitrite,

CH3.CH ( CH3) .CH2.CH2.ONO

with smaller proportions of optically active, sec-
ondary and amyl nitrite, CH3.CH2.CH(CH3).-
CH2.ONO. Read et al. {Chinese J. Physiol, 1933,
7, 253) made comparative physiological studies
of the effects of the various isomeric amyl nitrites;
they found that all act qualitatively alike but be-
lieve that the tertiary amyl nitrite is the most
valuable from the standpoint of practical thera-
peutics.

Description. — "Amyl Nitrite is a clear, yel-
lowish liquid, having a peculiar, ethereal, fruity
odor. It is volatile even at low temperatures and
is flammable. Amyl Nitrite is almost insoluble in
water, but is miscible with alcohol and with ether.
The specific gravity of Amyl Nitrite is not less
than 0.865 and not more than 0.875." U.S.P.

Standards and Tests. — Identification. — (1)
Amyl valerate, recognizable by its odor, is pro-
duced when a mixture of 2 ml. of sulfuric acid, 2
drops of amyl nitrite and 2 drops of water is di-
luted with water. (2) A greenish brown color is
produced on adding a few drop of amyl nitrite to
a mixture of 1 ml. of ferrous sulfate T.S. and 5
ml. of diluted hydrochloric acid. Acidity. — The
red tint of a mixture of 1 ml. of normal sodium
hydroxide, 10 ml. of water and 1 drop of phenol-
phthalein T.S. is not discharged by 5 ml. of amyl
nitrite when the glass-stoppered cylinder used as
a container is inverted three times. Aldehyde. —
No brown or black color is developed on mixing,
successively, 1.5 ml. of silver nitrate T.S., 1.5 ml.
of aldehyde-free alcohol, enough ammonia T.S. to
redissolve the precipitate which forms, and 1 ml.
of amyl nitrite, the mixture being heated gently
for 1 minute. U.S.P.

The B.P. specifies that not less than 85 per cent
shall distil between 90° and 100°. The residue on
evaporation is not more than 0.01 per cent w/v.
A test for aldehyde, based on the color produced
with sodium hydroxide, is also given.

Assay. — A 3-ml. sample of amyl nitrite is
weighed in alcohol and the solution diluted to 100
ml. A 10-ml. portion of this solution is assayed
gasometrically, by the method described under
Ethyl Nitrite Spirit. U.S.P.

The B.P. assay is practically the same as that
of the U.S.P. The LP. assay is based on the re-
duction of potassium chlorate by the nitrite to
potassium chloride, the amount of the latter being
determined by precipitation with a measured ex-
cess of 0.1 A7 silver nitrate, followed by titration
of the excess silver nitrate with 0.1 N ammonium
thiocyanate, with the silver chloride being re-
moved by filtration. Since three molecules of amyl
nitrite are required to reduce one molecule of
potassium chlorate to chloride, the equivalent
weight of amyl nitrite is three times its molecular

90 Amyl Nitrite

Part I

weight. Each ml. of 0.1 N silver nitrate repre-
sents 35.1 mg. of C5H11O2N. LP.

Uses. — Physiologically, amyl nitrite acts like
sodium nitrite (g. v.), except that it is much
quicker and more evanescent, its effect appearing
in about 30 seconds and lasting for only about 3
minutes. Amyl nitrite is used in medicine for
three purposes: To relax spasms in the arteries,
to control convulsions, and for the relief of the
asthmatic paroxysm. It is of service only where
an immediate, transient effect is desired.

Cardiac. — In angina pectoris it improves cir-
culation in the coronary arteries, even though a
drop in blood pressure occurs. Since the duration
of angina attacks is less than 3 minutes in the
majority of cases (Riseman and Brown, New
Eng. J. Med., 1937, 217, 470) only the rapidly
acting substances, amyl nitrite or nitroglycerin,
are effective. The pain due to demonstrable (elec-
trocardiogram or gross pathology) myocardial
infarction is usually not benefited by nitrites;
since such patients often manifest peripheral cir-
culatory collapse, nitrites must be employed with
great caution. Goldberger {Am. Heart J., 1945,
30, 60) made electrocardiograms following amyl
nitrite inhalation by patients with hypertension
and enlargement of the heart; most of these pa-
tients showed a change of the T wave from nega-
tive to positive for 3 to 4 minutes. Gross {Am.
Heart J ., 1945, 30, 19) reported on the use of
the time between the first inhalation of amyl
nitrite and the appearance of a definite heat sensa-
tion in the face as a measurement of lung-to-face
circulation time; in normal persons the time
ranged from 14 to 25 seconds; in congestive heart
failure the time varied from 31 to 54 seconds; in
emphysematous patients it was normal. In a study
of the effect of several drugs on the pressure in
the pulmonary artery of unanesthetized dogs
(/. Pharmacol., 1943, 77, 80), amyl nitrite is re-
ported to have no effect. In such dogs, Stephens
(/. Physiol, 1940, 99, 127) found that amyl
nitrite caused contraction of the spleen.

Cerebral. — In convulsive disorders, amyl ni-
trite is of service only when it is necessary to
cause immediate relaxation; thus in tetanus, be-
cause of the duration of the convulsive tendency,
the fugaciousness of its action renders it of rela-
tively small service ; on the other hand, in strych-
nine poisoning, by restraining the convulsions long
enough for more durable motor depressants to
act, it may prove a life-saving remedy. In ordi-
nary epilepsy it is of little service, but in status
epilepticus, in which the patient passes from one
convulsion to another, the drug may be of great
benefit. Again, in those occasional cases of epi-
lepsy in which the seizure is preceded by an aura
of sufficient length, inhalation of amyl nitrite as
soon as the aura commences may abort the
paroxysm. Brief cessation of the tremors in
Parkinson's disease following inhalation of amyl
nitrite has been reported by Garai {Arch. Neurol.
Psychiat., 1951, 65, 452).

Pulmonary. — In many cases of asthma it will
cause an immediate, if only temporary, cessation
of the paroxysm. Epinephrine and aminophylline
are usually more effective. The claim of Hare that
"amyl nitrite is of great value for the relief of

hemoptysis has been confirmed by a number of
observers (see Brit. M. L, July 15, 1911J. Its
action in this condition is probably the result of
dilatation of the splanchnic blood vessels.

Colic. — Although the short-acting nitrites are
of little value in most spasms of the gastrointes-
tinal tract, they may be effective in lead colic
{Arch. Int. Med., 1932, 49, 270) and may aid in
the differentiation between spasm and organic
lesions during x-ray examinations. These drugs are
often beneficial in the relief of biliary colic {Surg.,
Gynec. Obst., 1936, 63, 451) both before and
after cholecystectomy, including instances of
biliary dyskinesia. Amyl nitrite is also indicated
in the treatment of renal colic {Arch. urug. de
med., 1944, 24, 105). Prytz (Ugeskr. f. laeger,
1949, 111, 426) described its use, by inhalation,
in obstetrics for the relief of constriction ring
dystocia (BandFs contraction ring). It is also
valuable in some cases of migraine (see Nicotinic
Acid). In the management of cyanide poisoning,
amyl nitrite plays an important role (see Diluted
Hydrocyanic Acid).

Amyl nitrite is generally administered by in-
halation, usually in doses of from three to five
drops, although much larger quantities have been
given. The initial dose should be three drops on
a handkerchief held close to the nose, the dose
being gradually increased pro re nata. The hand-
kerchief should be withdrawn as soon as the face
flushes or severe palpitation is noted, as the effects
increase for some time after inhalation is discon-
tinued. The best method, however, of administer-
ing the very volatile liquid is by the use of glass
pearls — small flask-shaped vessels containing the
nitrite; these are crushed in a handkerchief or
towel when wanted for inhalation, the thin and
fragile glass causing no inconvenience. The drug
may also be given by mouth.

Toxicology. — "When inhaled in doses of from
five to ten drops, amyl nitrite produces in man
violent flushing of the face, accompanied by a
feeling as though the head would burst, and a very
excessive action of the heart. Along with these
symptoms, after a larger quantity, there is a sense
of suffocation, and more or less marked muscular
weakness. Since amyl nitrite increases intraocular
tension, it must be used with caution in patients
with glaucoma. In addition to the headache which
it causes, it increases the pressure of the cerebro-
spinal fluid and is contraindicated in patients
suffering from head trauma, cerebral hemorrhage,
etc. In some persons it produces a reaction com-
parable to shock — nausea, vomiting, weakness,
restlessness, pallor, sweating, syncope and incon-
tinence— due to pooling of blood in the post-
arteriolar vessels and failure of the return of
venous blood to the heart {Arch. Int. Med., 1938,
62, 97; /. Clin. Inv., 1938, 17, 41). Treatment
consists of the head-low position, deep breathing
and exercising the extremities to aid venous re-
turn; the reaction is aggravated by epinephrine. S

The usual dose is 0.3 ml. (approximately 5
minims), by inhalation, as required. The maxi-
mum safe dose is 0.3 ml. and the total dose in 24
hours should rarely exceed 1.5 ml.

Storage. — Preserve "in tight containers. Con-
tainers for the administration of Amyl Nitrite by

Part I

Anethole

inhalation should be loosely wrapped in gauze or
other suitable material." U.S.P. Horswell and
Silverman (Ind. Eng. Chem., Anal. Ed., 1941, 13,
555) reported that amyl nitrite, whether in vapor
or liquid state, is stable in air and relatively stable
when exposed to artificial light, but decomposes
within two hours when exposed to direct sunlight.

AMYLENE HYDRATE. U.S.P., B.P., LP.

Tertiary Amyl Alcohol, [Amyleni Hydras]

C2HB.C(CH3)2.0H

The B.P. defines amylene hydrate as ethyl-
dimethylcarbinol and states that it may be made
by hydration of amylene (2-methylbutene-l). The
I. P. defines the substance as 2-methyl-butanol-2.

Dimethylethylcarbinol; Tertiary Pentanol. Amylenum
Hydratum; Hydras Amylenicus. Fr. Hydrate d'amylene.
Ger. Amylenhydrat; Tertiarer Amylalkohol. It. Idrato di
amilene. Sp. H idrato de Amileno.

Amylene hydrate, an alcohol, is prepared com-
mercially by hydrating amylene, a hydrocarbon
obtained by the chlorination of isopentane and
hydrolysis of the resulting products. Hydration
of the amylene is effected by treatment with a
mixture of sulfuric acid and water at 0°; after
neutralization of the acid the amylene hydrate is
separated by distillation.

Description. — "Amylene Hydrate occurs as
a clear, colorless liquid, having a camphoraceous
odor. Its solutions are neutral to litmus. One Gm.
of Amylene Hydrate dissolves in about 8 ml. of
water. It is miscible with alcohol, with chloro-
form, with ether, and with glycerin. The specific
gravity of Amylene Hydrate is not less than 0.803
and not more than 0.807. Amylene Hydrate distils
completely between 97° and 103°." U.S.P. The
I. P. states that at temperatures below —13°
amylene hydrate forms hygroscopic acicular
crystals.

Standards and Tests. — Identification. — (1)
A mixture of amylene hydrate, sulfuric acid,
potassium dichromate and water is heated for 2
hours under a reflux condenser, forming acetic
acid and acetone. These are removed by distilla-
tion. Acetone, being the more volatile, distils over
first and is identified in the first portion of dis-
tillate by test (2). The remainder of the distillate
is neutralized with sodium hydroxide T.S. and
evaporated to dryness: the residue responds to
tests for acetate. (2) A deep red liquid, developing
a violent tint on dilution with water, is produced
when sodium nitroprusside T.S. is added to a
dilution of the reserved distillate, acidified slightly
with acetic acid. (3) A violet red color results
on adding 5 ml. of a 1 in 100 solution of vanillin
in sulfuric acid to 10 ml. of a 1 in 10 solution of
amylene hydrate. Water. — Anhydrous cupric sul-
fate does not become blue when agitated with
amylene hydrate. Non-volatile residue. — Not over
25 mg. when 10 ml. of amylene hydrate is evapo-
rated and finally dried at 105° for 1 hour. Heavy
metals. — The limit is 5 parts per million. Readily
oxidizable substances. — The pink color of a mix-
ture of 10 ml. of 1 in 20 solution of amylene
hydrate and 0.1 ml. of 0.1 N potassium per-
manganate is not entirely discharged in 10 min-
utes. Aldehyde. — No darkening occurs on heating

a mixture of 10 ml. of 1 in 20 solution of amylene
hydrate and 1 ml. of ammoniacal silver nitrate
T.S. for 10 minutes at 60°. U.S.P.

The B.P. test for limit of water is performed
by adding fight petroleum to amylene hydrate;
the resulting mixture should show no cloudiness.

Uses. — In 1887 amylene hydrate, a central
nervous system depressant, was proposed by Von
Mering as a hypnotic. Advantages claimed were
that it was quicker and more potent than paral-
dehyde or sulfonal, and that it did not depress
the heart like chloral hydrate. As a hypnotic it
ranks between chloral hydrate and paraldehyde
and it is relatively non-toxic. It was rarely used
until it was employed as a vehicle for the basal
anesthetic tribromoethanol. It is official because
of this use (see Tribromoethanol Solution).

Harnack and Meyer (Ztschr. klin. Med., 1894,
24, 374) reported it produced quiet sleep in
herbivorous animals but was an excitant to dogs
and cats. It antagonized the convulsant effects of
strychnine, picrotoxin and santonin, and in a
general way its action was like that of alcohol.
Barlow and Gledhill (/. Pharmacol, 1933, 49, 36)
studied the effects of amylene hydrate on rats
both alone and combined with tribromoethanol.
They found the lethal dose, rectally or subcu-
taneously, was about 1.4 Gm. per Kg. Although
the rate of respiration was increased, the volume
of air moved per minute was lessened by all doses.
While it was possible to produce complete anes-
thesia with amylene hydrate it required 65 per
cent of the lethal dose and was accompanied by
reduction of about 75 per cent in the volume of
air breathed (Hofmann, Arch. exp. Path. Pharm.,
1936, 183, 127).

In humans the hypnotic dose, dissolved in glyc-
erin, is 1 to 4 Gm. Since the average dose of
Tribromoethanol Solution contains over 2 Gm.
of amylene hydrate, it may contribute to the
hypnotic action of this solution.

Amylene hydrate is an important commercial
solvent; it is used especially in dry cleaning of
cellulose acetate materials.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Tribromoethanol Solution, U.S.P. ,
B.P.

ANETHOLE. U.S.P.

Anethol, [Anethole]

CH,0

^ /

-CH=CHCH3

"Anethole is parapropenyl anisole. It is ob-
tained from anise oil and other sources, or is pre-
pared synthetically." U.S.P.

Anise Camphor. l-Methoxy-4-propenylbenzene.

Anethole occurs in several volatile oils. From
80 to 90 per cent of anise oil is anethole; the
latter may be separated by cooling the oil. Ane-
thole may also be obtained from pine oil; indeed
this oil was the only available source of anethole
when supplies of anise oil were cut off during the
Second World War. It may be synthesized from
anisole and acetaldehyde.

Anethole

Part I

Description. — "Anethole is a colorless or
faintly yellow liquid at or above 23°. It has a
sweet taste, the aromatic odor of anise, and its
alcohol solutions are neutral to litmus. It is af-
fected by light. Anethole is readily miscible with
ether and with chloroform. It dissolves in 2 vol-
umes of alcohol. It is slightly soluble in water.
The specific gravity of Anethole is not less than
0.983 and not more than 0.988." U.S.P.

Standards and Tests. — Congealing tempera-
ture.— Not less than 20°. Distillation range. —
Anethole distils completely between 231° and
237°. Optical rotation. — Anethole is optically in-
active or shows a rotation of not more than 0.15°
in a 100-mm. tube. Refractive index. — Not less
than 1.5570 and not more than 1.5610. Aldehydes
and ketones. — No appreciable diminution in the
volume of anethole occurs, nor does a crystalline
deposit form, when 10 ml. of anethole is shaken
with 50 ml. of a saturated aqueous solution of
sodium bisulfite and /allowed to stand 6 hours.
Phenols. — No purplish color is produced upon the
addition of 3 drops of ferric chloride T.S. to 10
ml. of the filtrate separated from 1 ml. of anethole
shaken with 20 ml. of distilled water. U.S. P.

Anethole is used like, and for the same pur-
poses as, anise oil (which see).

Dose, from 0.06 to 0.3 ml. (approximately 1 to
5 minims).

Storage. — Preserve "in tight, fight-resistant
containers." U.S.P.

Off. Prep. — Diphenhydramine Hydrochloride
Elixir, U.S.P. ; Compound Cardamom Spirit, N.F.

ANISE OIL. U.S.P., B.P. (LP.)

[Oleum Anisi]

"Anise Oil is the volatile oil distilled with steam
from the dried, ripe fruit of Pimpinella Anisum
Linne (Fam. Umbelliferce) or from the dried, ripe
fruit of Illicium verum Hooker filius (Fam. Mag-
noliacece). Note. — If solid material has separated
from Anise Oil, carefully warm the mixture
until it is completely liquefied, and mix it thor-
oughly before using." U.S.P. The B.P. and LP.
recognize oil distilled from the same plant sources.

I. P. Oil of Anise. Oil of Aniseed. Oleum Anisi
^thereum; Essentia anisi. Fr. Essence d'anis. Ger. Ani-
sol. It. Essenze di anice. Sp. Esencia de anis.

Anise oil, which is imported into this country
chiefly from India and French Indo-China, is ob-
tained mostly from Illicium verum, or Star Anise,
which is described in Part II under the title
Illicium. For a description of Pimpinella Anisum
see under Anise, in Part II.

Description. — "Anise oil is a colorless or pale
yellow, strongly refractive liquid, having the char-
acteristic odor and taste of anise. One volume of
Anise Oil dissolves in 3 volumes of 90 per cent
alcohol. The specific gravity of Anise Oil is not
less than 0.978 and not more than 0.988." U.S.P.

Standards and Tests. — Congealing tempera-
ture.— Not below 15°. Optical rotation. — The
optical rotation in a 100-mm. tube, at 25°, is be-
tween + 1° and —2°. Refractive index. — Not less
than 1.5530 and not more than 1.5600, at 20°.
Heavy metals. — The oil meets the official require-
ments. Phenols. — A 1 in 3 solution of recently

distilled anise oil in 90 per cent alcohol is neutral
to moistened litmus paper, and the solution de-
velops no blue or brown color on adding 1 drop
of ferric chloride T.S. to 5 ml. of it. U.S.P.

Constituents. — Anise oil contains 80 to 90
per cent of anethole (which see), together with
small amounts of its isomer methyl-chavicol, of
anisaldehyde, and of terpenes.

Adulterants. — Because of its high price anise
oil is often adulterated. Spermaceti, wax and
camphor are adulterants that have been used in
times past; fennel stearoptene has been found
also. The so-called Japanese star anise oil (from
Illicium anisatum), with which the official oil may
be confused, is derived from leaves, rather than
fruit, and contains eugenol and safrol, and much
less anethole than the oil from the fruit (see
Illicium, Part II).

Uses. — Anise oil is one of the most popular of
flavoring agents. Therapeutically it is useful to
stimulate peristalsis in colic and as an expectorant.
Boyd and Pearson (Am. J. Med. Sc, 1946, 211,
602) found it to be more effective than the oils of
turpentine, pine, lemon or eucalyptus. They be-
lieve that the expectorant volatile oils act directly
on the secretory cells of the respiratory tract.
Anise oil has also been recommended as a means
of destroying body lice. Parutz (Schim. Rep.,
1920) used a 1 per cent ointment for scabies. The
N.F. IX recognized Anise Spirit, a 10 per cent
v/v solution of the oil in alcohol, also Anise
Water, a saturated solution of the oil in distilled
water.

Dose, of the oil, 0.2 to 0.3 ml. (approximately
3 to 5 minims).

Storage. — Preserve "in well-filled, tight con-
tainers and avoid exposure to excessive .heat."
U.S.P.

Off. Prep. — Glycyrrhiza Syrup; Compound
Orange Spirit, U.S. P.; Aromatic Cascara Sagrada
Fluidextract; Camphorated Opium Tincture,
U.S. P., B.P.; Compound Sarsparilla Syrup, N.F.

ANTAZOLINE HYDROCHLORIDE.

U.S.P.. LP.

Antazolinium Chloride, 2-(N-Benzylanilinomethyl)-2-
imidazoline Hydrochloride

\ \-CH2-N-CH2-r^ ^

^ ' ^-^ HM 1

HN-

"Antazoline Hydrochloride, dried at 105° for 3
hours, contains not less than 98 per cent of
C17N19N3.HCI." U.S.P. The LP. rubric is the
same, referred to the substance as it occurs.

I. P. Antazolini Hydrochloridum. 2-(N-Phenyl-N-benzyl-
aminomethyl)imidazoline Hydrochloride. Antistine Hydro-
chloride (Ciba). Phenazoline Hydrochloride.

This antihistaminic substance is characterized
by the fact that the side chain (see article on
Antihistaminic Drugs, in Part II), which in many
such compounds is a dialkylaminoethyl group, has
been replaced by an imidazoline radical, thus

Part I

Antazoline Hydrochloride 93

making antazoline similar to the sympathomimetic
drugs Privine [2-(l-naphthylmethyl)-2-imidazo-
line] and Otrivine [(2-anilinomethyl)-2-imidazo-
line] . Antazoline may be synthesized by the inter-
action of anilinomethylimidazoline and benzyl
chloride, the first reactant being prepared from
anilinoacetimidoester and ethylenediamine (see
Idson, Chem. Rev., 1950, 47, 340).

Description. — "Antazoline Hydrochloride oc-
curs as a white, odorless, crystalline powder. Its
solutions are neutral to litmus. One Gm. of
Antazoline Hydrochloride dissolves in about 40
ml. of water, and in about 25 ml. of alcohol. It
is practically insoluble in chloroform, in ether,
and in benzene. Antazoline Hydrochloride melts,
with decomposition, between 232° and 238°."
U.S.P.

Standards and Tests. — Identification. — (1)
A deep red color is produced when 25 mg. of
antazoline hydrochloride is dissolved in 5 ml. of
nitric acid, the color persisting when the solution
is diluted with 20 ml. of water. (2) A 1 in 100,000
solution exhibits an ultraviolet absorbancy maxi-
mum at 242 mn ± 1 mjx, and a minimum at 222
m\t ± 1 mn; the specific absorbancy, E(l%,
1 cm.), at 242 m\i is between 495 and 515. (3)
Antazoline hydrochloride responds to tests for
chloride. Loss on drying. — Not over 0.5 per cent,
when dried at 105° for 3 hours. Residue on igni-
tion.— Not over 0.2 per cent. U.S.P.

Assay. — About 600 mg. of antazoline hydro-
chloride, dried at 105° for 3 hours, is dissolved in
80 ml. of glacial acetic acid and, after adding
10 ml. of mercuric acetate T.S., is titrated with
0.1 N perchloric acid, the end-point being deter-
mined potentiometrically. Each ml. of 0.1 N
perchloric acid represents 30.18 mg. of C17H19-
N3.HCI. U.S.P. This non-aqueous titration is
based upon the principle that each molecule of
antazoline base represented in the sample releases
one acetate ion when the salt is dissolved in acetic
acid. Each acetate ion, being basic, in turn com-
bines with a hydrogen ion released by perchloric
acid, forming a molecule of acetic acid. Since the
solvent medium is acetic acid, this reaction is one
of neutralization, comparable to the combination
of hydrogen and hydroxyl ions to form water
when the latter is the solvent medium. The pur-
pose of adding mercuric acetate is to prevent in-
terference by the hydrochloride component of the
salt, which reacts with the mercuric acetate to
form acetic acid and non-ionized mercuric chlo-
ride (for additional information see Kleckner and
Osol, /. A. Ph. A., 1952, 41, 573). The LP. assays
the substance gravimetrically as the picrate.

Uses. — This drug has received extensive phar-
macological and clinical study. Its antihistaminic
activity in animals is 10 to 20 per cent of that of
tripelennamine hydrochloride, but its toxicity is
likewise low (Meier and Bucher, Schweiz. med.
Wchnschr., 1946, 76, 294; Craver et al., Ann.
Allergy, 1951, 9, 34). Used prophylactically, it
protects the guinea pig from anaphylactic shock
and in human skin it prevents wheal formation
following injection of histamine or of the specific
allergen in the allergic patient (Serafini, /. Allergy,
1948, 19, 256; Schwartz and Wolf, ibid., 1949,
20, 32). Dutta (Brit. J. Pharmacol. Chemother.,

1949, 4, 281) reported it to have 2.3 times the
local anesthetic effect of procaine hydrochloride;
he also observed it to have antiacetylcholine action
and a more intense effect than that of quinidine
in decreasing the response of muscle to electrical
stimulation. Its use does not prevent a positive
tuberculin patch test (Kendig et al., J. Pediat.,
1949, 35, 750) and it does not increase or de-
crease the antibody titer following diphtheria-
tetanus toxoid (Regamey and Wantz, Schweiz. Zt.
Path. Bakt., 1947, 10, 426).

Many clinical reports have appeared on its use
in allergic disorders. A number of these have been
summarized by Loveless and Dworin (Bull. N. Y.
Acad. Med., 1949, 25, 473), with the general con-
clusion that while a lower percentage of thera-
peutic effectiveness was found than with most
other antihistamines, the incidence of untoward
effects was likewise among the lowest. Friedlaender
and Friedlaender (Ann. Allergy, 1948, 6, 23) con-
cluded that 100 mg. of antazoline hydrochloride
is clinically equivalent to 50 mg. of tripelennamine
hydrochloride. Antazoline was found to be the
least effective of 13 antihistaminics tested by
Sternberg et al. (J.A.M.A., 1950, 142, 969) for
ability to raise the histamine whealing threshold
in man.

Antazoline absorbs the erythema-producing
wave lengths of the ultraviolet region (Fried-
laender et al, J. Invest. Derm., 1948, 11, 397).
Studies of the living mesoappendix by Haley and
Harris (/. Pharmacol, 1949, 95, 293) showed
that it causes contraction of the precapillary
sphincter.

Since it is less irritating than some other anti-
histaminics antazoline hydrochloride is used in an
0.5 per cent buffered (pH 6.1) isotonic solution
in the conjunctival sac (see reference to use of
antazoline phosphate below) and the nose (Fried-
laender and Friedlaender, loc. cit.). Hurwitz (Am.
J. Ophth., 1948, 31, 1409) reported relief of
allergic eye conditions with one drop of this solu-
tion applied every 3 or 4 hours; momentary
smarting was observed. Taub et al. (Am. Pract.,
1949, 3, 664), however, do not advise use of this
solution because of the short period of sympto-
matic relief and the danger of sensitizing the
tissue to the drug. A solution containing 0.025 per
cent naphazoline hydrochloride and 0.5 per cent
antazoline hydrochloride is intended for nasal use
by application in the form of drops, spray, or by
tampon; the antihistamine component also pos-
sesses vasoconstrictive action. The solution is in-
dicated in allergic and vasomotor rhinitis, sinusitis
and, perhaps, in the common cold. A concentra-
tion in excess of 1:1000 inhibits ciliary activity
(Craver et al, loc. cit.). See also the general dis-
cussion of Antihistaminic Drugs in Part II.

The untoward effects are similar to those of
other antihistamines but the incidence is lower,
with the possible exception of thonzylamine.
Nausea and drowsiness are most frequent. Intra-
venously the drug must be given very slowly to
minimize flushing and vertigo; the dose by this
route should not exceed 50 to 100 mg.

Dose. — The usual dose is 100 mg. (approxi-
mately \Yz grains) up to 4 times daily by mouth,
with a range of 50 to 100 mg. The maximum safe

94 Antazoline Hydrochloride

Part I

dose is 100 mg. and the total dose in 24 hours
should generally not exceed 400 mg.

A 0.5 per cent solution in isotonic sodium
chloride solution is used in the nose. For oph-
thalmic use, a 0.5 per cent isotonic solution of
Antazoline Phosphate (N.N.R.), is preferable to
that prepared from the hydrochloride because it
produces less smarting and stinging.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

ANTAZOLINE HYDROCHLORIDE
TABLETS. U.S.P.

"Antazoline Hydrochloride Tablets contain not
less than 93 per cent and not more than 107 per
cent of the labeled amount of C17H19N3.HCI."
U.S.P.

Assay. — The antazoline hydrochloride in a
representative portion of powdered tablets is ex-
tracted with alcohol and the content of the active
ingredient calculated from observation of the
absorbancy at the wavelength of maximum ab-
sorption, in this case 242 mn. While the position
of the absorbancy maximum in the case of anta-
zoline hydrochloride is the same in both alcohol
and water solution, which is not the case with all
antihistaminic drugs similarly assayed, there is
somewhat more intense absorption in alcohol solu-
tion, which accounts for the difference in values
of specific absorbancy given for the water solution
employed in identification test (2) under anta-
zoline hydrochloride and for the alcohol solution
employed in the assay of the tablets. U.S.P.

Usual Size. — 100 mg. (approximately 1J^
grains).

ANTHRALIN. N.F. (B.P.)

[Anthralinum]
0 H OH OH

"Anthralin. dried over sulfuric acid for 4 hours,
contains not less than 95 per cent of C14H10O3."
N.F. Under the title Dithranol the B.P. defines
this substance as 1,8-dihydroxyanthranol; no assay
rubric is stipulated.

B.P. Dithranol. Dioxyanthranol; 1,8,9-Anthratriol.
Cignolin (Winthrop).

This chrysarobin substitute may be synthesized
by reducing l,S-dihydroxyanthraquinone, the lat-
ter obtained by heating with lime the 1,8-anthra-
quinonedisulfonic acid prepared by sulfonation of
anthraquinone in the presence of mercury.

The 1,8-dihydroxyanthraquinone, which is the
parent substance of anthralin, is closely related
to chrysophanol, structurally l,8-dihydroxy-3-
methylanthraquinone, which is the parent com-
pound of the constituents of chrysarobin (q.v.)
and is itself an important constituent of cascara,
rhubarb and senna. As might be expected, 1.8-di-
hydroxyanthraquinone is laxative, being official
as Danthron.

Description. — "Anthralin occurs as an odor-
less, tasteless, crystalline, yellowish brown pow-
der. When suspended in water and filtered, the
filtrate is neutral to litmus paper. Anthralin is
soluble in chloroform, in acetone, and in benzene.
It is soluble in solutions of alkali hydroxides. It
is slightly soluble in alcohol, in ether, and in
glacial acetic acid. It is insoluble in water. An-
thralin melts between 175° and 181V' N.F. The
B.P. indicates anthralin to be soluble in fixed oils.
Standards and Tests. — Identification. — (1)
A yellowish to orange solution, having a green
fluorescence, results when anthralin is dissolved
in sodium hydroxide T.S.; on exposure to air the
solution turns to a strong orange-red color. (2)
A greenish brown color is produced when anthra-
lin is dissolved in alcohol and ferric chloride T.S.
is added. Chloride. — Addition of silver nitrate
T.S. to a saturated solution of anthralin produces
no opalescence. Sulfate. — Addition of barium
chloride T.S. to a saturated solution of anthralin
produces no turbidity. Loss on drying. — Not over
0.5 per cent, when dried over sulfuric acid for 4
hours. Residue on ignition. — The residue from 500
mg. is negligible. N.F. The B.P. specifies, as a test
to exclude dihydroxyanthracene, that 100 mg. of
anthralin should dissolve completely in 5 ml. of
hot benzene, forming a clear yellow or orange
solution. As a test to exclude dihydroxy anthra-
quinone 1 mg. is required to produce a clear
orange solution in a few drops of sulfuric acid, no
trace of violet color being evident. The loss on
drying to constant weight at 100° should not be
more than 1 per cent and the ash should not ex-
ceed 0.1 per cent.

Assay. — Using a chloroform solution contain-
ing 0.01 mg. of anthralin per ml. optical .density
readings are taken at 354 mn and at 432 mn in a
suitable spectrophotometer and the corresponding
values of E(l%, 1 cm.) are calculated. The con-
tent of anthralin is calculated by means of an
equation utilizing a difference function of the E
values. iVJ7. No assay is specified by the B.P.

Uses. — Anthralin has the action and uses of
chrysarobin (q.v.) over which it has several ad-
vantages, as follows: It is a definite compound,
rather than an indefinite mixture; it is effective
at lower concentrations; it is less irritant to the
skin, conjunctiva and kidneys; it causes less
coloration of clothing (Beerman et al., J. A.M. A.,
1935, 104, 26, 48).

Anthralin is used in psoriasis, dermatophytoses,
chronic eczemas, alopecia areata and other dis-
eases of the skin in which a stimulant application
is indicated. Goodman (Arch. Derm. Syph., 1939,
40, 76) warned against its prolonged use because
exhaustion of the epidermal tissues may result.
The drug should be discontinued if pustular
folliculitis or renal irritation develops.

Anthralin is usually employed in concentrations
of 0.1 to 1 per cent, in the form of an ointment
or cream, in a benzene solution, or in a collodion
vehicle; the lowest concentration should be em-
ployed first, then increased if found necessary
and well-tolerated.

Storage. — Preserve "in tight containers, pro-
tected from light." N.F.

Part I

Antimony Potassium Tartrate 95

ANTHRALIN OINTMENT. N.F. (B.P.)

[Unguentum Anthralinum]

"Anthralin Ointment labeled to contain more
than 0.1 per cent of anthralin (C14H10O3) con-
tains not less than 90 per cent and not more than
115 per cent of the labeled quantity of C14H10O3
and contains not more than 115 per cent of
C14H10O3 and 1,8-dihydroxyanthraquinone (C14-
H8O4) combined. Not more than 10 per cent of
the labeled quantity of anthralin is C14H8O4.

"Anthralin Ointment labeled to contain 0.1 per
cent or less of C14H10O3 contains not less than
90 per cent and not more than 130 per cent of
the labeled quantity of C14H10O3 and not more
than 130 per cent of C14H10O3 and C14H8O4 com-
bined. Not more than 20 per cent of the labeled
quantity of anthralin is C14H8O4." N.F.

B.P. Ointment of Dithranol; Unguentum Dithranolis.

Anthralin ointment may be prepared by thor-
oughly mixing 10 Gm. of finely powdered anthra-
lin with a portion of white petrolatum and then
incorporating sufficient white petrolatum to make
1000 Gm. Due to slow oxidation of anthralin to
1,8-dihydroxyanthraquinone upon standing, oint-
ments intended not to be used for some time
should be prepared with about 5 per cent excess
of anthralin for ointments containing more than
0.1 per cent, and a 20 per cent excess of anthralin
for ointments containing 0.1 per cent or less. N.F.

The B.P. recognizes Ointment of Dithranol,
containing 0.1 per cent of dithranol in a base of
yellow soft paraffin (yellow petrolatum), and a
Strong Ointment of Dithranol, containing 1 per
cent of dithranol in the same base.

For uses of anthralin ointment, see the preced-
ing monograph.

Storage. — Preserve "in well-closed, light-
resistant containers." N.F.

ANTIMONY
Sb (121.76)

Stibium. Fr. Antimoine. Ger. Antimon. It. Antimonio.
Sp. Antimonio.

Antimony, earlier called stibium, may have been
known as long ago as 4000 B.C. In ancient times
it was employed as a medicine and as a cosmetic.
Late in the 15th century Basil Valentine described
its preparation and his observations of properties
of the element and some of its compounds.

The free element is found in nature in rela-
tively small amounts. Its chief ore, stibnite
(Sb2S3), occurs rather abundantly, especially in
China, Mexico, Bolivia, Algeria, Portugal and
France; comparatively few deposits have been
found in the United States. The metal is obtained
either by heating stibnite with scrap iron, or by
roasting the ore to convert it to oxides of anti-
mony which are subsequently reduced to metal
by heating with carbon.

Properties. — Antimony is a brittle, brilliant
metal, ordinarily of a lamellated texture, of a
silver-white color when pure, but bluish white as
it occurs in commerce. Its density is about 6.7,
and it melts at 630°. When heated in oxygen it

burns with a bright bluish flame, forming the
trioxide. Several allotropic forms may be pre-
pared by special treatment. It forms three com-
binations with oxygen, antimony trioxide (anti-
monious oxide), SD2O3, antimony tetr oxide, Sb204
(by some considered to be an antimonate of the
radical antimonyl, SbO.SbOs), and antimony pent-
oxide (antimonic oxide), Sb20s.

By virtue of the fact that antimony has the
property of imparting hardness to metals, par-
ticularly lead, it is used in the manufacture of
lead alloy for storage battery plates, in Babbitt
metal and other antifriction alloys, in pewter and
Britannia metal, in type metal, and in other alloys.
It has the important property of expanding on
cooling which, in type metal, makes it possible
to obtain an accurate cast of a letter. Antimony
has been used as an alloy with lead for shrapnel
and the bullet cores of small arms ammunition.
One of the important newer uses of compounds
of antimony is that of antimony trioxide in flame-
proofing compounds for application to military
and household textiles. Large amounts of anti-
mony trisulfide and antimony pentasulfide are
used in the rubber industry for producing vul-
canized rubber of red color.

Inorganic antimony compounds are not em-
ployed in therapeutics because of their toxicity,
but a number of organic compounds are safe
enough to use. The activity of antimonials is
proportional not merely to their solubility in the
gastric juices but, according to the researches of
Brunner (Arch. exp. Path. Pharm., 1912, 68,
186), especially depends upon whether the metal
is in the trivalent or pentavalent condition, the
latter being comparatively innocuous (see the
study by Goodwin, /. Pharmacol., 1944, 81, 224).
In recent years organic preparations of antimony
have received considerable attention as thera-
peutic agents in various protozoal diseases (see
Antimony Potassium Tartrate, Antimony Sodium
Thiogly collate, Stibophen, and the article on Anti-
monials, Organic, in Part II). For a comprehen-
sive report on the toxicology of antimony see
Fairhall and Hyslop (Supplement No. 195 to the
Public Health Reports, 1947).

ANTIMONY POTASSIUM TARTRATE
U.S.P., B.P. (LP.)

Antimonyl Pot.'.ssium Tartrate, Tartar Emetic,
[Antimonii Potassi Tartras]

"Antimony Potassium Tartrate contains not less
than 99 per cent of C4H4K07Sb.^H20." U.S.P.
The B.P. and LP. rubrics are the same.

I. P. Potassium Antimonyltartrate ; Stibii et Kalii
Tartras. Tartrated Antimony. Antimonium Tartaratum;
Tartarus Stibiatus; Kalium Stibio Tartaricum; Stibii et
Potassii Tartras; Tartarus Emeticus. Fr. Antimoniotar-
trate acide de potassium; Tartre stibie; Tartrate d'anti-
moine et de potasse. Ger. Brechweinstein ; Weinsaures
Antimonylkalium. It. Tartrato di antimonio e di potas-
sio; Tartaro stibiato. Sp. Tartrato de antimonio y de
potasio; Tartrato Potdsico Antimonico; Tartaro estibiado.

Antimony potassium tartrate may be prepared
by the interaction of antimony trioxide and potas-
sium bitartrate.

The structure of this salt is a subject of contro-
versy. Reihlen and Hezel (Ann. Chem., 1931, 487,

96 Antimony Potassium Tartrate

Part I

213) proposed a cyclic structure in which the
water is attached by coordination to the antimony,
as follows:

0:C

OH2

Evidence for this cyclic structure has been ob-
tained also by Pfeiffer and Schmitz (Pharmazie,
1949, 4, 451).

Description. — "Antimony Potassium Tartrate
occurs as colorless, odorless, transparent crystals,
or as a white powder. The crystals effloresce upon
exposure to air. Its solutions are acid to litmus.
One Gm. of Antimony Potassium Tartrate dis-
solves in 12 ml. of water and in about 15 ml. of
glycerin. One Gm. dissolves in about 3 ml. of boil-
ing water. It is insoluble in alcohol. U.S.P.

Standards and Tests. — Identification. — (1)
Antimony potassium tartrate chars, emits an odor
like that of burning sugar, and leaves a blackened
residue when heated to redness; the residue is
alkaline and confers a violet tint to a non-lumi-
nous flame. (2) An orange red precipitate forms
on adding hydrogen sulfide T.S. to a 1 in 10 solu-
tion of antimony potassium tartrate, acidified with
hydrochloric acid; the precipitate dissolves in am-
monium sulfide T.S. and in sodium hydroxide T.S.
Arsenic. — The limit is 200 parts per million.
U.S.P. The B.P. limits for arsenic and lead are
8 parts per million and 5 parts per million, re-
spectively; the corresponding LP. limits are 10
parts per million and 5 parts per million.

Assay. — About 500 mg. of antimony potassium
tartrate is dissolved in water, a saturated solution
of sodium bicarbonate is added, and the trivalent
antimony is oxidized to the pentavalent state by
titration with 0.1 N iodine, employing starch T.S.
indicator. Each ml. of 0.1 N iodine represents
16.70 mg. of C4H4K07Sb.^H20. U.S.P. The
B.P. and LP. assays are practically identical with
that of the U.S.P.

Incompatibilities. — Mineral acids added to
aqueous solutions of tartar emetic precipitate the
respective basic salts of antimony, with possibly
some potassium bitartrate. Alkali hydroxides and
carbonates, in sufficient amounts, precipitate anti-
mony trioxide, soluble in excess of fixed alkali.
The precipitation may be prevented by an excess
of citrates, tartrates, glycerin, or sugar. Most
metallic salts, including those of lead and silver,
form insoluble tartrates when added to aqueous
solutions of tartar emetic. Tannic and gallic acids,
or infusions of tannin-containing drugs, yield
precipitates with tartar emetic. Solutions of al-
bumin and of soap behave similarly. Lime water
forms insoluble calcium and antimony tartrates;
mercuric chloride is reduced to calomel.

Uses. — Tartar emetic is a slow-acting local
irritant, capable of causing not only redness but
also vesicles and pustules at the orifices of the
glands of the skin; this action appears to be
associated with the formation of antimony tri-
oxide. It has been used as a counterirritant in
the form of an ointment or plaster.

When taken internally, tartar emetic provokes
salivation and nausea; in sufficient dose active
vomiting occurs. The emetic effect is the result
chiefly of the local irritant action of antimony
upon the gastric mucosa. This is true even when
the drug is injected hypodermicWly, because it is
excreted through the walls of the stomach in
sufficient quantity to act as an irritant. On the
other hand, the drug will produce vomiting move-
ments in the dog even after complete removal of
the stomach (Hatcher and Weiss, /. Exp. Med.,
1923, 37, 97). Tartar emetic is poorly absorbed
from the gastrointestinal tract.

When absorbed into the circulation, as by in-
travenous injection, the antimony solution causes
a marked lowering of blood pressure, decreased
cardiac output, dilatation of the splanchnic ves-
sels, increased pressure in the pulmonary vessels
and, in large doses, respiratory depression. Changes
in the electrocardiogram occur in patients treated
with antimony compounds, more frequently when
tartar emetic is used than when other organic
antimonials are employed; these changes have
not been permanent and seemed to have no seri-
ous clinical import (see Mainzer and Krause,
Trans. Roy. Soc. Trop. Med. Hyg., 1940, 33,
405; Tarr, Bull. U. S. Army M. Dept., 1946, 5,
336; Schroeder et ah, Am. J. Med. Sc, 1946,
212, 697).

Tartar emetic is excreted rapidly (see also
under Stibophen) , elimination being almost com-
plete in 72 hours. It is found in the urine; large
doses cause signs of renal irritation. Kramer
{Bull. Johns Hopkins Hosp., 1950, 86, 179) re-
ported a higher concentration of antimony in the
thyroid of the rabbit than in any other tissue
except the fiver but no histological or functional
abnormality was observed.

While it is a powerful emetic, antimony has
been almost completely abandoned for such use
in favor of less dangerous and equally efficient
emetic drugs. It is, however, still occasionally em-
ployed as a nauseant expectorant in the treatment
of acute bronchitis and is an ingredient of some
cough syrups. Its use should be avoided in very
young or very- old persons, also in persons with
feeble circulation.

Tartar emetic and other antimony compounds
(see Stibophen and Antimonials, Organic) have
been used widely in treating various tropical in-
fections. Chemotherapy with heavy metal com-
pounds usually depends on a differential toxicity
whereby the parasites are destroyed or made sus-
ceptible to cellular or humoral defense mechan-
isms of the body by a dose of the metallic com-
pound which is insufficient to cause serious damage
to the host; while this general statement is
applicable to antimony compounds, the exact
mechanism of their action has not been elucidated
(see Most and Lavietes, Medicine, 1947, 26, 221).
In an in vitro study of several antimony com-
pounds Mansour {Brit. J. Pharmacol. Chemother.,
1951, 6, 588) observed paralysis of the liver fluke.
Fasciola hepatica, only if 50 per cent of blood
serum was added to a 1:1000 solution of tartar
emetic; stibophen was not active, either alone or
in the presence of serum.

Part I

Antimony Potassium Tartrate 97

In schistosomiasis japonica, the War Depart-
ment, U.S.A. (TB Med 167, see War Med., 1945,
7, 397) recommended use of Fuadin (see Stibo-
phen) or antimony potassium tartrate. The latter
is administered intravenously, slowly, about 2 or
3 hours after a light meal. The needle must be
wiped off before insertion and there must be no
extravasation of the solution. The patient should
remain recumbent for at least an hour after the
injection. For the first dose 8 ml. of 0.5 per cent
solution is given; on alternate days the dose is
increased by 4 ml. each time until a maximum
dose of 28 ml. is reached, which is repeated 15
times. Coughing immediately upon injection is a
common though unimportant untoward effect;
this may be minimized by injecting slowly, at a
rate not exceeding 8 ml. per minute. Other toxic
manifestations include nausea, vomiting, stiffness
of the joints and muscles, sensation of constric-
tion in the chest, pain in the epigastrium, brady-
cardia, dizziness and collapse; if any of these
symptoms occurs during the injection, it should
be stopped. Subsequent doses should be decreased
or omitted entirely, depending on the severity of
the reaction. If viable eggs persist four weeks
after the completion of the course of injections,
the course should be repeated, or another drug
employed, if the patient can tolerate it. When
instituted early, this treatment prevents develop-
ment of severe sequelae. If cirrhosis of the liver
has developed, the treatment cannot correct it.
Injections should not be given in the presence of
severe disease of the heart, liver or kidney. Gen-
erally, other heavy metals or emetine should not
be given at the same time. Beneficial effects have
been obtained with similar treatment regimens
employed against Schistosoma mansoni and
S. haematobium (see the extensive review Ad-
vances in the Therapeutics of Antimony, Schmidt
and Peter, Leipzig, 1938). Successful treatment
of a case of cerebral schistosomiasis manifesting
Jacksonian convulsive seizures has also been re-
ported (Salis and Smith, Ann. Int. Med., 1951,
34, 238).

For granuloma inguinale (characterized by the
presence of Donovan bodies in the lesion and not
to be confused with the venereal, "virus" disease
lymphogranuloma inguinale), the "broad-spec-
trum" antibiotics, such as aureomycin (q.v.), have
proved to be more effective, safer and much easier
to use than antimony compounds. Tartar emetic
has, however, been rather extensively employed,
one of the treatment programs, recommended
when a course of stibophen had failed after six
weeks (see TB Med 157, Bull. U. S. Army M.
Dept., 1945, 4, 326), consisting of the initial in-
jection of 3 ml. of 1 per cent solution, given
slowly intravenously, repeated on alternate days
with an increase in the dose of 3 ml. each time
until 12 ml. is reached, which is given 15 times.

Tartar emetic was the first successful form of
therapy for visceral leishmaniasis (kala-azar),
but the treatment was prolonged, uncomfortable
and difficult, with toxic effects often preventing
satisfactory clinical results; it is therefore not
recommended for such use, Neostibosan (see
Part II) being advised instead. Tartar emetic

has been used effectively in the treatment of
oriental sore. Mucocutaneous leishmaniasis in
South America has been treated with an initial
dose of 4 ml. of a 1 per cent solution of tartar
emetic, this being increased by 1 ml. at each in-
jection to a maximum dose of 10 ml., at which
level injections were given twice weekly for about
six weeks (Snow et al., Arch. Dermat. Syph.,
1948, 57, 90) ; combined therapy with arsenic
and antimony (stibophen) is, however, preferred.

Tartar emetic has been employed in trypano-
somiasis but arsenicals (see Tryparsamide) are
less toxic, and diamidines (see in Part II) seem
to be more effective. It has failed in the treatment
of clonorchiasis ; it is of possible value in filariasis
but is not recommended (War Med., 1945, 7,
377). Cochrane (Med. Press, May 9, 1945) ad-
vised on alternate days 3 doses of 20 mg. fol-
lowed by 3 doses of 40 mg. for the true lepra-
reaction in leprosy. It has been employed for
trachoma with corneal complications (Brit. M. J.,
1939, 1, 516) and for trypanosomiasis in cattle
(Cawston, /. Trop. Med. Hyg., 1935, 38, 305).
It was also recommended by Rogers (Brit. M. J.,
Jan. 6, 1917) for the destruction of the crescents
in the treatment of tertian malarial fever. Grove
(J.A.M.A., 1925, 85, 349) reported a case of
trichinosis in which the larvae were demonstrated
in the blood stream, and in which, following the
intravenous injection of a solution of tartar
emetic, the symptoms promptly subsided and the
parasites disappeared from the blood. Tomlinson
and Bancroft (J.A.M.A., 1934, 102, 36) reported
two cases of that rare and often fatal mycodermal
infection known as granuloma coccidioides, which
were apparently cured by its intravenous use.

Tartar emetic has recently been recommended
as a spray in the control of thrips on lemons,
gladioli, and onions. lYl

Poisoning. — Symptoms of acute poisoning by
the drug are an austere metallic taste, excessive
nausea, copious vomiting, frequent hiccough,
burning pain in the stomach, colic, frequent stools
and tenesmus, fainting, rapid and feeble pulse,
coldness of the skin, and even of the internal
organs, difficult and irregular respiration, cutane-
ous anesthesia, convulsive movements, painful
cramps in the legs, anuria, prostration, and death.
In rare cases vomiting and purging do not take
place, and when they are absent, the other symp-
toms are aggravated. Sometimes a pustular erup-
tion is produced, like that caused by the external
application of the antimonial. Although because
of the promptness of its emetic action recovery
may occur after very large amounts, one case is
on record in which 130 mg. proved fatal.

The symptoms of antimony poisoning fre-
quently so closely resemble those of arsenic that
a diagnosis may be well-nigh impossible except
through chemical examinations. The post-mortem
lesions also resemble those of arsenic poisoning;
commonly ulcerations are found in the esophagus
and stomach — although sometimes lacking — but
rarely in the intestines. In the less acute cases
there also develop fatty degenerations of the
liver, kidneys or heart, and sometimes also de-
generative changes in the nervous system.

98 Antimony Potassium Tartrate

Part I

In the treatment of antimony poisoning, even
though the patient has vomited, it is usually
advisable to wash out the stomach, using a solu-
tion of tannic acid. Tannic acid should be ad-
ministered repeatedly as the poison is eliminated
from the blood through the walls of the stomach.
The use of milk or albumin water as demulcents,
opiates to check the diarrhea and relieve the pain,
and various stimulants should be employed as
symptoms may indicate. Rosenthal and Severn
(Arch. exp. Path. Pharm., 1912, 67, 275) asserted
that potassium hexatantalate is capable of fol-
lowing the drug after its absorption and producing
a non-toxic compound in the system. Dimercaprol
(g.v.) decreased the mortality of animals poisoned
with tartar emetic and several organic antimonial
compounds (Eagle et al., J. Pharmacol., 1947, 89,
196; Braun et al, ibid., Suppl., 1946, 87, 119).
In all cases of suspected poisoning, the vomit, the
passages from the bowels, and especially the urine
should be reserved for chemical examination. The
metal has been found in all the tissues of the body
and is most abundant in the liver.

Dose. — The dose of tartar emetic varies
greatly according to the purpose for which it is
employed. As a diaphoretic or expectorant it may
be given 2 or 3 times daily in doses of 2 to 8 mg.
(approximately %o to y& grain) by mouth. If
used as an oral emetic, the dose is usually about
30 to 60 mg. (approximately Y to 1 grain).

As an intravenous injection in the treatment
of protozoal or other infections it is usually given
in the form of a 0.5 to 1 per cent solution in dis-
tilled water, normal saline or dextrose-saline solu-
tion. The drug is preferably taken from a freshly
opened container and dissolved in a sterile solvent
with aseptic precautions although sterilization may
be accomplished by boiling gently for 5 minutes
or by filtration; solutions should not be auto-
claved (War Med., 1945, 7, 403, but see steriliza-
tion method described under Injection of Anti-
mony Potassium Tartrate). For doses employed
see under Uses. The U.S. P. gives the usual in-
travenous dose as 40 mg. (approximately Yz
grain), in the form of 0.5 per cent solution, three
times a week, with a range of dose of 20 to 100
mg.; the maximum single dose is 100 mg., which
should not be exceeded in 24 hours, and the total
course should not exceed 1.5 to 2 Gm.

Great care is required in injecting these solu-
tions because of the danger of very troublesome
cellulitis if any should escape into the surrounding
tissues.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep. — Compound Opium and Glycyr-
rhiza Mixture; Compound Squill Syrup, NJ?.

INJECTION OF ANTIMONY
POTASSIUM TARTRATE. B.P. (LP.)

Injection of Potassium Antimonyltartrate, Injectio
Antimonii et Potassii Tartratis

This injection is a sterile solution of antimony
potassium tartrate in water for injection, the solu-
tion being sterilized by heating in an autoclave
(115° to 116° for 30 minutes) or by filtration
-through a bacteria-proof filter. It is required to

contain not less than 94.0 per cent and not more
than 105.0 per cent of the labeled amount of anti-
mony potassium tartrate. B.P. The LP. limits for
Injection of Potassium Antimonyltartrate are the
same. For uses and dose see the preceding mono-
graph.

ANTIMONY SODIUM TARTRATE.
B.P. (LP.)

Sodium Antimonyltartrate, Antimonii et Sodii Tartras

Antimony Sodium Tartrate is made by the in-
teraction of antimonious oxide and sodium acid
tartrate. It contains not less than 96.0 per cent
of C4H407SbNa, with reference to the substance
dried to constant weight at 105°; the LP. specifies
the same rubric but refers to the substance dried
at 110°.

I. P. Sodium Antimonyltartrate; Stibii et Natrii
Tartras.

Description and Standards. — Antimony so-
dium tartrate occurs as colorless and transparent,
or whitish, scales or powder, it is odorless, has a
sweetish taste, and is hygroscopic. It dissolves in
1.5 parts of water but is insoluble in alcohol. It
responds to tests for sodium, antimony, and tar-
trates. Not more than 2 ml. of either 0.01 N
sulfuric acid or 0.01 AT sodium hydroxide is re-
quired to bring the pH of a solution containing
1 Gm. in 50 ml. to a pH of 4.5 (corresponding to
a green color with bromocresol green). The
arsenic limit is 8 parts per million; the lead limit
is 5 parts per million. At 105° it loses not more
than 6.0 per cent of its weight.

Assay. — The assay is as described under Anti-
mony Potassium Tartrate. Each ml. of 0.1 N
iodine represents 15.44 mg. of C4H40-SbNa. B.P.
The LP. assay differs from that of the B.P. only
in minor details.

Uses. — Antimony sodium tartrate is used for
the same therapeutic purposes and in about the
same dose as tartar emetic (see Antimony Potas-
sium Tartrate). It has the advantages over the
potassium salt of being considerably more soluble
in aqueous media, and less irritant when injected.

Doses. — As an expectorant, 2 to 8 mg. (ap-
proximately %o to y& grain) ; as an emetic, 30 to
60 mg. (approximately Y to 1 grain) ; as a proto-
zoicide, 30 to 120 mg. (approximately Y to 2
grains), by intravenous injection. |v]

Storage. — Sodium Antimony Tartrate should
be kept in a well-closed container. LP.

INJECTION OF ANTIMONY SODIUM
TARTRATE. B.P. (LP.)

Injection of Sodium Antimonyltartrate, Injectio
Antimonii et Sodii Tartratis

This injection is a sterile solution of antimony
sodium tartrate in water for injection, the solu-
tion being sterilized by heating in an autoclave
(115° to 116° for 30 minutes) or by filtration
through a bacteria-proof filter. It is required to
contain not less than 85.5 per cent and not more
than 105.0 per cent of the labeled content of anti-
mony sodium tartrate. B.P. The corresponding
LP. limits for Injection of Sodium Antimonyl-
tartrate are 95.0 and 105.0 per cent, respectively.
For uses and dose see the preceding monograph.

Part I

Antipyrine 99

SODIUM ANTIMONYLTHIOGLY-
COLLATE. I.P.

Stibii et Natrii Thio'glycollas

/S.CH2.COONa

Sbr

\s.cH2.coo

"Antimony Sodium Thioglycollate, dried at
105° for 2 hours, contains not less than 96 per
cent and not more than 101 per cent of C-tHtNaO-i-
S2SD." U.S.P. XIV. The I.P. requires not less than
35.5 per cent and not more than 38.5 per cent of
Sb, calculated with reference to the substance
dried at 100° for 4 hours.

U.S.P. XIV. Antimony Sodium Thioglycollate. Sp.
Tioglicolato de Sodio y Antimonio.

Antimony sodium thioglycollate may be ob-
tained by dissolving antimony trioxide in a solu-
tion containing an equimolecular mixture of thio-
glycollic acid and sodium thioglycollate; on evapo-
rating the solution the salt is obtained.

Description. — "Antimony Sodium Thioglycol-
late occurs as a white or pink powder. It is odorless
or has a faint mercaptan odor, and is discolored
by light. Antimony Sodium Thioglycollate is
freely soluble in water. It is insoluble in alcohol."
U.S.P. XIV.

Standards and Tests. — Identification. — (1)
A transient blue color is produced on adding 1
drop of diluted hydrochloric acid and 2 drops of
a 1 in 100 ferric chloride solution to 3 ml. of a 1
in 100 solution of antimony sodium thioglycol-
late; on subsequently adding 1 drop of dilute am-
monia T.S. (1 in 10) a deep red color is produced.
(2) A white precipitate is produced on adding 1
ml. of sodium hydroxide T.S. to 3 ml. of a 1 in 100
solution of antimony sodium thioglycollate. (3)
An orange precipitate is produced on passing hy-
drogen sulfide into a solution of 100 mg. of anti-
mony sodium thioglycollate in 2 ml. of water.
Loss on drying. — Not over 2 per cent when dried
at 105° for 2 hours. U.S.P. XIV.

Assay. — About 600 mg. of antimony sodium
thioglycollate, previously dried at 105° for 2
hours, is dissolved in water containing hydro-
chloric acid. After adding tartaric acid hydrogen
sulfide is passed into the solution until precipita-
tion of antimonous sulfide is complete; the pre-
cipitate is successively washed with hydrogen sul-
fide T.S., alcohol, ether, carbon disulfide, alcohol
and ether, and dried to constant weight. The
weight of sulfide multiplied by 1.913 represents
the equivalent in terms of C4H4Na04S2Sb. U.S.P.
XIV. The I.P. assay is practically identical.

Uses. — This trivalent antimonial was reported
by Randall (Am. J. Med. Sc, 1924, 168, 723) to
be less toxic and more effective than antimony
potassium tartrate in the treatment of granuloma
inguinale (due to Leishmania donovani). He ad-
vised at least 12 doses to be administered after
the healing of the lesion. These findings were con-
firmed by Patch and Blew (Can. Med. Assoc. J.,
1930, 23, 637) and by Senear and Cornbleet
(Arch. Dermat. Syph., 1932, 25, 167). The com-
pound has also been employed in treating kala-
azar. It has proved to be less toxic than antimony
thioglycollamide (see in Part II), but also less

stable; as is generally true of the trivalent anti-
monials, it is more toxic than the pentavalent
derivatives.

Dose. — From 50 to 100 mg. (approximately
Yi, to 1^2 grains), dissolved in 10 to 20 ml. of
sterile distilled water, may be given every third
or fourth day, intravenously, subcutaneously or
intramuscularly, for 15 or 25 doses.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P. XIV.

INJECTION OF SODIUM ANTI-
MONYLTHIOGLYCOLLATE. I.P.

Injectio Stibii et Natrii Thioglycollatis

This injection is a sterile solution of sodium
antimonylthioglycollate in water for injection;
1.0 per cent of sodium citrate and 0.1 per cent of
thioglycollic acid may be used for preservation;
the solution is sterilized by heating in an autoclave
(30 minutes at 115° to 116°) or by filtration
through a bacteria-proof filter. The content of
sodium antimonylthioglycollate (C4H404S2SbNa)
is not less than 93.0 per cent and not more than
107.0 per cent of the labeled amount.

Storage. — Preserve preferably in single-dose,
hermetically-closed containers, or in multiple-
dose containers, protected from light. I.P.

ANTIPYRINE. N.F. (I.P.)

Phenazone, [Antipyrina]

CH,

The I.P. defines Phenazone as 2 : 3 -dimethyl- 1-
phenyl-5-pyrazolone.

I.P. Phenazone ; Phenazonum. Phenyldimethylpyra-
zolonum; Pyrazolonum Phenyldimethylicum. Fr. Phenyl-
dim^thylpyrazolone; Dimethyloxyquinizine. Ger. Phenyl-
dimethylpyrazolon; Antipyrin. It. Fenil-dimetilisopira-
zolone; Antipirina. Sp. Antipirina; Fenazona.

Antipyrine was one of the first important syn-
thetic medicinals ; it was introduced into medicine
in 1887 as a result of research by Knorr directed
toward the preparation of compounds possessing
a quinine-like structure. Structually it is 1,5-di-
methyl-2-phenyl-3-pyrazolone, named according to
the standard nomenclature used in the United
States, or l-phenyl-2,3-dimethyl-5-pyrazolone, if
the tautomeric designation followed by the I.P.
is used. Antipyrine may be classed as a derivative
of pyrrole, C4H5N, found in coal tar, or more
directly of pyrazole, which differs from pyrrole in
having an atom of nitrogen in the number two
position in place of — CH= in pyrrole. Pyrazole
has the formula

HC5

HC-

-CH

and is isomeric with imidazole (the parent com-
pound of histamine) ; in imidazole the tertiary

100 Antipyrine

Part I

nitrogen is at the number three position (see under
Histamine Phosphate).

Synthesis of antipyrine may be effected in sev-
eral ways. In one process phenylhydrazine,
Cr,H.-.XH.XH2, is heated with ethyl acetoacetate,
(CH3CO)CH2.COOC2H5) to form the phenylhy-
drazone of ethyl acetoacetate which loses a mole-
cule of alcohol and forms a phenyl-methyl-pyra-
zolone; this is methylated to antipyrine. Other
syntheses use methylphenylhydrazine along with
the enol form of ethyl acetoacetate or a halogen-
crotonic ethyl ester without subsequent methyla-
tion.

Description. — "Antipyrine occurs as colorless
crystals, or as a white, crystalline powder. It is
odorless, has a slightly bitter taste, and its solu-
tions are neutral to litmus paper. One Gm. of
Antipyrine dissolves in less than 1 ml. of water,
in 1.3 ml. of alcohol, in 1 ml. of chloroform, and
in 43 ml. of ether. Antipyrine melts between 110°
and 112.5°." N.F. ,

Standards and Tests. — Identification. — (1)
A white precipitate forms on adding tannic acid
T.S. to an aqueous solution of antipyrine. (2) A
nearly colorless solution results on adding 100
mg. of sodium nitrite to 12 ml. of a 1 in 100 solu-
tion of antipyrine ; addition of 1 ml. of diluted sul-
furic acid produces a deep green color. (3) A
deep red color forms when one drop of ferric
chloride T.S. is added to 2 ml. of a 1 in 1000
solution of antipyrine; on adding 10 drops of sul-
furic acid the color changes to a light yellow. (4)
An orange-yellow precipitate forms on heating to
boiling a mixture of 100 mg. antipyrine, 100 mg.
vanillin, 5 ml. of distilled water, and 2 ml. of sul-
furic acid. Loss on drying. — Not over 1 per cent,
when dried at 60° for 2 hours. Residue on ignition.
— Xot over 0.15 per cent. Heavy metals. — The
limit is 20 parts per million. Completeness and
color of solution. — Antipyrine dissolves com-
pletely in an equal weight of cold distilled water,
forming a colorless or not more than slightly yel-
low (viewed transversely in a tube of 20 mm.
diameter) solution. N.F.

Incompatibilities. — Antipyrine is precipi-
tated by most of the alkaloidal reagents, including
potassium mercuric iodide, iodine, mercuric chlo-
ride, and tannic acid. It partially decomposes
calomel with the production of mercuric chloride
and metallic mercury, the mixture darkening in
color. This reaction is more rapid in the presence
of sodium bicarbonate. With nitric acid it be-
comes first yellow and later red. With nitrites
such as ethyl nitrite, the green compound iso-
nitrosoantipyrine is formed. With ferric salts a
red color is produced. With copper salts a green
color is produced. It liquefies or forms a soft mass
when triturated with acetanilid, betanaphthol,
chloral, phenol, phenyl salicylate, pyrogallol, so-
dium salicylate, and thymol.

Uses. — Locally antipyrine exercises an anes-
thetic effect upon the nerve endings (see Sollman,
J. A.M. A., 1918, 70, 216) and causes constriction
of the superficial vessels. When ingested it acts
as an analgesic and mild antipyretic. It has been
used in measurement of body water in humans
(see Soberman, /. Biol. Chem., 1949, 179, 31).

Brodie and Axelrod (/. Pharmacol, 1950, 98,
97) found antipyrine to be completely absorbed
from the gastrointestinal tract and then to be
evenly distributed throughout the body water.
Only about 5 per cent of the drug is excreted in
the urine, the remainder being metabolized in
the body.

Antipyrine is useful in medicine for the relief
of pain, as neuralgias, myalgias, migraine and
similar conditions. Its action is more prompt than
that of aniline derivatives but it has lost favor
to the less toxic and equally effective salicylates.
It is less effective that aminopyrine but it is not
known to have caused agranulocytosis. It has been
used in certain spasmodic disorders, especially
whooping-cough and epilepsy. Antipyrine has also
been used as a mild antipyretic.

In the treatment of various inflammatory con-
ditions of the mucous membranes, as rhinitis and
laryngitis, antipyrine is sometimes employed for
its local anesthetic and vasoconstricting effects.
For this purpose it is usually applied in strengths
of from 5 to 15 per cent. It is occasionally used
as a styptic in nasal hemorrhage, [v]

Toxicology. — Antipyrine occasionally pro-
duces unpleasant and sometimes alarming symp-
toms, even after doses which would scarcely be
regarded as excessive. The most common type of
antipyrine poisoning is characterized by giddiness,
tremor, free sweating with more or less collapse,
a peculiar lividity with, in many cases, eruption
of the skin most commonly morbilliform, but
sometimes erythematous or urticarial. It causes
less cyanosis than does acetanilid. After very
large doses there may be drowsiness, deepening
into coma, with dilatation of the pupil and epilep-
tiform convulsions. Various irregular symptoms
have been noted, such as amaurosis, pseudomem-
branous stomatitis, swelling of the lips and tongue,
laryngeal interference with the respiration. In
some cases fever with nervous unrest and epilepti-
form convulsions have been reported.

The treatment of antipyrine poisoning is purely
symptomatic. Circulatory stimulants, as ammonia,
strychnine and atropine, should be given and the
bodily temperature maintained by external appli-
cation of heat.

Dose. — The usual dose is 300 mg. (approxi-
mately 5 grains); the I.P. gives the usual daily
dose as 1 Gm. but indicates that as much as 1 Gm.
at a time, and 4 Gm. daily, may be given.

Storage. — Preserve "in tight containers." N.F.

N.F. ANTISEPTIC SOLUTION. N.F.

Liquor Antisepticus N.F.

Dissolve 25 Gm. of boric acid in 650 ml. of hot
purified water and allow the solution to cool. Dis-
solve 0.5 Gm. of thymol, 0.5 Gm. of chlorothymol,
0.5 Gm. of menthol, 0.1 ml. of eucalyptol, 0.2 ml.
of methyl salicylate, and 0.01 ml. of thyme oil in
300 ml. of alcohol. Mix the two solutions and
add sufficient purified water to make 1000 ml.
Keep the product in a tightly closed container
during 2 hours or more, cool to 10° and filter at
this temperature, using purified talc, if necessary,
to clarify the product. Note. — Specially denatured

Part I

Apomorphine Hydrochloride 101

alcohol Formula No. 38-B, prepared by adding
6 pounds of boric acid and V/z pounds each of
thymol, chlorothymol, and menthol to 100 gallons
of ethyl alcohol, has been approved by the U. S.
Treasury Department as being suitable for use in
making this solution provided that adjustment is
made for the quantities of formula ingredients in
the denatured alcohol. N.F.

Description. — "N.F. Antiseptic Solution is a
clear, colorless liquid having an aromatic odor and
a characteristic taste. It is acid to litmus paper.
The specific gravity of N.F. Antiseptic Solution
is about 0.971." N.F.

Tests. — Quantitative test for boric acid. — The
intensity of color produced on adding a turmeric
solution to N.F. antiseptic solution is not less than
that developed by adding the turmeric solution
to a 2.3 w/v per cent solution of boric acid in a
30 in 100 solution of alcohol in water. Antibac-
terial test. — To 5 ml. of N.F. antiseptic solution
is added 0.5 ml. of a standard culture of Staphylo-
coccus aureus, both having been kept at 37.5°
before mixing; after mixing, the liquid is also
kept at this temperature. After exactly 5 minutes,
a standard loopful of the mixture is transferred
to each of 3 subculture tubes containing 10 ml.
of standard culture medium and the tubes incu-
bated at 37.5° for 48 hours, at the end of which
time no bacterial growth appears in the tubes.
For information concerning the standard culture,
the standard culture medium, and the standard
loopful reference should be made to the National
Formulary.

Alcohol Content. — From 26 to 29 per cent,
by volume, of C2H5OH. N.F.

Uses. — Although this preparation is an anti-
septic it is too much to expect that its use in the
mouth — which is the reason for its existence — will
have material influence on the oral flora. As ordi-
narily used by the laity, adequate time is not
provided for the solution to exert its full effect;
moreover, constant flow of saliva dilutes and
washes away this and any other soluble antiseptic.
But the solution is useful as a deodorant wash
and is probably as valuable for this purpose as
any proprietary solution on the market. The N.F.
recommends that the wash be used undiluted.

Storage. — Preserve "in tight containers."
N.F.

APOMORPHINE HYDROCHLORIDE.
U.S.P., B.P., LP.

Apomorphinium Chloride, [Apomorphinae
Hydrochloridum]

CH3.H

cr.^Hp

"Apomorphine Hydrochloride is the hydrochlo-
ride of an alkaloid prepared from morphine."

U.S.P. XIV. The B.P. requires it to contain not
less than 83.0 per cent of C17H17NO2, calculated
with reference to the substance dried to constant
weight at 105°. The LP., like the U.S.P., has no
assay requirement.

I. P. Apomorphini Hydrochloridum. Apomorphinum
Hydrochloricum; Chloretum Apomorphinicum; Apomorphi-
num Chlorhydricum. Fr. Chlorhydrate d'apomorphine.
Ger. Apomorphinhydrochlorid; Salzsaures Apomorphin. It.
Cloridrato di apomorfina. Sp. Clorhidrato de apomorfina.

Apomorphine, in the form of its sulfate, was
first prepared by Arppe in 1845. The base is
obtained by the elimination of the elements of a
molecule of water from a molecule of morphine
on heating the latter alkaloid in the presence of
acids; a slight rearrangement of the molecular
structure occurs simultaneously. In one process,
apomorphine is prepared by heating morphine
with eight times its weight of concentrated hydro-
chloric acid in a suitable glass-lined autoclave
for 2 or 3 hours at 140° to 150°. After evaporat-
ing a portion of the free acid, the apomorphine
hydrochloride crystallizes on cooling. The crude
product is purified by recrystallization. Because
of the ease of oxidation, exposure to air must be
avoided as much as possible. Apomorphine may
also be made from codeine, which is a methyl-
morphine.

Apomorphine base crystallizes with one mole-
cule of water. It is soluble in alcohol, acetone,
chloroform ; sparingly soluble in ether or benzene,
and insoluble in petroleum benzin. According to
Heiduschka and Meisner {Arch. Pharm., 1923)
apomorphine sublimes in a vacuum. Apomorphine,
in the form of its dimethyl ether, has been syn-
thesized by Pschorr and Avenarius, and by Spaeth
and Hromatka {Ber., 1929).

Description. — "Apomorphine Hydrochloride
occurs as minute, white or grayish white, glisten-
ing crystals or white powder. It is odorless. It
gradually acquires a green color on exposure to
light and air. Its solutions are neutral to litmus.
One Gm. of Apomorphine Hydrochloride dissolves
in about 50 ml. of water and in about 50 ml. of
alcohol. One Gm. dissolves in about 20 ml. of
water at 80°. It is very slightly soluble in chloro-
form and in ether." U.S.P.

Standards and Tests. — Identification. — (1)
A white or greenish white precipitate is formed on
adding a slight excess of a 1 in 20 solution of
sodium bicarbonate to 5 ml. of a 1 in 100 solution
of apomorphine hydrochloride. On adding to this
3 drops of iodine T.S. and shaking, an emerald
green solution is produced. If this mixture is
shaken with 5 ml. of ether and the layers are
allowed to separate, a deep ruby red color is ob-
served in the ether layer while the aqueous phase
remains green. (2) A dark purple solution is
formed when apomorphine hydrochloride is dis-
solved in nitric acid. (3) A white precipitate, in-
soluble in nitric acid, results when silver nitrate
T.S. is added to a solution of apomorphine hydro-
chloride; the precipitate soon turns black because
of reduction to metallic silver. Addition of am-
monia T.S. hastens the reduction. Water. — Not
over 3.5 per cent, determined by drying 500 mg.
of apomorphine hydrochloride at 105° for 2 hours.

102 Apomorphine Hydrochloride

Part I

Specific rotation. — Not less than —49° and not
more than —51°, determined in 0.02 N hydro-
chloric acid containing the equivalent of 150 mg.
of anhydrous apomorphine hydrochloride in each
10 ml. Color of solution. — A solution of 100 mg. of
apomorphine hydrochloride in 10 ml. of oxygen-
free distilled water has no more color than a
standard prepared as follows: to 1 ml. of a solu-
tion containing 5 mg. of apomorphine hydrochlo-
ride in 100 ml. of water are added, successively,
6 ml. of distilled water, 1 ml. of a 1 in 2Q sodium
bicarbonate solution, and 0.5 ml. of iodine T.S.;
after standing 30 seconds 0.6 ml. of 0.1 N sodium
thiosulfate is added and the solution is diluted to
10 ml. Residue on ignition. — A negligible residue
is obtained from 200 mg. of apomorphine hydro-
chloride. Decomposition products. — Not more
than a pale reddish color develops when 100 mg.
of apomorphine hydrochloride is shaken with 5 ml.
of ether. U.S.P.

The B.P. requires'that the precipitate produced
on addition of sodium bicarbonate be soluble in
ether with the production of a purple solution, in
chloroform to produce a blue solution and in 90
per cent alcohol to form a green solution. The B.P.
permits up to 5.0 per cent loss of weight on drying
at 105°. The LP. limits loss of weight on drying
also to 5.0 per cent, but the substance is dried
to constant weight in a vacuum desiccator over
sulfuric acid or phosphorus pentoxide.

Incompatibilities. — Apomorphine hydrochlo-
ride forms precipitates with sodium bicarbonate,
tannic acid and most alkaloidal reagents. It is
incompatible with oxidizing agents, forming col-
ored solutions.

Aqueous or alcoholic solutions of apomorphine
are unstable, gradually acquiring a green color.
Amy (/. A. Ph. A., 1931, 20, 1153) has shown
that this change is not due to the action of light;
it may be prevented by replacing the air in am-
puls of the solution with carbon dioxide. The
oxidation takes place more readily in alkaline
solutions, and may be retarded by the addition of
a little hydrochloric or acetic acid. The B.P. adds
0.1 per cent w/v of sodium metabisulfite to delay
decomposition of the official injection of apomor-
phine hydrochloride. Solutions which have a
green color are not to be used.

Uses. — Apomorphine hydrochloride is a prompt
and efficient emetic, producing results in 10 to 15
minutes. Apomorphine induces emesis through a
central action only. Eggleston and Hatcher
(/. Pharmacol, 1912, 3, 551) located the site
of action at the vomiting center in the medulla,
but more recently Wang and Borrison {Arch.
Neurol. Psychiat., 1950, 63, 928, and Proc. S. Exp.
Biol. Med., 1951, 76, 335) described a chemo-
sensitive trigger zone in the floor of the fourth ven-
tricle which is sensitive only to emetic chemicals
and does not respond as does the previously
described vomiting center to electrical stimula-
tion. Ablation of this zone produces in dogs tol-
erance to apomorphine in doses as high as 1 Gm.
intravenously (Gastroenterology, 1952, 22, 1).

Therapeutic doses ordinarily have very little
other action although in large doses, and occa-
sionally in therapeutic doses, it has a hypnotic
effect (Rosenwasser, Med. Rec, July, 1907). At

times it causes euphoria, restlessness and tremors.
There have been instances of serious depression
and even death of feeble patients from the use of
therapeutic doses. Although very large doses have
a depressant action on the heart, it is probable
that these unfortunate occurrences are due to
the marked relaxation of the arteries and conse-
quent fall of blood pressure which accompanies
violent nausea. Apomorphine should not be used
as an emetic in persons with enfeebled circulation
such as occurs in cases of corrosive poisoning with
peripheral vascular collapse, or narcosis due to
opiates, barbiturates, ethyl alcohol, etc.

Rovenstine and Hershey (Anesth., 1945, 6, 574)
brought under control within 5 to 10 minutes the
excessive central nervous system stimulation in
patients with emergence delirium following gen-
eral anesthesia by the slow intravenous or intra-
muscular administration of 1.3 to 2 mg. of
apomorphine hydrochloride in 10 ml. of isotonic
sodium chloride solution. Similar results were
obtained in patients with excessive muscular or
psychic activity due to other causes.

Apomorphine hydrochloride is useful in cases
of poisoning or any other condition where it is
desired promptly to empty the stomach. Its ad-
vantages are its lack of irritation of the gastric
mucosa, the smallness of dose which makes it
possible to carry it in the form of a hypodermic
tablet, and the promptness of its effect. In cases
of narcotic poisoning, however, it frequently fails
to act because of the depression of the vomiting
center. When vomiting does not result from the
first dose, it should not be repeated. In doses too
small to act as an emetic, it is a nauseating
expectorant in the early stages of acute bronchitis.
One drawback to its wider use for this purpose is
its instability in solution. White (Am. J. Obst.
Gynec, 1952, 64, 91) found apomorphine in
combination with scopolamine useful in producing
analgesia and amnesia during labor. Subcuta-
neous doses of 0.6 to 1.2 mg. appeared to poten-
tiate scopolamine analgesia and the combined
drugs decreased the need for inhalation anesthesia.
No untoward effects were observed.

Apomorphine hydrochloride is best used hypo-
dermically; orally, its emetic action is not de-
pendable and from 3 to 5 times the hypodermic
dose is required. Nor is oral administration suit-
able for the "conditioned reflex" method of treat-
ing alcoholism (Quart. J. Stud. Alcohol, 1940, 1,
501). It is absorbed sublingually (Walton,
J.A.M.A., 1944, 124, 139), the emetic dose
being from 6.5 to 10 mg. (approximately Vio to Vs
grain), [v]

The usual dose, subcutaneously, is 5 mg. (ap-
proximately Yn grain) with a range of 1 to 5 mg. ;
the maximum safe dose is 5 mg. and the total
dose in 24 hours should seldom exceed 10 mg.
The emetic dose for an infant is 1 mg. (approxi-
mately Y60 gr.) hypodermically or 3 to 5 mg.
orally (J. A.M. A., 1944, 124, 138). As an expec-
torant, 1 to 2 mg. has been used subcutaneously.

Storage. — Preserve "in small, tight, fight-re-
sistant vials containing not more than 350 mg.
The restriction of 350 mg. applies only to con-
tainers from which prescriptions are filled." U.S.P.

Part I

Aprobarbital 103

INJECTION OF APOMORPHINE
HYDROCHLORIDE. B.P., I.P.

Injectio Apomorphinae Hydrochloridi

This injection is a sterile solution of apomor-
phine hydrochloride in water for injection; it
contains also 0.1 per cent w/v of sodium meta-
bisulfite. The solution is sterilized by heating with
a bactericide (0.2 per cent w/v of chlorocresol
or 0.002 per cent w/v of phenylmercuric nitrate
in the solution) to maintain a temperature of
98° to 100° for 30 minutes, or by filtration
through a bacteria-proof filter. B.P. The I.P. em-
ploys 0.05 per cent of sodium pyrosulfite (meta-
bisulfite). Neither pharmacopeia provides an as-
say rubric.

The injection should be protected from light;
it may decompose on standing and if a green
color develops the solution should be rejected.

APOMORPHINE HYDROCHLORIDE.
TABLETS. U.S.P.

[Tabellae Apomorphinae Hydrochloridi]

"Apomorphine Hydrochloride Tablets contain
not less than 90 per cent and not more than 110
per cent of the labaled amount of C17H17NO2.-
HC1.^H20." U.S.P.

Sp. Tabletas de Clorhidrato de Apomorfina.

Assay. — A representative sample of powdered
tablets, equivalent to about 50 mg. of apomor-
phine hydrochloride, is dissolved in water and,
after adding sodium bicarbonate, extracted with
peroxide-free ether to remove the apomorphine.
After washing the combined ether extracts 20 ml.
of 0.02 N sulfuric acid is added and the mixture
agitated thoroughly; the excess of acid in the
aqueous phase is titrated with 0.02 N sodium hy-
droxide, using methyl red T.S. as indicator. Each
ml. of 0.02 N sulfuric acid represents 6.256 mg. of
Ci7Hi7N02.HCl.^H20. U.S.P.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Usual Size. — 5 mg. (approximately Vvi grain).

APROBARBITAL. N.F.

Allylisopropylbarbituric Acid, Allylisopropylmalonyurea

{C^2

CH2CH=CH2

Alurate (Hoffmann-LaRoche) .

Aprobarbital, which is 5-allyl-5-isopropylbar-
bituric acid, may be prepared either by treating
isopropylbarbituric acid with allyl halide at low
temperature, according to German Patent 539,806
(1920), or by heating isopropylallylmalonic acid
with urea in the presence of sodium alcoholate,
acidification of the product yielding the free acid,
according to Swiss Patent 167,802 (1934).

Description. — "Aprobarbital occurs as a fine,
white, odorless crystalline powder having a
slightly bitter taste. It is stable in air. A saturated
solution is acid to litmus paper. Aprobarbital is
very slightly soluble in cold water and is soluble

in alcohol, in chloroform, and in ether. Apro-
barbital melts between 140° and 141.5°." N.F.

Standards and Tests. — Identification. — Tests
(1) and (2) are practically identical with iden-
tification tests (1) and (2) under Barbital and
Cyclobarbital, while test (3) is the same as iden-
tification test (3) under Cyclobarbital. Loss on
drying. — Not over 1 per cent, when dried at 105°
for 2 hours. Residue on ignition. — Not over 0.1
per cent. Readily carbonizable substances. — A
solution of 500 mg. of aprobarbital in 5 ml. of
sulfuric acid has no more color than matching
fluid A. N.F.

Aprobarbital Sodium. — The sodium deriva-
tive of aprobarbital is not officially recognized
but it is included in N.N.R., where it is described
as a white, microcrystalline, hygroscopic, odorless
powder with a slightly bitter taste. It is very
soluble in water, very slightly soluble in alcohol,
and practically insoluble in ether. Aqueous solu-
tions of aprobarbital sodium are alkaline to litmus.
The N.N.R. states that the uses of aprobarbital
sodium are the same as those of aprobarbital.
The soluble sodium salt is intended for oral or
rectal administration, particularly as preanesthesia
medication; it may also be used in other cases in
which large individual doses are required.

Uses. — According to the classification by Fitch
and Tatum (/. Pharmacol., 1932, 44, 325) apro-
barbital is regarded as having intermediate dura-
tion of action (see article on Barbiturates, in
Part II, for general discussion). It is longer act-
ing than amobarbital, but shorter than barbital
(Tatum, Physiol. Rev., 1939, 19, 472). Actually
the actions and uses of aprobarbital are similar
to those of barbital but it is more active, hence
the dosage is smaller.

Aprobarbital has been reported to reduce the
convulsive threshold to epileptogenic stimuli, as
does phenobarbital and phenylhydantoin (Barany,
Arch, internat. pharmacodyn. therap., 1947, 74,
155). It is useful for general mild sedation, when
it is administered orally. Aprobarbital has been
reported to be useful as a rectal analgesic agent
during labor, the sodium derivative being used
for this purpose. Graham and Pettit {Am. J. Obst.
Gyn., 1938, 35, 1023) reported that when ad-
ministered in this manner they were able to pro-
duce amnesia in 67 per cent of cases and partial
amnesia in an additional 22 per cent. However, it
tended to prolong duration of labor 2 to 5 hours.
Hauch {Acta obst. et gynec. Scandinav., 1938, 18,
164) previously had employed the drug as a basal
amnesic agent in normal deliveries, and Huard
et al. {Rev. med. franc, d' Extreme-Orient., 1938,
16, 279) attested to intravenous use of the so-
dium derivative preoperatively for basal sedation.

Apparently the fairly long duration of sedation
produced by aprobarbital is due to its slow elimi-
nation by excretion and by degradation. Maynert
and Van Dyke {Pharmacol. Rev., 1949, 1, 217)
quote available literature to the effect that the
compound is excreted by man to the extent of
13 to 24 per cent of a single dose. Following re-
peated administration it may continue to be
excreted in urine for 3 to 5 days. Masson and
Beland {Anesthesiology, 1945, 6, 483) reported
that aprobarbital is partially metabolized, mainly

1 04 Aprobarbital

Part I

in the liver. While the compound has not been
found to be particularly toxic, Hoick et al. (J. A.
Ph. A., 1950, 39, 630) reported development of
tolerance to aprobarbital and cross-tolerance to
Nostal. Jurgens (Arch. exp. Path. Pharm., 1951,
212, 440) found that this drug did not produce
any blood dyscrasias when administered to rabbits.

Dose. — For mild sedation, 60 mg. (approxi-
mately 1 grain) of aprobarbital at bedtime; in
obstinate cases 130 mg. may be administered.
For preoperative use the average dose, commonly
of the sodium derivative, is 10 mg. per Kg. of
body weight. One-third of the calculated dose is
administered orally 10 to 12 hours (or the eve-
ning) before surgery; the remainder being given
2 hours before the operation. Since this is a large
dose, care and judgment must be exercised in its
use to avoid undesirably heavy sedation.

Storage. — Preserve "in well-closed contain-
ers." N.F.

ARALIA. N.F.

American Spikenard, Spignet, [Aralia]

"Aralia consists of the dried rhizome and roots
of Aralia racemosa Linne (Fam. Araliacece) ."
N.F.

American Spikenard is a perennial herb with
several widely branched, unarmed, aerial stems
which arise to the height of 1 to 1.8 meters and
bear ternately to quinately compound leaves,
each with broadly ovate leaflets having acumi-
nate apices, cordate bases and doubly serrate
margins. The flowers are small, greenish-yellow,
and borne on panicles of umbels. The fruits are
sub-globular, dark purplish to reddish-brown
berries. It is indigenous to eastern North Amer-
ica west to Minnesota and Missouri. The rhi-
zomes and roots are collected in summer and
autumn, cut into segments, the thicker rhizomes
cut lengthwise and all carefully dried. Most of
the commercial drug comes from Indiana, Mis-
souri, North Carolina, Virginia, Washington and
Illinois.

Description. — "Unground Aralia. — The rhi-
zome of Aralia is oblique, about 12 cm. long and 5
cm. thick, somewhat flattened, tortuous, externally
weak brown to weak yellowish orange, often scaly,
somewhat annulately roughened, frequently cut
longitudinally, and lighter-colored internally. The
nodes are approximate, each having a prominent
stem-scar about 3 cm. in width. The fracture is
fibrous. Roots are numerous, of varying length
and up to 25 mm. thick; externally furrowed,
sometimes with transverse ridges and corky
patches, pale red-purple to weak yellowish orange,
usually cut longitudinally, the cut surfaces lighter-
colored and spongy. The fracture of the cortex is
short and of the wood short-fibrous. Aralia has
an aromatic odor and a mucilaginous, pungent,
and slightly acrid taste." N.F. For histology see
N.F.X.

"Powdered Aralia is light yellowish brown. The
starch grains are simple or compound, spherical
or angular, from 5 to 25 n in diameter. The ro-
settes of calcium oxalate are from 30 to 70 n
in diameter. The vessels have sclariform or reticu-
late thickenings and simple or bordered pits.

The powder also shows characteristic lignified
cells from the hypodermis, 40 to 100 n in length
and about one-half as broad, their walls showing
simple pits (distinction from Aralia nudicaulis
root)." N.F.

Closely allied to the official species, both bo-
tanically and therapeutically, are the A. nudi-
caulis L. (American, False or Wild Sarsaparilla
or Shot-bush) and the A. spinosa L. (Angelica
Tree, Hercules Club or Prickly Elder) . The latter
has sometimes been referred to, improperly, as
"prickly ash" and has occurred as an adulterant
of the true prickly ash, Xanthoxylum Ameri-
canum.

There appear to be no published reports of a
phytochemical study of A. racemosa but Holden
(Am. J. Pharm., 1880) found in A. spinosa a
saponin to which he gave the name of araliin. It
is probable that the official species owes whatever
medicinal virtue it may possess to the presence
of a small amount of a volatile oil.

Standards and Tests. — Aralia contains not
more than 5 per cent of attached stem-bases, nor
more than 2 per cent of foreign organic matter
other than stem-bases, and yields not more than
2 per cent of acid-insoluble ash. AT.F.

Uses. — Aralia has been used, especially in do-
mestic practice, as an "alterative" similar to
sarsaparilla. in the treatment of rheumatic, syphi-
litic and cutaneous affections. In medical practice
it was, at one time, occasionally employed in
pectoral complaints but now is no longer pre-
scribed. Its therapeutic value is extremely ques-
tionable and it is official only because it is an
ingredient of the compound white pine syrup.

The N.F. assigns an average dose of 2 Gm.
(approximately 30 grains).

Off. Prep. — Compound White Pine Syrup.
N.F.

ARECA. N.F.

Areca Nut, Betel Nut, [Areca]

"Areca is the dried ripe seed of Areca Catechu
Linne (Fam. Palmce). Areca yields not less than
0.35 per cent of ether-soluble alkaloids calculated
as arecoline." N.F.

Betel Xut; Areca Nut; Areca Seed. Semen Areca:.
Fr. Arec; Noix d'arec. Ger. Arekasamen ; Arekanusz;
Pinangnusz.

Areca Catechu is a tall palm tree, reaching a
height of 30 to 50 feet, indigenous to the Malay
Archipelago but now cultivated also in India,
southern China, Philippine Islands and East
Africa. Its fruit, borne in pendent panicles, is
ovoid and from 2 to 3 cm. in diameter, and of
an orange-yellow color, contains the seeds (or
"nuts") embedded in a fibrous, fleshy envelope,
and invested with a brittle shell which adheres
to the exterior flesh. The seed, the betel nut
of commerce, is of a rounded-conical shape,
rather larger than a chestnut, externally of a
deep brown, diversified with a fawn color, so as
to present a reticulate appearance, internally
brownish-red with whitish veins, very hard, of a
feeble odor when broken, and of an astringent,
somewhat acrid taste.

Immense quantities of areca nut are consumed

Part I

Arecoline Hydrobromide 105

in the East. The method used by betel chewers
consists of smearing fresh leaves of the Betel-
pepper (see Betel, Part II) with lime and cutch
and placing slices of areca nut on the leaves, some-
times with added flavoring. The entire mass is
placed in the mouth, acting as a masticatory
known by the name of Betel. The red color which
this mixture imparts to the saliva and the excre-
ments is caused by the areca nut, which is also
powerfully astringent, and, by its internal use,
tends to counteract the relaxation of bowels to
which the heat of the climate so strongly pre-
disposes.

Description. — "Unground Areca. — Areca oc-
curs as rounded-conical seeds, up to 3.5 cm. in
length and up to 3 cm. in diameter. Externally it
is weak reddish brown to light yellowish brown
and is marked with a network of paler lines.
Adhering portions of the silvery brittle endocarp
and fibers of the mesocarp are usually found at
the base of the seed. The seed is hard, the cut
surface exhibiting a marbled appearance (rumi-
nate endosperm) of brownish tissue alternating
with whitish tissue. Areca has a slight odor and
an astringent, slightly bitter taste." N.F. For
histology see N.F.X.

"Powdered Areca is weak reddish brown to
light brown. It consists principally of fragments
of the endosperm, with porous reserve-cellulose
walls, irregularly thickened stone cells of the seed
coat, a few aleurone grains up to 40 m. in diameter
and a few oil globules. Starch is absent, and spiral,
pitted and annular tracheids and vessels are few."
N.F.

Constituents. — Areca nut contains tannin,
also gallic acid, a fixed oil, gum, a little volatile
oil, lignin and several alkaloids. It yields its
astringency to water, and in some parts of Hin-
dustan an extract is prepared from it having the
appearance and properties of catechu. A red
coloring matter known as Areca red is extracted,
probably resulting from the decomposition of a
tannin. It is insoluble in cold water and ether,
soluble in boiling water and alkaline liquids, from
which it is precipitated by acids.

From the seeds of areca Jahns isolated, in 1888,
the alkaloids arecoline, arecaidine, arecaine and
gavacaine; the second and third of these have
been shown to be identical. To these have been
added arecolidine, guvacoline and, possibly, a
sixth alkaloid called isoguvacine. There is some
basis for believing the last-named to be mainly
arecaidine. Arecoline has been shown to be the
methyl ester of arecaidine, and the latter has
been identified and synthesized as 1 -methyl- A3-
tetrahydropyridine-3-carboxylic acid. Guvacoline
is now known to be the methyl ester of guvacine ;
this, too, has been identified and synthesized as
A3-tetrahydropyridine-3-carboxylic acid. For a
further discussion of these alkaloids see Henry
{Plant Alkaloids, 4th ed., 1949).

Standards and Tests. — Areca contains not
more than 2 per cent of adhering pericarp, nor
more than 1 per cent of foreign organic matter,
and yields not over 2.5 per cent of ash. N.F.

Assay. — A sample of 8 Gm. of areca, in mod-
erately coarse powder, is macerated with ether
and ammonia; an aliquot representing 5 Gm. of

drug is decanted after clarification, and most of
the ether distilled off. The alkaloids in the con-
centrated ethereal solution are extracted with
15 ml. of 0.02 N sulfuric acid and the excess acid
titrated with 0.02 N sodium hydroxide, using
methyl red T.S. as indicator. Each ml. of 0.02 N
sulfuric acid represents 3.104 mg. of alkaloids
calculated as arecoline. N.F.

Uses. — Areca nut owes its therapeutic uses
almost entirely to the alkaloid arecoline, the other
bases which it contains being relatively inert.
For description of its effects see under Arecoline
Hydrobromide.

This drug is so far as we know, almost never
used in human medicine but is employed, as a
vermifuge, by veterinarians. Its use in veterinary
medicine is described in Part III. The N.F. gives
the dose for dogs as 2 to 4 Gm. (approximately
30 to 60 grains) and for sheep as 4 to 8 Gm.
(approximately 1 to 2 drachms) depending on the
weight of the animal.

ARECOLINE HYDROBROMIDE. N.F.

Arecolinium Bromide, [Arecolinae Hydrobromidum]

"Arecoline Hydrobromide is the hydrobromide
of an alkaloid obtained from the dried ripe seed
of Areca Catechu Linne (Fam. Palmaz) or pro-
duced synthetically." N.F.

Arecolinum Hydrobromicum; Arecolinae Bromhydras.
Fr. Bromhydrate d'arecoline. Ger. Arekolinhydrobromid.
Sp. Bromhidrato de arecolina.

This alkaloid, discovered by Jahns in 1888,
is obtained from areca nut (betel nut), which
contains 0.3 to 0.6 per cent of arecoline.
In a commercial process for preparing arecoline
the powdered drug is extracted with alcohol, the
solvent evaporated under vacuum, the syrupy
residue dissolved in carbon tetrachloride and this
solution extracted with dilute sulfuric acid, which
removes the arecoline. The alkaloid may then be
separated from the aqueous solution by alkaliniz-
ing it and extracting with chloroform. The hydro-
bromide provides the most suitable means for
purifying the alkaloid by recrystallization.

Arecoline has been synthesized by several dif-
ferent methods. Mannich (Ber., 1942, 75B, 1480)
prepared it starting with methylamine hydrochlo-
ride, formaldehyde, acetaldehyde and water. Dan-
kova et al. (see Chem. Abs., 1943, 37, 381) de-
scribed what is said to be a commercially feasible
synthesis starting with ethylene oxide (see also
Ugryumov, Chem. Abs., 1941, 35, 3644).

Arecoline has the structure of methyl 1,2,5,6-
tetrahydro-1-methylnicotinate; it is a partially
hydrogenated nicotinic acid derivative. The base
is an oily, strongly alkaline, optically inactive
liquid, boiling at about 209°. It is miscible with
water, ether or chloroform and is volatile with
steam.

Description. — "Arecoline Hydrobromide oc-
curs as a white, crystalline powder, or in the form
of white crystals. It is odorless and has a bitter
taste. It is affected by light. One Gm. of Areco-
line Hydrobromide dissolves in about 1 ml. of
water, in about 10 ml. of alcohol, and in about
2 ml. of boiling alcohol. It is slightly soluble in

106 Arecoline Hydrobromide

Part I

ether or chloroform. Arecoline Hydrobromide
melts between 170° and 175°." N.F.

Standards and Tests. — Identification. — (1)
A 1 in 20 solution of arecoline hydrobromide re-
sponds to tests for bromide. (2) A red-brown
precipitate forms on adding iodine T.S. to a 1 in
50 solution of arecoline hydrobromide; a yellow
precipitate is produced by bromine T.S. Loss on
drying. — Not over 1 per cent, when dried at 80°
for 2 hours. Ash. — Not over 0.5 per cent. Acidity.
— Not over 0.2 ml. of 0.1 N sodium hydroxide is
required to neutralize 500 mg. of arecoline hydro-
bromide, using methyl red T.S. as indicator. Sul-
fate.— No turbidity or precipitate forms in 30
seconds when 1 ml. of barium chloride T.S. is
added to 10 ml. of a 1 in 100 solution of areco-
line hydrobromide, acidulated with 5 drops of
diluted hydrochloric acid. Other alkaloids. — No
precipitate or turbidity is produced when ammo-
nia T.S. or sodium hydroxide T.S. is added to a
1 in 20 solution of arecoline hydrobromide (areco-
line base is soluble in water). N.F.

In a study of the stability of aqueous solutions
of arecoline hydrobromide on sterilization, Schou
(Dansk Tids. Farm., 1936, 10, 175) found that
no hydrolysis occurred after heating for one hour
at 100° but that autoclaving for 20 minutes
at 120° decomposed 5 per cent of the areco-
line. He found that solutions of the salt are
stabilized by the addition of small amounts of
hydrochloric acid.

Uses. — Arecoline closely resembles pilocarpine
in physiological action, both drugs stimulating
structures innervated by postganglionic nerves
(see the monograph in Part II on Parasympatho-
mimetic Agents and Cholinesterase Inhibitors).
Arecoline causes a marked increase of secretions,
especially of the salivary gland, contraction of
the pupil when instilled into the eye, increased
intestinal peristalsis, constriction of bronchi, and
a slowing of the heart and vasodilatation with
resulting fall in blood pressure (Platz, Ztschr.
exp. Path. Ther., 1910, 7; Jackson, /. Pharmacol.,
1914, 5, 479). Mentova (Farmakol. i Toksikol.,
1940, 3, 1) observed constriction of the coronary
arteries in rabbits following administration of
arecoline, acetylcholine or physostigmine.

Arecoline has been employed to a small extent
in the treatment of glaucoma. A 1 per cent solu-
tion produces a marked reduction in the intra-
ocular tension, but its effects are more transient
than those of pilocarpine or physostigmine. It
may cause considerable irritation of the cornea
but apparently does not injure the continuity of
the epithelium.

Arecoline is a very potent taeniacide and ap-
parently is also poisonous to the roundworm,
but, according to Schueffner, has no influence on
the hookworm (Arch. Schiffs-Tropen-Hyg., 1912,
16, 569). Because, however, of its toxic systemic
action it has been abandoned in human medicine
but is still used by veterinarians, (v]

Toxicology. — Excessive doses cause saliva-
tion, vomiting, diuresis, coma and convulsions
(Wachholz, Ztschr. ges. gerichtl. Med., 1932, 19,
224). If ingested, gastric lavage and use of po-
tassium permanganate are indicated. Atropine

sulfate parenterally may minimize the effects of
strong parasympathetic stimulation. The N.F.
gives a dose lor horses of 30 mg. (approximately
^2 grain) subcutaneously and for dogs of 1.5 mg.
per kilogram of body weight (approximately %d
grain per pound).

Storage. — Preserve in "tight, light-resistant
containers." N.F.

ARECOLINE HYDROBROMIDE
TABLETS. N.F.

[Tabellae Arecolinae Hydrobromidi]

"Arecoline Hydrobromide Tablets contain not
less than 91 per cent and not more than 109 per
cent of the labeled amount of CsHisNCte.HBr."
N.F.

Assay. — Not less than 20 tablets are allowed to
disintegrate in distilled water, the mixture diluted
to 200 ml., filtered, and an aliquot portion equiva-
lent to about 0.3 Gm. of arecoline hydrobromide
assayed by the Volhard method for bromide con-
tent by adding a measured excess of 0.1 N silver
nitrate and some nitric acid and titrating the ex-
cess of silver nitrate with 0.1 TV ammonium thio-
cyanate using ferric ammonium sulfate T.S. as
indicator. Each ml. of 0.1 N silver nitrate repre-
sents 23.61 mg. of C8Hi3N02.HBr. N.F.

Usual Sizes. — 8, 15. 30 and 60 mg. (approxi-
mately %, x/i, Yz and 1 grain).

ARNICA. N.F.

Arnica Flowers, [Arnica]

"Arnica consists of the dried flower head of
Arnica montana Linne, known in commerce as
European Arnica or of Arnica fulgens Pursh,
Arnica sororia Greene and Arnica cordi folia
Hooker, known in commerce as American Arnica
(Fam. Compositor)" N.F.

Wolf's Bane; Mountain Tobacco. Flores Arnica. Fr.
Arnica; Fleurs d'araica. Ger. Arnikabliiten; Bergwurzel-
blumen; Blutblumen; Engelblumen ; Gamsblumen. It.
Arnica; Fiori di arnica. Sp. Arnica.

Arnica montana L. is a perennial herb having
a woody, brownish, horizontal rhizome, from 2
to 10 cm. long, and 0.5 to 5 mm. thick, ending
abruptly, and sending forth numerous slender
fibers of the same color. The stem is up to 6 dm.
in height, cylindrical, striated, glandular-hairy,
and terminating in one, two, or three peduncles,
each bearing a flower head. The radical leaves are
oblanceolate, entire and ciliated; those of the
stem, which usually consist of two opposite pairs,
are elliptic oblong or lance-shaped. Both are
bright green, and somewhat pubescent on their
upper surface. The flower heads are orange-yellow.

This plant is a native of the mountains and
meadows of Europe. It has been introduced into
England, and cultivated in northern gardens in the
United States. The flowers, leaves and root are
employed; but the flowers only are official. In
the Swiss and German Pharmacopoeias the defini-
tion of arnica flowers is restricted to the flowers
separated from the receptacles, this being done
as the latter contain the eggs or larvae of Trypeta
arnicivora. On the other hand the Austrian Phar-
macopoeia permits the use of the entire flower

Part I

Arnica

107

heads, but the receptacles containing larvae must
be removed.

The American species of Arnica recognized by
the N.F. are Arnica fulgens, A. sororia and A,
cordifolia. All of them are glandular-hairy, per-
ennial herbs with slender horizontal rhizomes bear-
ing basal rosettes of radical leaves from the
centers of which arise one or more aerial stems
bearing from 1 to 3 peduncles which terminate
in showy flower heads of yellow to orange {A.
julgens) ray and disk florets. A. julgens and A.
sororia are native to southwestern Canada and
western United States. A. cordifolia has a range
from Alaska down the Rocky Mountains to New
Mexico and Arizona, in the Sierra and Cascade
ranges south to San Diego County, California.

Arnica julgens Pursh or orange arnica is espe-
cially characterized by possessing dense tufts of
tawny hairs in the axils of the bases of its radical
leaves of previous years which are attached to the
rhizome, by its aerial, puberulent, glandular-hairy
stem bearing from 4 to 6 pairs of cauline leaves,
the upper pairs reduced and separated by a long
internode from the lower pairs which are oblance-
olate, entire or with a few teeth and by its flower
head of dark orange to orange flowers.

A. sororia Greene somewhat resembles the last
species but its rhizome is less than half as thick
with few or no tufts of hairs in the axils of the
old attached radical leaves, its aerial stem bears
4 to 5 pairs of cauline leaves, the two to three
pairs near the base being oblanceolate, and its
flower head bears yellow ray and disk florets.

A. cordifolia Hooker or heart leaf arnica is char-
acterized by having 2 to 4 pairs of cauline leaves,
the basal and lower leaves being petiolate with
slender, sometimes margined petioles as long as or
exceeding the lamina, the latter varying from
ovate to ovate-orbicular, cordate or lanceolate
with cordate to truncate base and entire to
coarsely toothed margin. Its flower heads are
broadly turbinate to bell-shaped with yellow ray
and disk florets. Its involucral bracts differ from
those of the preceding species in being frequently
irregularly toothed to laciniate along the margins.
For details on the official Arnica yielding species
and the gross structure and histology of their
flower heads see the report of Youngken and
Wirth, /. A. Ph. A., 1945, 34, 65.

The flower heads of arnica are collected when
fully expanded, the florets of European arnica
being usually separated from their receptacles and
carefully dried. American arnica flower heads are
dried intact. European arnica has been imported
into the U. S. A. from Germany, Belgium, Yugo-
slavia, France and Italy. American arnica is being
collected chiefly in the Rocky Mountain states,
especially Montana and Wyoming, and also in
the Dakotas.

Description. — "Unground Arnica occurs as
entire flower heads or as tubular and ligulate
florets usually with some receptacles and invo-
lucres. The heads are either hemispherical, tur-
binate, or campanulate, up to 2.8 cm. in height.
The receptable is flat to slightly convex (Arnica
montana) or prominently convex (American
Arnicas), deeply pitted, and covered with short

hairs. The involucral bracts are lanceolate to
elliptic oblong, those of A. cordifolia being fre-
quently toothed or laciniate along the margins,
light olive-green to weak reddish brown, puberu-
lent and glandular-hairy, up to 25 mm. in length
and from 1 to 3.5 mm. in width. The ligulate
florets are yellow to moderate orange, pistillate,
the ligulate corolla being up to 27 mm. in length,
up to 6 mm. in width, its ligule usually 3-toothed
and 7- to 12-nerved. The tubular florets are per-
fect, goblet-shaped, yellow to yellowish orange,
their stamens bearing 2 oblong-elliptic anther
lobes united by an elongated triangular connective.
The achenes are oblong to spindle-shaped, ap-
pressed-hispid, longitudinally striate or dotted,
3.5 to 7 mm. in length, brownish gray to light
olive-brown, with a collar near the summit bearing
a single circle of barbellate pappus bristles, a
little longer than the achene. The odor is charac-
teristic and agreeable.

"Powdered Arnica is light yellowish brown to
light olive-brown. The pollen grains are numerous,
25 to 40 |x in diameter, spheroidal and spinose.
The non-grandular hairs are of the following
kinds : unicellular and uniseriate-articular, straight,
curved or dagger-shaped, the uniseriate hairs up to
9-celled, rarely 11-celled, some with short basal
cells and elongated distal cell, and double hairs,
the latter up to 384 n in length, mostly unequal
in length of parts, with bifid summits, each with
numerous pits on the dividing wall separating
the 2 components, one of which is either 1- or
2-celled. The glandular hairs are of the following
kinds: with a unicellular stalk and a 1- to 2-celled
head; or with a uniseriate or biseriate stalk and
a 1-, 2-, or 4-celled head. The pappus bristles
possess a multicellular axis and unicellular
branches." N.F.

Arnica flowers of commerce are not infre-
quently admixed with and substituted by other
composite flowers. Farwell states that the heads
of Lapachis columnaris T. et G., a western com-
posite, have been offered in large quantities for
arnica. Hartwich has reported a sample of arnica
adulterated with the flowers of the common dan-
delion. Beilstein reported having found in one
lot approximately 90 per cent of the flowers of
Inula. The following flowers also have been used:
Anthemis tinctoria, L., Calendula officinalis, L.,
Doronicum Pardalianches, L., Inula britannica,
L., Scorzonera humilis, L., Heterotheca inuloides.
The first three of these are distinguished by the
fact that the achenes do not have any pappus. In
Inula britannica the receptacle is naked and the
ligulate flowers are four-nerved (for other char-
acteristics see Ewing and Stitt, I. A. Ph. A., 1945,
34, 151). In Scorzonera the flowers are all ligulate
and the pappus is feather-shaped. In Heterotheca
inuloides the florets have an inner long pappus
and an outer short pappus.

The rhizome (Arnica Radix) was formerly
official and was described as follows :

"Rhizome about 5 cm. long and 3 or 4 mm.
thick; externally brown, rough from leaf-scars;
internally whitish, with a rather thick bark, con-
taining a circle of resin-cells, surrounding the
short, yellowish wood-wedges, and large, spongy

108

Arnica

Part I

pith. The roots numerous, thin, fragile, grayish-
brown, with a thick bark containing a circle of
resin-cells. Odor somewhat aromatic; taste pun-
gently aromatic and bitter." U.S.P., 1890.

It appears to contain the same active con-
stituents as the flowers.

Standards. — Arnica contains not more than
3 per cent of foreign organic matter, and not more
than 2 per cent of acid-insoluble ash. N.F.

Constituents. — In 1851 Bastick reported the
presence of an alkaloid in arnica flowers but his
findings have not been confirmed. The term
arnicin has been applied to a variety of sub-
stances which have been extracted from arnica
but which are not related and most, if not all, of
which are not pure principles. There is present
about 0.5 per cent of a volatile oil, the most im-
portant constituent of which is the dimethyl ether
of thymohydroquinone. For further information
on this oil, see Kondakow (/. pharm. chim., 1910,
2, 79) and also Gildemeister and Hoffman, The
Volatile Oils. There is present also in arnica
flowers a colorless crystalline substance, known
as arnidiol or arnisterin (Klobb, Pharm. Ztg.,
1905, 40, 846), for which Dieterle and Engelhard
Arch. Pharm., 1940, 278, 225) proposed the name
arnidendiol ; it is a triterpenediol found also in
dandelion flowers {Zimmermann, Helv. Chim.
Acta, 1941, 24, 393). Small amounts of angelic
and formica acids have also been reported. From
a petroleum ether extract of arnica flowers
Dieterle and Fay {Arch. Pharm., 1939, 277, 65)
isolated three crystalline substances, as yet in-
completely identified. About 56 per cent of this
extract consists of fatty acids, the composition
of which is reported in their paper, along with
other analytical data for the extract.

Uses. — Arnica is rarely prescribed by physi-
cians but has been used in domestic medicine as
a counterirritant embrocation in the treatment of
bruises and sprains, generally in the form of the
tincture. It has also been used in the treatment
of palsies and various other diseases, but little
knowledge concerning its action is available. Forst
{Arch. exp. Path. Pharm., 1943, 201, 242) re-
ported that both aqueous and alcoholic extracts
of A. montana contain, besides choline, two un-
identified substances which affect the heart and
vascular systems.

Toxicology. — Arnica is an active irritant and
is capable, when taken in an overdose, of produc-
ing symptoms of violent toxic gastroenteritis, with
considerable nervous disturbance, reduction or in-
crease of pulse rate, and collapse. On the skin it
may cause severe dermatitis.

In a number of cases of severe or even fatal
poisoning by arnica, the symptoms have been
burning pains in the stomach, vomiting, choleraic
diarrhea, giddiness, intense muscular weakness,
dilated pupils, and finally complete insensibility
and collapse (Schoenemann, Munch, med. Wchn-
schr., 1938, 85, 787; Merdinger, ibid., 1469;
Forst, ibid., 1939, 86, 145). In some cases the
disturbances of the gastrointestinal tract have
been absent, and the symptoms have been chiefly
of cerebral origin. An ounce of the tincture lias
produced serious, although not fatal, symptoms.

An emetic, a saline purge, demulcent drinks and
supportive and symptomatic measures are indi-
cated for treatment of arnica poisoning.

Arnica flowers have been given in a dose of 60
to 200 mg. (approximately 1 to 3 grains).

ARNICA TINCTURE. N.F.

[Tinctura Arnicae]

Arnica Flowers Tincture. Tinctura Arnica Florum.
Fr. Teinture d'arnica. Ccr. Arnikatinktur. It. Tintura
di arnica. Sp. Tintura de arnica.

Prepare a tincture by Process P (see under
Tinctures), from 200 Gm. of arnica, in moderately
coarse powder, using a menstruum of 3 volumes
of alcohol and 1 volume of water; macerate the
drug during 48 hours, percolate slowly, repeat the
maceration during 24 hours after 500 ml. of perco-
late has been collected, then percolate until 1000
ml. is collected. N.F.

Alcohol Content. — From 63 to 69 per cent,
by volume, of C2H5OH. N.F.

This tincture is sometimes used externally as a
mild counterirritant. The N.F. formerly assigned
an average dose of 0.5 ml. (approximately 8
minims) but it is rarely given internally (see
under Arnica).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

AROMATIC ELIXIR. U.S.P.

Simple Elixir, [Elixir Aromaticum]
Sp. Elixir Aromdtico.

To 12 ml. of compound orange spirit add
enough alcohol to make 250 ml. To this solution
add 375 ml. of syrup in several portions, agitating
vigorously after each addition; afterwards add,
in the same manner, enough purified water to
make 1000 ml. Mix 30 Gm. of talc with the
liquid, filter the mixture through a filter wetted
with diluted alcohol, returning the filtrate until a
clear liquid is obtained. U.S.P.

The only difficulty encountered in the prepara-
tion of this popular vehicle is that of obtaining a
clear filtrate, the colloidal dispersion of the drop-
lets of volatile oils separated from compound
orange spirit by dilution with a large proportion
of water being largely responsible for the persist-
ing turbidity. The high degree of fineness of many
samples of talc is a contributing factor as is, ap-
parently, also the large proportion of syrup which
seems to delay flocculation as well as slow down,
because of its viscosity, the rate of filtration.
Several suggestions have been offered for im-
proving the process — and the product — but none
of these has been given official recognition. For a
brief review of some of the recommendations for
improving the formula see Saute and Lee {J. A.
Ph. A., Prac. Ed., 1954, 15, 101), who proposed
a modification in which a polyoxyalkalene nonionic
solubilizer {Pluronic, Wyandotte Chemical Corp.)
is added to the volatile oil component of the elixir
and which avoids the need for filtering the elixir,
since it is clear.

Aromatic elixir, once very widely used as a

Part I

Arsenic

109

vehicle, still finds considerable use for this pur-
pose ; it is employed in the formulation of several
official elixirs and also in Iron and Ammonium
Acetate Solution.

Alcohol Content. — From 21 to 23 per cent,
by volume, of C2H5OH. U.S.P.

Storage. — Preserve "in tight containers."
U.S.P.

RED AROMATIC ELIXIR. N.F.

Red Elixir, Elixir Aromaticum Rubrum

Mix 14 ml. of amaranth solution with 986 ml.
of aromatic elixir. N.F.

Alcohol Content. — From 21 to 24 per cent,
by volume, of C2H5OH. N.F.

This vehicle is employed in the same way as
aromatic elixir, differing from it only in color.

Storage. — Preserve "in tight containers." N.F.

ALKALINE AROMATIC SOLUTION

N.F.

Liquor Aromaticus Alkalinus
Liquor Antisepticus Alkalinus.

Mix 20 Gm. each of potassium bicarbonate and
sodium borate with 100 ml. of purified water and
add 100 ml. of glycerin; when effervescence ceases
add the mixture to 500 ml. of purified water. Dis-
solve 0.5 Gm. of thymol, 1 ml. of eucalyptol, 0.5
ml. of methyl salicylate, and 14 ml. of amaranth
solution in 50 ml. of alcohol; add the solution of
salts to the alcoholic solution, agitating con-
stantly, and finally add enough purified water to
make 1000 ml. Allow the mixture to stand 24
hours, shaking occasionally, then filter, using 10
Gm. of purified talc, if necessary, to clarify the
product. N.F.

The effervescence which occurs in the prepara-
tion of this solution is explained by the fact that
sodium borate, which may be considered to repre-
sent four molecules of boric acid only half neutral-
ized by two molecules of sodium bicarbonate, is
converted by glycerin to an acid-reacting complex
capable of neutralizing two more molecules of an
alkali such as potassium bicarbonate. The reac-
tion is similar to that which occurs in the prepara-
tion of compound sodium borate solution.

Description. — "Alkaline Aromatic Solution is
a clear, purplish red liquid, with an aromatic odor
and taste. It is alkaline to litmus paper. Its specific
gravity is about 1.04." N.F.

Standard and Test. — Residue on ignition. —
The residue from 10 ml. of alkaline aromatic solu-
tion yields, on ignition, not less than 223 mg. and
not more than 273 mg. of residue. N.F.

Alcohol Content. — From 4 to 7 per cent, by
volume, of C2H5OH. N.F.

Uses. — This is a valuable substitute for a solu-
tion of borax for washing the nasal or pharyngeal
cavities. Its chief advantages are a mild alkalinity
which helps to dissolve mucus and the fact that
when diluted with an equal volume of water it is
almost isotonic with the body fluids. For use in a
dental spray bottle, it is diluted with 5 volumes of
water.

Storage. — Preserve "in tight containers." N.F.

ARSENIC

Arsenum

As (74.91)

Arsenium. Arsenicum. Fr. Arsenic. Ger. Arsen. It.
Arsenico. Sp. Arsenico.

Arsenic has been known since ancient times.
It is sometimes found free in nature, but is gen-
erally combined. Important ores include realgar,
AS2S2; orpiment, AS2S3; and mispickel or arseni-
cal pyrites, FeAsS. The element is usually pre-
pared by heating the last-named ore in the absence
of air, the arsenic subliming. When heated under
pressure, arsenic can be melted; its melting point
at 36 atmospheres is 814°. At atmospheric pres-
sure it sublimes at about 450°. The element exists
in several allotropic modifications, of which the
steel-gray form, having a metallic luster and a
density of about 5.7, is the most important.

Two oxides of arsenic are known. Arsenous
oxide or anhydride (white arsenic) is the trioxide,
AS2O3, formed when the metal is heated in air.
For further information on this substance, see
under Arsenic Trioxide. The higher oxide is
arsenic oxide (arsenic pentoxide) ; it is formed by
the oxidation of the trioxide suspended in con-
centrated nitric acid and heated. It is a white,
amorphous mass which melts at a dull red heat.
It is hygroscopic, absorbing water to form
H3ASO4, orthoarsenic acid. Chemically, arsenic
behaves as a metal only toward the halide acids;
it does not form salts with the oxygen acids. Two
classes of compounds are known in which arsenic
is acid- forming : the arsenites derived from the
trioxides, and arsenates, derived from arsenic
pentoxide. In these compounds, arsenic closely
resembles phosphorus.

Arsenic added in small amount (1 in 1000) to
lead increases its hardness. It is used for this pur-
pose in making lead shot. Large quantities of
arsenic compounds, especially those of lead and
copper, are used in plant sprays as insecticides.

Arsine is of interest because of its extraor-
dinary toxic properties. Most metallic ores con-
tain arsenic as an impurity. On contact with sul-
furic acid such metals give off hydrogen arsenide,
H3AS, or arsine, which is a colorless, inflammable
gas, with a strong garlic-like odor, approximately
2.7 times as heavy as air. Cases of poisoning have
been reported arising from arsine generated in
storage batteries, in smelting and other chemical
industries (Spolyar and Harger, Arch. Ind. Hyg.
Occup. Med., 1950, 1, 419; Morse and Setterlind,
ibid., 2, 148; Josephson et al., ibid., 1951, 4, 43;
Steel and Feltham, Lancet, 1950, 1, 108). The
symptoms do not appear until some hours after
exposure to the gas. They begin with headache,
followed by nausea and vomiting and chills. The
gas destroys red blood cells, in vivo. Acute hemo-
lytic anemia with hemoglobinuria and jaundice
develops. Neuropathy may develop. The only
treatment, outside of removal from exposure, is
that for acute hemolytic anemia — rest, inhalation
of oxygen, blood transfusions, alkalinization of
the urine.

The detection of arsenic in forensic procedures
is of great importance, several tests being of espe-

Arsenic

Part I

rial usefulness for such purposes. In the Reinsch
test arsenic is detected by deposition, as copper
arsenide, on metallic copper placed in a hydro-
chloric acid solution of the sample to be tested;
the identity of the arsenic compound is confirmed
by heating in an ignition tube with access to air
whereupon, if arsenic is present, a sublimate of
crystals of arsenic trioxide is obtained in the cooler
part of the tube. In the Marsh test the presence
of arsenic is evidenced by treating the sample with
nascent hydrogen (produced by the reaction of
zinc and acid), by which arsenic is reduced to the
gas arsine; this, when burned, decomposes to form
arsenic which may be deposited on a cool surface
as a brown to black mirror and which is soluble
in sodium hypochlorite solution. The modified
Gutzeit test, employed officially in testing for
arsenic in medicinals, involves formation of arsine
as in the Marsh test, but its presence is detected
by the formation of a yellow to brown stain on
mercuric bromide paper. Bettendorf's test, used
chiefly in testing antimony compounds because
the latter element does not interfere in the test,
depends on the reduction of arsenic to the ele-
mental state by stannous chloride ; the arsenic de-
posits as a black precipitate.

For medicinal uses of arsenic compounds see
under Arsenic Trioxide and Carbarsone.

ARSENIC TRIOXIDE.

N.F., B.P., LP.

Arsenious Acid, Arsenious Oxide, [Arseni Trioxidum]

"Arsenic Trioxide, when dried at 105° for 2
hours, contains not less than 99.5 per cent of
AS2O3. Caution. — Arsenic Trioxide is extremely
poisonous." N.F. The B.P. requires not less than
99.8 per cent of AS2O3, the calculation being re-
ferred to the substance as it is found. The LP.
requires not less than 99.5 per cent of AS2O3,
calculated with reference to the substance dried
at 100° for 3 hours.

LP. Arseni Trioxydum. Arsenous Acid Anhydride;
Arsenic Sesquioxide; White Arsenic; "Arsenic." Acidum
Arsenosum; Acidum Arsenicosum; Arsenicum Album;
Anhydridum Arseniosum. Fr. Anhydride arsenieux ; Acide
arsenieux; Arsenic blanc; Oxyde blanc d'arsenic. Ger.
Arsenige Saure ; Arsentrioxyd; Arsenigsaureanhydrid. It.
Anidride arseniosa; Acido arsenioso; Arsenico bianco. Sp.
Anhidrido arsenioso; Trioxido de Arsenico; Acido
arsenioso.

Arsenic trioxide is found native in octahedral
crystals, called arsenalite, or as monoclinic crys-
tals, called clandetite. It is formed when arsenic
or arsenical minerals are heated or roasted in the
presence of air, and is a by-product in a number
of metallurgic operations, as in the roasting of
cobalt, copper, lead, nickel and tin ores. The
arsenic trioxide condenses as an impure dust, and
is purified by resublimation.

Description. — "Arsenic Trioxide occurs as a
white, odorless powder. It is stable in air. Arsenic
Trioxide is slowly soluble in water. It is slightly
soluble in alcohol and in ether, and freely soluble
in glycerin. It is soluble in hydrochloric acid and
in solutions of alkali hydroxides and carbonates."
N.F. The B.P. describes it as a heavy white
powder, or irregular lumps having a vitreous frac-
ture, usually appearing stratified, and containing
frequently both transparent and opaque varieties.

The solubility is given as 1 part in 60 parts of
water, the rate of solution depending upon the
relative proportion of the two varieties present,
and upon the degree of subdivision.

Standards and Tests. — Identification. — A
yellow mixture is produced when hydrogen sulfide
T.S. is added to a 1 in 100 solution of arsenic tri-
oxide; addition of a few drops of hydrochloric
acid to the mixture precipitates yellow arsenic tri-
sulfide. Loss on drying. — Not over 1 per cent,
when dried at 105° for 2 hours. Residue on igni-
tion.— Not over 0.1 per cent. Foreign substances.
— 1 Gm. of arsenic trioxide dissolves completely
in 10 ml. of ammonia T.S., with the aid of gentle
heat, or leaves only a very light trace of white,
insoluble material. N.F.

The N.F. has no requirement concerning the
fineness of powder. The U.S. P. X required that
when powdered arsenic trioxide was administered
in solid form the particles should not be greater
than 0.0125 mm. in diameter. This specification
would appear to be a desirable one, as it has been
demonstrated that the absorption of arsenic from
the alimentary tract is largely dependent on the
fineness of the powder administered.

Assay. — About 200 mg. of arsenic trioxide.
previously dried at 105° for 2 hours, is dissolved
in boiling water with the aid of sodium hydrox-
ide T.S.; the solution is neutralized with diluted
sulfuric acid, sodium bicarbonate is added, and
the mixture is titrated with 0.1 A7 iodine, using
starch T.S. as indicator. In the assay, the arsenic
is oxidized from the trivalent to the pentavalent
state. Each ml. of 0.1 N iodine represents 4.946
mg. of AS2O3. N.F.

Uses. — In sufficient concentration all of the
official preparations of arsenic are violent. irritants
or escharotics. Taken internally in a dose of 100
mg. or more they are exceedingly poisonous to
both man and the lower animals. Arsenic, in
soluble forms, is absorbed from the mucous mem-
branes and skin and from sites of parenteral ad-
ministration; it is distributed by the blood to all
parts of the body, being detectable in the hair in
about two weeks and for many months thereafter.
It is found in the urine within a few hours after
oral or parenteral administration and excretion
continues for several weeks; because of its slow
elimination, cumulative action is an important
consideration. For details of a recent study on
the storage and metabolism of arsenic in tissues
see Ewing et al. {Texas Rep. Biol. Med., 1950,
8, 556; 1951, 9, 27).

The local application of arsenic produces mild
irritation followed, after prolonged or repeated
application, by necrosis of tissue. Because rapidly
proliferating tissue appears to be most sensitive
to this action of arsenic it has been used in a
variety of mixtures ("cancer paste") for the local
treatment of neoplastic growths but its lack of
penetration into the deeper portions of the tumor
makes it ineffective (see U.S.D., 21st ed., p. 188).
Arsenic is a marked capillary poison, causing
dilatation and abnormal permeability with a re-
sulting loss of protein and other blood plasma
constituents into the tissues. Edema is a common
manifestation of arsenic poisoning. The blood
pressure does not decrease until the arterioles are

Part I

Arsenic Trioxide

111

similarly damaged or the loss of blood volume be-
comes significant. The myocardium is also de-
pressed. Hyperemia of the gastrointestinal tract
follows either oral or parenteral administration
and may promote the formation of digestive se-
cretions and the absorption of food. Slightly larger
doses, however, cause severe irritation of the
mucosa with the formation of submucosal blebs
and the loss of blood plasma into the lumen of
the bowel accompanied by increased peristalsis,
a condition which results in "rice water" stools
which may become bloody. Vomiting is frequent.
In addition to its action on the capillaries of the
glomeruli of the kidney, arsenic produces necrosis
and degeneration of the tubules. Oliguria, albu-
minuria, hematuria and cylindruria are observed
and the clinical features of the nephrotic stage of
glomerular nephritis may develop. Vasodilatation
in the skin causes a "healthy" flush but, except in
minimal doses, abnormal proliferation of the skin
and other epidermal structures such as the hair
and nails results. Peripheral neuropathy involv-
ing both the sensory and the motor elements is a
frequent result of large doses of arsenic or pro-
longed exposure to smaller amounts. Cell forma-
tion in the bone marrow is temporarily stimu-
lated, then depressed to a degree dependent on the
amount of arsenic; this involves both the red and
the white blood cell-forming elements. In toxic
doses arsenic increases the excretion of nitrogen
due to its destructive action on the tissues of
many organs of the body. For many years small
doses of arsenic were employed as a tonic in con-
valescent, neurasthenic, and malnourished pa-
tients. Although a decreased excretion of nitrogen
and of carbon dioxide has been reported, the
cumulative action of arsenic has made it clinically
impractical to avoid toxic effects and this use of
arsenic is no longer popular. Early toxic effects
may even simulate clinical improvement through
a flushed skin, minimal edema, and possibly im-
proved absorption induced by hyperemia of the
intestinal tract.

The apparent tolerance to arsenic developed by
the mountaineers of Styria and the Tyrol who are
able to consume large quantities is explicable on
the basis of the insolubility and poor absorbability
of the form ingested (/. Pharmacol., 1922, 20,
181); no tolerance has been observed following
parenteral administration of arsenic compounds.

Although arsenic is a protoplasmic poison it
does not actively precipitate protein and in con-
centrations and forms which are not caustic its
action is slow. The theory that arsenic interferes
with essential protoplasmic oxidation and reduc-
tion processes has long been held. Voegtlin and
his associates {Pub. Health Rep., 1923, 38, 1882;
/. Pharmacol., 1930, 39, 347) produced evidence
that arsenic combines with the sulfhydryl ( — SH)
groups in cells to prevent normal oxidative proc-
esses both in vitro and in vivo. They found that
the administration of substances with free sulfhy-
dryl groups had prophylactic and therapeutic
value against the action of arsenic on mammals
and on protozoa. Eagle and his associates (/. Phar-
macol, 1938, 64, 164 and 1939, 66, 10 and 436;
Am. J. Syph. Gonor. Ven. Dis., 1939, 23, 310)
and Kolmer and his colleagues (Am. J. Syph.

Gonor. Ven. Dis., 1940, 24, 201) have also pre-
sented information on the mechanism of the action
of arsenic. Eagle et al. (Fed. Proc, 1946, 5, 175)
and others (Science, 1945, 102, 601) have re-
ported that the dithiol compound, dimercaprol
(q.v.), is far superior to the monothiol com-
pounds such as glutathione, methionine (Peters
et al., Quart. J. Med., 1945, 14, 35), etc. in the
prevention and treatment of arsenical poisoning
in man, animals, and protozoa. Arsenic inhibits
the action of cellular enzymes (Maver and
Voegtlin, Am. J. Cancer, 1937, 29, 333) and pre-
vents mitosis and other nuclear functions. The
hazard of epithelioma of the skin in occupations
with exposure to arsenic is presented by Hueper
(Occup. Med., 1948, 5, 157) and Hill and Faning
(Brit. J. Ind. Med., 1948, 5, 1).

In dentistry, equal parts of arsenic trioxide and
cocaine hydrochloride made into a stiff paste with
creosote is used in root canals to destroy ("kill")
the nerve. Utilizing the radioactive isotope, As76,
Gotte et al. (Ztschr. Naturforsch., 1951, 6b, 274)
showed that the arsenic diffused into the dentin
to a considerable extent, where it may cause latent
degenerative changes.

Although the inorganic forms of arsenic are
highly toxic to many protozoa they are less suc-
cessful in the treatment of parasitic infections
than the organic forms, because the latter can be
given in so much larger doses without danger to
the host (see Carbarsone). To what action arsenic
owes its value in pulmonary diseases is unknown
but there has been a clinical impression that in
chronic bronchitis, especially of the aged, and in
asthma, it is beneficial. With the advent of liver
therapy, arsenic was abandoned in pernicious
anemia.

When preparations of arsenic are given for their
tonic effect alone, they should be used in doses so
small as not to cause any general symptoms (see
also Potassium Arsenite Solution). Mixtures of
arsenic with nux vomica, quinine and other "bit-
ters" are less popular than formerly. To avoid
gastrointestinal irritation, pain and diarrhea as
much as possible, the remedy should be given
after meals. S

Toxicology. — The specific symptoms of ar-
senicalism are a general disposition to edema,
especially of the face and eyelids, a feeling of
stiffness in these parts, itching of the skin, tender-
ness of the mouth, loss of appetite, and uneasi-
ness and sickness of the stomach, usually with
diarrhea. The symptoms of chronic arsenic poison-
ing are so protean as to defy detailed description ;
most of them fall into 3 groups. First, those due
to irritation of the gastrointestinal tract, nausea
and diarrhea; or, when the arsenic has been in-
haled, symptoms of laryngitis and bronchitis.
Second, when used continuously over long periods
of time, even in doses too small to cause the cus-
tomary symptoms of arsenicalism, the drug may
give rise to alterations in the skin. The most im-
portant of these are peculiar dryness and a tend-
ency to the overgrowth of keratin as shown by
the formation of warts, ridges on the finger nails
or coarseness of the hair. In the diagnosis of sus-
picious cases of arsenic poisoning, chemical ex-
amination of the hair or finger nails for arsenic

112

Arsenic Trioxide

Part I

is valuable (Althausen and Gunther, J.A.M.A.,
1929, 92, 2002; Hamori, Deutsche med. Wchn-
schr., 1941, 67, 628). In some instances the in-
ternal use of arsenic causes a rash not unlike that
of measles attended, as in that affection, with
catarrhal symptoms. Sometimes salivation is pro-
duced, and occasionally the hair and nails fall off.
Third, the group of cases in which peripheral
neuritis is the outstanding manifestation. This
neuropathy may involve either motor or sensory
elements with paralysis, paresthesia or pain. Im-
paired vision has resulted. Any of these symptoms
call for the discontinuance of arsenic therapy.

Arsenic is still one of the most commonly used
poisons for criminal purposes. Arsenic compounds
are used as insecticides and rodenticides and acci-
dental human poisoning occurs. The symptoms of
acute poisoning, which generally do not appear
for a period of from one-half to one hour after
the ingestion of the poison, are somewhat varied
in different cases. The most frequent are; pain in
the epigastrium; vomiting, the vomitus being
occasionally bloody, more commonly not; profuse
serous purging; great thirst; rapid, weak pulse;
prostration and restlessness, sometimes with de-
lirium and convulsions. Any or all of these symp-
toms, however, may be lacking, death occasionally
taking place with no prodromal symptoms except
heart failure or stupor. At post-mortem examina-
tion there will be found evidence of inflammation
of the alimentary canal and of the kidney and fre-
quently fatty degeneration in various of the in-
ternal organs. In the series of cases of arsenic
poisoning reported by Lawson {J. A.M. A., 1925,
85, 24) enlargement of the liver was observed
in more than half of the cases and enlargement
of the spleen in about one-quarter. Death usually
occurs in the fatal cases within 48 hours (few
hours to several weeks).

The diagnosis of acute arsenical poisoning is
sometimes impossible without chemical examina-
tion. For the methods of detecting arsenic in the
human body, see U.S.D., 19th ed., p. 202 and
Morris and Calvery, Ind. Eng. Chem., Anal. Ed.,
1937, 9, 447. It should be remembered that even
after the post-mortem injection of arsenic, as in
the use of some embalming fluids, the poison may
be diffused throughout the entire body.

In the treatment of poisoning by arsenic, it is
of the utmost importance to prevent the absorp-
tion of the drug, because after the poison has once
entered the system, it is difficult to mollify its
baneful effects. The most important method of
preventing absorption is the mechanical evacua-
tion of the stomach — unless nature has already
done so by vomiting — either by use of the stomach
tube with large amounts of warm water or milk,
or by means of a promptly acting emetic such as
2 Gm. (approximately 30 grains) of zinc sulfate
in water. It is to be remembered that the poison
may remain in the stomach for long periods, espe-
cially if it has been taken in solid form, and
cleansing of the stomach is advisable even if the
patient is not seen immediately after the ingestion.
Prior to evacuation of the stomach, the inges-
tion of a precipitant or adsorbent to decrease the
amount of dissolved arsenic available for absorp-
tion seems rational. Formerly, a freshly precipi-

tated ferric hydroxide suspension {Magma Ferri
Hydroxidi, U.S. P. XI) was advocated (see U.S.D.,
24th ed., p. 105), this being prepared by adding
a solution of ferric sulfate to a suspension of
magnesium oxide in water or to magnesia magma.
A quick substitute may be prepared by adding
any alkaline hydroxide solution to the solution of
any available soluble ferric salt. Evacuation of
the intestines by a saline purgative such as mag-
nesium sulfate should follow removal of the
gastric contents. Loss of fluid and electrolytes
should be corrected by intravenous injection of
isotonic sodium chloride solution.

As soon as the diagnosis of arsenic poisoning
has been made, whether it is in an early or a late
stage, Dimercaprol Injection (q.v.) should be
given intramuscularly in a dose of 2.5 to 3 mg.
of dimercaprol per kilo of body weight and re-
peated every 4 hours for 3 or 4 doses; if neces-
sary, single daily doses should be continued for
several days (Bull. U. S. Army M. Dept., 1945,
Xo. 88, 13). In acute and severe cases the inter-
val between the first and second doses should be
shortened to 2 hours. Eagle reported the urinary
excretion of arsenic to be increased as much as
100 times during 1 to 2 hours after each injection,
with an incidence of only 1 per cent of untoward
reactions. The reactions usually occur within 15
to 30 minutes after the injection and consist of
sensations of constriction in the throat, oppression
in the chest, burning of the lips, lacrimation and
congestion of the conjunctiva, local tenderness,
restlessness and nervousness, sweating of the
hands, mild nausea and vomiting, headache and a
transient rise in blood pressure. Since the intro-
duction of dimercaprol the use of sodium thio-
sulfate routinely in the treatment of arsenical
poisoning has been abandoned. Evidence for its
value was never clear (J.A.M.A., 1942, 120, 124).
Although Ayres and Anderson (J.A.M.A., 1938,
110, 886) reported that sodium thiosulfate in-
creased the urinary excretion of arsenic, Muir,
Stenhouse and Becker (Arch. Dermat. Syph.,
1940, 41, 308) and other observers found no such
action.

The subsequent treatment consists in the ad-
ministration of mucilaginous drinks, and the treat-
ment of symptoms as they arise. An adequate
intake of protein, carbohydrate and vitamins,
orally or parenterally, is important. Conva-
lescence is generally long and distressing; usually
dyspeptic symptoms mark the presence of gastro-
intestinal inflammation or even ulceration, while
not rarely violent neuralgic pains, with loss of
power, wasting of the muscle, and other trophic
changes, show that a peripheral neuritis has been
produced.

Chronic arsenical poisoning is a not infrequent
— but often unrecognized — result of the continued
absorption of small amounts of the element
through either the alimentary or the respiratory
tract. It has occurred from the inhalation of the
dust of arsenical pigments, from the ingestion of
contaminated foods and from the prolonged use
of medicinal preparations. The arsenical dyes are
not used today for coloring foods, but vegetables
and fruit are occasionally injurious from the resi-
due of agricultural insecticides. A serious epi-

Part I

Asafetida

113

demic in Manchester, England, in 1900 was traced
to contaminated sulfuric acid used in making glu-
cose. The increasing use of arsenic sprays, espe-
cially lead arsenate, in agriculture constitutes a
menace to public health (Calvery, J. A.M. A., 1938,
111, 1722). Some of these foods enter our mar-
kets today containing enough arsenic to be po-
tentially dangerous.

Dose, of arsenic trioxide, 1.5 to 3 mg. (ap-
proximately y±o to V20 grain) .

Storage. — Preserve "in well-closed containers."
N.F.

Off. Prep.— Arsenic Trioxide Tablets, N.F.;
Potassium Arsenite Solution, N.F., B.P.

ARSENIC TRIOXIDE TABLETS. N.F.

Arsenous Acid Tablets, [Tabellae Arseni Trioxidi]

"Arsenic Trioxide Tablets contain not less than
92.5 per cent and not more than 107.5 per cent of
the labeled amount of AS2O3." N.F.

Assay. — A representative sample of powdered
tablets, equivalent to about 60 mg. of arsenic tri-
oxide, is boiled with water and then hydrochloric
acid and chloroform are added and the mixture
allowed to stand two hours, with occasional agi-
tation. The mixture is then titrated with 0.02 M
potassium iodate until the purple color which de-
velops in the chloroform layer during the first
part of the titration is discharged. In the reaction
with iodate the arsenic is oxidized to the pentava-
lent state while the iodate is reduced to iodine,
which gives to chloroform the purple color;
further addition of iodate oxidizes the iodine to
iodine monochloride, IC1, in which iodine has a
valence of +1. One mole of arsenic trioxide is
equivalent to one mole of potassium iodate; ac-
cordingly, 1 ml. of 0.02 M potassium iodate repre-
sents 3.956 mg. of AS2O3. N.F.

Usual Size. — 2 mg. (approximately Vao grain).

ASAFETIDA. N.F.

Gum Asafetida, [Asafoetida]

"Asafetida is the oleo-gum-resin obtained by
incising the living rhizome and roots of Ferula
Assa-fcetida Linne, Ferula rubricaulis Boissier,
and of Ferula jcetida (Bunge) Regel, and prob-
ably of other species of Ferula (Fam. Umbel-
lifer cb.)" N.F.

Gum Asafetida; Devil's Dung. Asa Foetida; Gum-
miresina Asafoetida. Fr. Asa fcetida. Ger. Asant ; Teufels-
dreck. It. Assa fetida. Sp. Asafetida. Pers. Ungoozeh.
Arab. Hilteet. Ind. Hing. Afgh. Angusakema.

Asafetida appears to have been introduced into
European medicine by the Arabian physicians. It
was in use in continental Europe during the Mid-
dle Ages. It has long been recognized in the U.S. P.
but was deleted from the twelfth revision and
admitted to the N.F. VII. The plants from which
it is obtained are natives of western Afghanistan
and eastern Persia.

Ferula Assa-fcetida was first described from
actual observation by H. Falconer, who found
it near Kashmir, and it has long been successfully
cultivated in the Edinburgh Botanical Gardens.
It is distinguished from allied plants by the greater
height of the stem (6 to 10 feet), and by the
numerous stem leaves furnished with broad sheath-

ing petioles. The flowers are pale yellow, and the
oval fruit thin, flat, foliaceous, and reddish brown,
with pronounced vittae. It yields a milky juice
having a powerful odor of asafetida.

Ferula fcetida is a coarse umbelliferous plant,
growing from 5 to 7 feet high, with a large fleshy
root, the crown of which is covered with coarse
bristly fibers, and gives origin to large bipinnate
radical leaves and a nearly naked stem which has
only a few bipinnate leaves and ends at the top
in very numerous umbels. This plant was first dis-
covered in the sandy desert near the sea of Aral,
by Lehmann, in 1844. Bunge found it in Persia
about twenty years later. It would seem to be
native all through Afghanistan.

Ferula rubricaulis Boissier is mentioned as a
source of galbanum in the Pharmacographia, 2nd
ed., and in Bentley and Trimen's Medicinal Plants,
but Holmes, studying Kotscky's specimen in the
British Museum, classifies it with the asafetida
plants partly because its fruit possesses an allia-
ceous taste which is wanting in the fruit of the
galbanum and partly because Boissier placed this
species in his Sect. Scorodosma along with Ferula
Assafcetida and F. alliacea, both of which are con-
sidered as sources of asafetida. F. rubricaulis is
claimed by Holmes to yield some of the white
asafetida of commerce. Its mericarp fruits are
said to be glabrous with broad thick wings, no
vittae, the three, primary, dorsal ridges being in-
conspicuous; there are 12 to 14 vittae on the
dorsal and 8 to 10 on the ventral side, the cuticle
on the dorsal surface is especially thick; the sub-
epidermal tissue is many layers thick; the cells
between the epidermis and the vittae are thin
walled, while those on the opposite side of the
vittae are tracheid-like in form. The plant is a
native of Persia.

On the basis of the study of fruits found in a
mixed sample of gum resin of asafetida, J. Small
concluded that Ferula rubricaulis yields some of
the "white asafetida" and F. fcetida, the "red
asafetida." Both of these varieties occur in com-
merce. Both contain tears which when fresh are
milky white or yellowish internally. In the case
of the red variety, the freshly exposed surface of
the fractured tear gradually changes in color to
pink, red, and finally reddish-brown, whereas in
that of the white variety it remains almost white.

It is possible that asafetida is obtained from
other species of Ferula, but the bulk of the drug
probably comes from the plants named in the
official definition. Among the other plants yielding
asafetida is Ferula Narthex Boiss. While this is
disputed by Aitchison yet it appears that it is
the source of the gum-resin obtained from certain
portions of Afghanistan. Tschirch describes this
plant with illustrations in Schweiz Wchnschr.
Pharm., 1910, p. 289. Holmes's discussion of the
asafetida plants {Pharm. J., ser. iii, 19, 1888-
1889) still remains one of our chief sources of
information on the subject. (See also article on
the sources of the fetid gum-resins by James
Small, Pharm. J., 1913, 90, 287.)

The asafetida plants are indigenous to western
Afghanistan and eastern Persia. The great cab-
bage-like heads of the asafetida plant, represent-
ing the primary stage of the flower heads covered

114

Asafetida

Part I

over by the stipules of its leaves, are eaten raw
by the natives as a sort of green. Collection of
the drug begins in mid-April and proceeds until
late in July. The root-stock is first laid bare by
sawing off the head, those plants only which have
not reached their flower-bearing stage being
selected. A slice is then taken from the top of
the root-stock, which is immediately covered with
twigs and clay, forming a sort of dome, with an
opening toward the north, so that the sun cannot
get at the exposed root. About five or six weeks
later, a thick, gummy, not milky, reddish sub-
stance found upon the exposed surface of the rhi-
zome in more or less irregular lumps is scraped
off with a piece of iron hoop or removed with a
slice of the rhizome and at once placed in a
leather bag. The product of many plants is mixed
and permitted to harden in the sun. The process
is continued for a second and third time, the root-
stock being cut lower on each occasion.

Most of the drug is' normally gathered in eastern
Persia and western Afghanistan. It is brought to
Herat and Kandahar, whence it enters com-
merce, being exported from Bunder Abbas and
other Persian Gulf ports to Bombay and thence
to Europe and the United States, usually arriving
in tin-fined cases. In 1952 importations of the
drug, from Iran, amounted to 83,175 pounds and
from Switzerland, 11,200 pounds.

Description. — "Asafetida occurs as a soft
mass sometimes almost semi-liquid, or as irregu-
lar, more or less pliable masses composed of
agglutinated tears imbedded in a weak brown to
moderate yellowish brown matrix, or as loose
ovoid tears, from 0.5 to 4 cm. in diameter, with a
few vegetable fragments. It becomes hard and
occasionally brittle on drying. The surface of the
freshly fractured tears is white to moderate yel-
lowish brown, changing gradually on exposure
to air or light to a strong pink and finally to a
moderate yellowish brown. When moistened with
water the tears become moderate orange to weak
yellow. The odor is persistent and alliaceous, and
the taste is bitter, alliaceous, and acrid." 7V..F.

Standards and Tests. — Identification. — (1)
A yellowish orange emulsion, turning to greenish-
yellow on addition of alkalies, is formed when
asafetida is triturated with water. (2) A reddish
brown solution results when a fragment of asa-
fetida is heated with sulfuric acid; on diluting
this solution with a large volume of water, filter-
ing, and alkalinizing the filtrate, a purplish blue
fluorescence is produced. (3) A pink color is pro-
duced on adding a few drops each of phloro-
glucinol T.S. and hydrochloric acid to 10 ml. of
the alcoholic extract obtained in the assay. Most
foreign resins. — A yellowish brown color produced
on adding a few drops of ferric chloride T.S. to 5
ml. of the alcoholic extract obtained in the assay
indicates absence of most foreign resins. Gal-
banum. — A bluish green color, fading on stand-
ing, obtained when enough hydrochloric acid to
produce a faint turbidity is added to 10 ml. of
alcoholic extract from the assay indicates absence
of galbanum. Ammoniac. — No momentary yel-
lowish orange to red color develops on adding 5
ml. of sodium hypobromite T.S. to 2 ml. of a 1 in
"24 aqueous emulsion of asafetida diluted with 5

ml. of water. Rosin. — No green color is formed
in the benzin layer on adding 10 ml. of a fresh 1
in 200 solution of copper acetate to the filtrate
from a 1 in 10 purified petroleum benzin extract
of asafetida. Acid-insoluble ash. — Not over 15
per cent. Alcohol-soluble extractive. — A sample
of 2 Gm. of asafetida is extracted with alcohol in
a Soxhlet or other extractor; the insoluble residue
is dried at 105° for 2 hours and weighed. A cor-
rection is applied for the amount of moisture in
the drug, as determined by the toluene distillation
method, and the content of alcohol-soluble extrac-
tive calculated. Asafetida yields not less than 50
per cent of such extractive. N.F.

Constituents. — The odor of asafetida, and
probably also its therapeutic virtues, depend
chiefly upon its volatile oil. When freshly distilled
it is a colorless liquid but it yellows on aging; it
has an offensive odor and a taste which is at first
flat but afterward bitter and acrid. According to
Mannich and Fresenius {Arch. Pharm., 1936, 274,
461), the main fraction of this oil is a mercaptan
of the formula C7H14S2. Baumann (Quart. J. P.,
1929, 2, 621) found in a sample of asafetida 69
per cent of an acetone-soluble resin fraction and
31 per cent of gum and impurities. Of the resin
fraction, 50.1 per cent (calculated to the original
material) consisted of resin and ethereal oil. 1 per
cent of ether-insoluble matter (apparently free
resinol), 16.57 per cent of asaresinol ferulic acid
ester and 1.33 per cent of free ferulic acid. The
ester, which is very labile, is responsible for the
change of color of asafetida on standing. The
resinol is apparently a phenol and not coniferyl
alcohol, as has been stated. Vanillin does not occur
in the freshly gathered drug but is formed later
by oxidation of the ferulic acid. On distillation of
the resin in vacuo, umbelliferone was produced.
Clevenger gives certain chemical and physical
data on asafetida and its volatile oil, based upon
examination of 41 lots of the drug offered for
entry at the Port of New York (/. A. Ph. A.,
1932, 21, 668). The content of alcohol-soluble
extractive varied from 54.5 to 74.7 per cent; that
of volatile oil ranged between 7.5 and 12 ml. per
100 grams of asafetida.

Impurities and Adulterations. — Asafetida
is often purposely adulterated; it frequently
comes of inferior quality, and mixed with various
impurities, such as sand, stones, galbanum, am-
moniac, gums, gypsum, vegetable tissues, or a
rose-colored marble. It is generally conceded to
be the worst adulterated drug upon the market.
The gum-resin imported from the Persian Gulf
and Bombay is largely adulterated with sand and
other gum-resins. In recent years, however, the
quality of the available asafetida has materially
improved.

Asafetida is sometimes kept in a powdered
state, but this is objectionable, as the drug loses
volatile oil, and is more liable to adulteration.
Powdered asafetida is best prepared by drying the
crude drug over freshly burnt lime and then
comminuting it at a low temperature.

For methods which have been proposed for the
detection of adulteration in asafetida, see U.S.D.,
22nd ed., p. 198.

Uses. — Asafetida is seldom prescribed in the

Part I

Ascorbic Acid

115

United States. It appears to have been used in
the East from the earliest times. Its therapeutic
action probably arose from the psychic effect of
its disagreeable odor and taste. In small amounts
it gives the distinctive aroma to the type of sauce
known as "Worcestershire." It is absorbed from
the intestinal tract but there is no evidence that
it has any distinct action. Pidoux took half an
ounce at one dose without effects other than local
action.

Asafetida has been employed as a carminative
in the treatment of flatulent colic. In colic, espe-
cially in infants, it is often administered per
rectum, either as the emulsion or as a suppository.
The emulsion is prepared by triturating 4 Gm. of
asafetida with 100 ml. of distilled water until a
uniform mixture results, after which it is strained;
15 to 30 ml. of this emulsion in 500 ml. of warm
water may be given as an enema. Such an enema
has been used for abdominal distention in pneu-
monia and in postoperative cases; it is less irritant
than the milk and molasses or the turpentine
enema. Generally such enemas should not be given
during the first 3 days after abdominal surgery,
and the enema can should not be placed higher
than 25 to 50 cm. above the level of the patient.

Following absorption, the volatile oil of asa-
fetida is eliminated through the lungs, for which
reason the drug has been used as a stimulating
expectorant in bronchitis, whooping cough, and
asthma.

Because of its disagreeable taste asafetida is
preferably administered as a pill or coated tablet.

Dose, 0.3 to 1 Gm. (approximately 5 to 15
grains) .

ASCORBIC ACID. U.S.P., B.P., LP.

Vitamin C, [Acidum Ascorbicum]

ASAFETIDA PILLS.

[Pilulae Asafcetidae]

N.F.

Prepare 100 pills, according to the General Di-
rections (see under Pills), from 20 Gm. of asa-
fetida, and 6 Gm. of hard soap, in fine powder,
using water as the excipient. Coat the pills, pref-
erably with gelatin, or dispense the mass in gela-
tin capsules.

These pills are a convenient form for admin-
istering asafetida, the unpleasant odor and taste of
which render it very offensive, particularly when
in liquid dispersion.

Dose, one to three pills.

ASAFETIDA TINCTURE. N.F.

[Tinctura Asafcetidae]

Tinctura Asa; Foetidae. Fr. Teinture d'asa foetida. Ger.
Asanttinktur. It. Tintura di assa fetida. Sp. Tintirra de
asafetida.

Prepare the tincture, by Process M (see under
Tinctures), from 200 Gm. of comminuted asa-
fetida, using as the menstruum sufficient alcohol
to make 1000 ml. of tincture. N.F.

Alcohol Content. — From 78 to 85 per cent,
by volume, of C2H5OH. N.F.

Dose, 1 to 4 ml. (approximately 15 to 60
minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

"Ascorbic Acid, dried in a vacuum desiccator
over sulfuric acid for 3 hours, contains not less
than 99 per cent of CeHsOc." U.S.P. The B.P.
defines ascorbic acid as the enolic form of 3-keto-
L-gulofuranolactone; not less than 98 per cent of
CeHsOe is required. The LP. requires not less
than 98.0 per cent of CeHsOe, calculated with
reference to the substance dried over sulfuric acid
for 24 hours.

Cevitamic Acid; Anti-scorbutic Vitamin. Ascorbin (.Lake-
side); Cantaxin (Winthrop); Cebione (Merck) ; Cevalin
(Lilly) ; Cevatine (Premo) ; Cevimin (Irwin, Neisler) ;
Ciamin (Massengill) ; Vitacee (Endo). Sp. Acido Ascorbico.

Scurvy has been for many centuries one of the
great human plagues. It is said that in the 17th
century more seamen died of scurvy than all other
causes combined — and it has also been known for
centuries that the disease was the result of dietetic
deficiencies and could be cured with fresh green
foods, lemon juice, and various other substances.

In 1932, Waugh and King separated from
lemon juice a "hexuronic acid" which possessed
strong antiscorbutic properties. The announce-
ment of this finding was followed in a few weeks
by the report of Svirbely and Szent-Gyorgyi that
"hexuronic acid" as prepared from adrenal glands
was protective against scurvy. Within a short
period of time several workers independently con-
firmed the chemical identity of the vitamin and
in 1933 its structural formula, as a lactone of
hexuronic acid, was firmly established. Ascorbic
acid occurs naturally in many plants, particularly
in the fruits. Asenjo and Guzman {Science, 1946,
103, 219) have reported that the West Indian
cherry, which grows on small trees native to
tropical and subtropical America, yields, on the
average, 1.707 Gm. of ascorbic acid per 100 Gm.
of cherries — approximately 34 times as much as
from oranges.

Even before the chemical structure was posi-
tively known, methods for the synthesis of ascor-
bic acid had been worked out. Because of the
relationship of the acid to many known sugars
and their derivatives, various syntheses of the
former utilize the latter as starting compounds.
The first synthesis of ascorbic acid used the rare
sugar L-xylose. A later synthesis starts with
D-glucose; this is first converted to the alcohol
D-sorbital by catalytic hydrogenation, then oxi-
dized through the action of Acetobacter sub-
oxydans to L-sorbose (which has the same con-
figuration at the fifth carbon atom as has ascorbic
acid), following which the primary alcohol group
in the Ci position of L-sorbose is oxidized to a
carboxyl group. This step is rendered difficult
because the L-sorbose molecule contains another
primary alcohol group at the Ce position; this
latter group must be protected against oxidation
by converting the sugar to a diacetone derivative.

116

Ascorbic Acid

Part I

Following the oxidation (with potassium perman-
ganate), the diacetone derivative is hydrolyzed to
2-keto-L-gulonic acid and finally subjected to
enolization and formation of the lactone ring to
produce ascorbic acid.

A number of sugar derivatives having struc-
tures analogous to that of ascorbic acid, as well
as stereoisomers of the latter, exhibit antiscor-
butic action, but in no case does the activity ap-
proach that of ascorbic acid. It appears certain
that antiscorbutic activity is contingent on hav-
ing the D-configuration of the fourth carbon atom
in the molecule and the L-configuration of the
fifth carbon atom.

Description. — "Ascorbic Acid occurs as white
or slightly yellow crystals or powder. It is odor-
less, and on exposure to light it gradually darkens.
In the dry state, Ascorbic Acid is reasonably
stable in the air, but in aqueous solution it rapidly
deteriorates in the presence of air. It melts at
about 190°. One Gm.' of Ascorbic Acid dissolves
in about 3 ml. of water and in about 30 ml. of
aicohol; it is insoluble in chloroform, in ether,
and in benzene." U.S.P. The B.P. gives the melt-
ing point as between 190° and 192°, with decom-
position; the I. P. requires it to be between 191°
and 194°, with decomposition.

Standards in Tests. — Optical rotation. — The
specific rotation of ascorbic acid, determined with
a 10 per cent w/v solution, is between +20.5°
and +21.5°. Identification. — (1) Alkaline cupric
tartrate T.S. is slowly reduced by a 1 in 50 solu-
tion of ascorbic acid at room temperature, more
readily when heated. (2) A blue color is immedi-
ately produced on adding a few drops of sodium
nitroprusside T.S. and 1 ml. of 0.1 N sodium
hydroxide to 2 ml. of a 1 in 50 solution of ascorbic
acid. (3) A blue color develops on heating with
a drop of pyrrole 5 ml. of filtrate obtained from
a well-shaken mixture of 15 mg. of ascorbic acid,
dissolved in 15 ml. of a 1 in 20 solution of tri-
chloroacetic acid, with 200 mg. of activated char-
coal. Residue on ignition. — Not over 0.1 per cent.
Heavy metals. — The limit is 20 parts per million.
U.S.P.

The B.P. requires an aqueous solution of ascor-
bic acid to decolorize a solution of 2:6-dichloro-
phenolindophenol. The specific rotation of a 2
per cent w/v solution is stipulated as follows:
22° to 23° in water; 50° to 51° in methyl alcohol.
The I. P. specifices an ultraviolet absorbancy of
550 in a 0.002 per cent w/v aqueous solution of
pH 3, or less, at 245 mix.

Preparation of Solutions of Ascorbic
Acid. — It has long been known that prolonged
boiling would destroy the antiscorbutic value of
fresh foods, and it was at one time believed that
this vitamin was heat-labile, but it is now known
that the destruction of the vitamin is an oxidative
process; ascorbic acid can be heated for long
periods of time without change, provided all
contact with oxygen is excluded. The products of
oxidation of ascorbic acid in aqueous solution
depend in part on the pH of the solution; in acid
solutions the main product is dehydroascorbic acid
while in alkaline solution hydrogen peroxide, oxa-
.late ion and L-threonate ion are formed. (J.A.C.S.,

1943, 65, 1212). It is reported that solutions
containing 10 per cent or more of ascorbic acid
sometimes undergo a decomposition in which
carbon dioxide is produced, and in such amount
that dangerously high pressure may result in
ampuls during normal storage. Unless oxygen is
kept out of contact with aqueous solutions of
ascorbic acid, or an antioxidant is used, the vita-
min cannot be expected to remain stable. Pien
and Meinrath (Compt. rend. acad. sc, 1939, 209,
462) found that displacement of oxygen by carbon
dioxide or nitrogen in aqueous solutions of as-
corbic acid results in their retaining nearly 90 per
cent activity after 20 minutes heating in an auto-
clave. Some decomposition occurs also in the
absence of oxygen, especially so if the solution
is alkaline. U. S. Patent 2,297,212 discloses that
the addition of thiourea (or its methyl or ethyl
derivative) in concentrations of 0.005 per cent is
effective in stabilizing ascorbic acid solutions ; the
thiourea is harmless. The stabilizing effect of
sodium chloride has also been reported, Vonesch
and Remezzano (Chem. Abs., 1942, 36, 217)
stating that addition of 3 parts of sodium chloride
for each 10 parts of ascorbic acid sufficed to retard
oxidation materially. Non-aqueous solvents, such
as propylene glycol, are sometimes used with
water in preparing injectable solutions of ascorbic
acid. For data on the stability of ascorbic acid in
various liquid formulations see Bandelin and
Tuschhoff (/. A. Ph. A., 1955. 44, 241).

Aqueous solutions of ascorbic acid, more prop-
erly referred to as solutions of sodium ascorbate,
may be prepared by the interaction of stoichio-
metric quantities of ascorbic acid and sodium
bicarbonate, while carbon dioxide is being passed
through the solution; the pH of the solution
should be adjusted to within 6.8 to 7.0 by the
addition of ascorbic acid or sodium bicarbonate,
as required. When required, a mixture of 0.09 per
cent of methylparaben and 0.01 per cent of
propylparaben may be used as bacteriostatic
agents. Ampuls may be sterilized at 120° for 15
minutes. Ciminera and Wilcox (/. A. Ph. A.,
1946, 35, 363) found that a solution of ascorbic
acid, adjusted to a pH of 6.0 to 6.5 with trisodium
phosphate and protected from air during manipu-
lation, was stable for at least one year at room
temperature in the dark.

Assay. — The U.S. P. directs that about 400 mg.
of ascorbic acid, previously dried in a vacuum
desiccator over sulfuric acid for 3 hours, be
titrated with 0.1 A7 iodine in an acid solution;
each molecule of ascorbic acid reacts with a mole-
cule of iodine to form dehydroascorbic acid and
two iodide ions. Each ml. of 0.1 N iodine repre-
sents 8.806 mg. of CeHgOe. U.S.P. Bandaruk
(Am. J. Pharm., 1941, 113, 18) and later Goett
et al. (J. A. Ph. A., 1943, 31, 7) advocated titra-
tion with potassium iodate solution as giving a
more satisfactory end-point than obtained with
iodine solution.

The B.P. assay utilizes the same reaction as
employed in the U.S.P. except that the former
directs titration of a 40-mg. sample with 0.01 N
iodine solution. The LP. assay employs about
900 mg. of ascorbic acid, neutralizes it with 0.1 N

Part I

Ascorbic Acid

117

sodium hydroxide in the presence of phenol-
phthalein, adds 50 ml. of 0.1 N iodine and titrates
the excess iodine with 0.1 N sodium thiosulfate.

The facility with which ascorbic acid is oxidized
to dehydroascorbic acid is the basis of several
other chemical assay procedures. Besides iodine,
ascorbic acid will reduce ferricyanides, copper
sulfate, methylene blue, etc. Perhaps the most
important method of determining ascorbic acid
in natural products is that involving decoloriza-
tion of the dye dichlorophenolindophenol. For a
description of this assay, which is also applied to
the official tablets, see Bessey, J.A.M.A., 1938,
111, 1291. Schmall et al. {Anal. Chem., 1954, 26,
1521) recently described a new method for the
colorimetric determination of ascorbic acid, this
depending on its interaction with diazotized 4-
methoxy-2-nitroaniline, the product having a
stable blue color in alkaline solution.

Uses. — Scurvy. — The disease known as scurvy,
for centuries one of the major plagues of human-
ity, especially in areas where the populace has
been unable to obtain fresh fruit or vegetables,
is caused by a lack of ascorbic acid. Frank scurvy
is less frequent now than formerly; in the United
States it is seen in infants (Follis et al., Bull.
Johns Hopkins Hosp., 1950, 87, 569) and in
indigent old men living alone. Most lower forms
of animals appear to be able to synthesize ascorbic
acid, but guinea pigs and primates must ingest
this essential substance in their food supply. The
amount of ascorbic acid in a diet of cow's milk
(about 0.7 mg. per 100 ml. of milk) is insufficient
for either an infant or an adult with peptic ulcer;
milk from a well-nourished woman contains the
adequate amount of approximately 5.2 mg. per
100 ml.

The outstanding symptoms of scurvy are great
fragility of the blood capillaries (Hines and
Parker, Quart. Bull. Northwest U. Med. Sch.,
1949, 23, 424), as shown by a tendency to ex-
ternal or internal hemorrhage on the slightest
injury, improper development of the teeth or
periodontal hemorrhage and inflammation after
eruption of teeth, and great muscular weakness.
The underlying pathology is a change in the char-
acter of the intercellular matrix of the connective
tissues (Dalldorf, J. A.M. A., 1938, 111, 1376).
Fibroblasts and ground substance are formed, but
collagen, osteoid tissue and dentine fail to form
(Follis, Bull. Johns Hopkins Hosp., 1951, 89, 9).
Severe deficiency of ascorbic acid may occur in
surgical conditions and result in disruption of
wounds {New Eng. J. Med., 1942, 226, 469; Am.
J. Surg., 1944, 66, 220), and failure of union of
fractures {Proc. Roy. Soc. Med., 1944, 37, 275).
Scorbutic patients often show evidence of de-
generation of skeletal muscles, anemia, enlarge-
ment of the heart, atrophy of the adrenals,
lowered resistance to infection, and disturbances
of calcium metabolism. Roentgen examination
often shows subperiosteal hemorrhages, broad
epiphyses and interruptions in the lamina dura of
the teeth. Physicians always look for swollen,
spongy, interdental papillae, of a blue or brown-
red color, which bleed easily, as a sign of scurvy,
although McMillan and Inglis {Brit. Med. J.,

1944, 2, 233) reported gingivitis in only 8 of 53
cases of scurvy.

A megaloblastic anemia in infants was described
by Zuelzer and Ogden {Am. J. Dis. Child., 1946,
71, 211) which responded to treatment with folic
acid but not to iron or the vitamin B12 in liver
extract. Analysis of the reported cases, and feed-
ing experiments on monkeys, demonstrated that
vitamin C deficiency in the diet of the infant was
responsible for the megaloblastic type of anemia
(May et al, ibid., 1950, 80, 191; 1952, 82, 282).
Treatment with ascorbic acid corrected the me-
galoblastic bone marrow and the anemia slowly.
If vitamin B12 was injected intramuscularly, cor-
rection was as rapid as with administration of
folic acid by mouth.

Physiological Function. — The physiological
role of ascorbic acid is beginning to unfold.
Sealock and Goodland {Science, 1951, 114, 645)
reported that ascorbic acid is an essential co-
enyme in the metabolic oxidation of tyrosine and
phenylalanine. Scorbutic guinea pigs and humans
excrete homogentisic acid and other hydroxy-
phenyl compounds in the urine; oxidation of the
phenyl nucleus seems to require ascorbic acid
(Rogers and Gardner, /. Lab. Clin. Med., 1949,
34, 1491). Urinary excretion of p-hydroxyphenyl-
pyruvic acid and />-hydroxyphenyllactic acid in
premature infants is corrected by administration
of ascorbic acid. Histochemical studies of experi-
mental wound healing in guinea pigs receiving
vitamin C demonstrate the presence of an acid
mucopolysaccharide in the early days of healing
which is shown by incubation with hyaluronidase
to be hyaluronic acid or chondroitin sulfate; this
ground substance is not found in wounds of
scorbutic animals (Penney and Balfour, /. Path.
Bad., 1949, 61, 171). An abnormal mucopoly-
saccharide and an abnormal precollagen have been
found in such wounds (Bradfield and Kodicek,
Biochem. J., 1951, 49, xvii). Even six weeks after
receiving an experimental wound well-nourished
guinea pigs, with good gross and microscopic evi-
dence of fibrotic healing, when fed for 18 days
on a vitamin C-deficient diet developed swelling,
herniation and hemorrhage in the scars, with his-
tologic evidence of degenerative changes, although
the overlying epithelium and the adjacent con-
nective tissue appeared normal (Pirani and Leven-
son, Proc. S. Exp. Biol. Med., 1953, 82, 95). Even
maintenance of a recent scar seems to require
adequate amounts of vitamin C. An increase in
the blood serum concentration of glycoproteins
was observed in scorbutic guinea pigs by Pirani
{Arch. Path., 1951, 51, 597); administration of
ascorbic acid is followed by a return to a normal
concentration. It is suggested that ascorbic acid
deficiency results in a depolymerization of carbo-
hydrate-containing constituents of the ground
substance of connective tissue, with absorption of
the smaller molecule into the blood stream. Rep-
pert et al. {Proc. S. Exp. Biol. Med., 1951, 77,
318) believe that ascorbic acid may inhibit the
hyaluronidase-hyaluronic acid system in inter-
stitial substance; loss of support for the capil-
laries from the surrounding ground substance
would be expected to increase capillary fragility.

118

Ascorbic Acid

Part I

Daubenmerkl (Acta Pharmacol. Toxicol., 1951,
7, 153) observed that ascorbic acid, in minute
concentrations in vitro, decreased the viscosity of
hyaluronic acid solutions at pH 7; with higher
concentrations of ascorbic acid this depolymeriz-
ing action was augmented and accelerated by the
addition of hydrogen peroxide and such a mixture
was an effective "spreading factor" for adminis-
tration of fluids by hypodermoclysis in children.
For clinical purposes this spreading factor is less
desirable than hyaluronidase because of some
irritation and the necessity for regulating the dose
within narrow limits.

In line with the observations of Moon and
Rhinehart (Circulation, 1952, 6, 481), Duff (Arch.
Path., 1935, 20, 371) and Aschoff, that the initial
lesion in atherosclerosis is an alteration in the
intercellular ground substance of the artery,
Willis (Can. Med. Assoc. J., 1953, 69, 17) re-
ported some thought-provoking observations.
Atherosclerosis was found in guinea pigs with
acute or chronic scurvy and with normal blood
cnolesterol levels and without lipid deposits in
the reticuloendothelial system; this simulates
human atherosclerosis more than does the ex-
perimental cholesterosis in rabbits or chickens fed
large amounts of fat and cholesterol.

Adrenals, Stress and Ascorbic Acid. — The
rapid depletion of ascorbic acid in almost any
severe illness has long been recognized. For ex-
ample, the concentration in blood and urine
drops rapidly to low levels in severe burns
(Levenson et al., Ann. Surg., 1946, 124, 840).
Furthermore, a large dose of ascorbic acid in such
a patient is not excreted but is retained in the
body, to be destroyed or utilized. The high con-
centration of ascorbic acid in the adrenal gland,
along with its rapid increase (as well as of cho-
lesterol) following administration of corticotropin
or application of stress, have resulted in con-
siderable study of the relationship of adrenal
corticoids and ascorbic acid (Sayers, Physiol.
Rev., 1950, 30, 241). The mechanism of this
relation is apparently not to be found in the
adrenal gland since no evidence of deficiency in
adrenal corticoids can be found in scorbutic
humans or animals (see Nutr. Rev., 1954, 12,
81). In fact, blood and urine levels of 17-hydroxy-
corticoids are increased in scurvy, and studies
with carbon- 14-labeled acetate in animals showed
greater conversion to adrenal cholesterol than in
well-nourished animals which served as a control
(Becker et al, J.A.C.S., 1953, 75, 2020). An in-
creased urinary excretion of corticoids, but not
of 17-ketosteroids, was found in children given
both corticotropin and ascorbic acid (Sprechler
and Vesterdal, Acta Endocrinol., 1953, 12, 207).
In rats, salicylates cause a decrease in adrenal
ascorbic acid, but not of cholesterol (Comulada
et al., Fed. Proc, 1953, 12, 313).

Metabolism. — Ascorbic acid is not stored in
the body to any considerable extent. In the ex-
periments of Crandon (New Eng. J. Med., 1940,
223, 353), who lived on a diet completely lack-
ing in ascorbic acid but adequate in all other sub-
stances, the blood plasma ascorbic acid fell within
.10 days to a low level and in 41 days completely

to zero. However, the concentration of ascorbic
acid in the leukocyte and platelet layer of the
blood did not drop to zero until 130 days. Hyper-
keratotic papules appeared on the thighs after 132
days and perifolicular hemorrhage after 161 days.
An incision in the skin healed normally after 95
days on the diet, when the blood plasma level of
ascorbic acid was, and had been, zero for 44 days,
but the white cell-platelet layer contained 4 mg.
of ascorbic acid per 100 Gm. After 160 days
clinical scurvy was present and an incision did not
heal until ascorbic acid was given. Pijoan and
Lozner (Bull. Johns Hopkins Hosp., 1944, 75,
303) confirmed Crandon's findings.

A portion of the ascorbic acid ingested with the
normal diet appears to be destroyed in the body
but a greater part is excreted. The rate of excre-
tion in the urine affords a criterion of the amount
in the blood. The renal threshold is about 1.4 mg.
per 100 ml. of plasma (Arch. Int. Med., 1945, 75,
407). Ascorbic acid is excreted in sweat, but
Henschel and his associates (Am. J. Trop. Med.,
1944, 24, 259) believe this to be negligible and
found no evidence for an increased requirement
for vitamin C in hot environments. Although
Crandon and others have shown that less than
25 mg. of ascorbic acid per 100 Gm. in the white
cell-platelet layer of the blood is a better criterion
of deficiency than a decrease in the blood plasma
level, Kyhos, Sevringhaus and Hagedorn (Arch.
Int. Med., 1945, 75, 407) reported that persons,
sick or well, who regularly ingest adequate
amounts of vitamin C-containing food seldom have
fasting blood plasma values lower than 0.8 mg.
per 100 ml. They do not believe that determina-
tions of ascorbic acid in whole blood are superior
to determinations in plasma. The disagreement
continues. After depletion of normal adult humans
with a daily intake of 10 mg. of ascorbic acid or
less to three-fourths to one-half of the initial
concentration in white blood cells, Steele et al.
(Fed. Proc, 1953, 12, 430) found that a daily
intake of 40 mg., but not of 20 or even 30 mg.,
caused an increase in the white blood cell content
of ascorbic acid, with a persistently low plasma
concentration of 0.2 mg. per 100 ml. Lutz et al.
(ibid., 1954, 13, 466) reported that subjects
saturated with ascorbic acid from a period of
large daily intake failed to maintain their high
concentration in the white blood cells on a daily
intake of 40 mg.; depleted subjects, however, did
maintain their initial subnormal concentration on
this daily intake. The minimum normal blood
plasma ascorbic acid concentration is 0.8 mg. per
100 ml. In many persons the concentration is
slightly lower in the spring of the year as a result
of the lower intake of fresh fruits and vegetables
during the winter period.

Optimal Nutritional Requirement. — In nor-
mal conditions the daily requirement for main-
tenance of optimal health in the adult male is
given as 75 mg. by the National Research Council
(U.S.A.). The Canadian Council on Nutrition
(Can. Pub. Health J., 1949, 40, 420), however,
recommended 30 mg. daily as adequate. On the
basis of the incidence of illness in a controlled
population, Scheunert (Intern. Ztschr. Vitamin-

Part I

Ascorbic Acid

119

forsch., 1949, 20, 374) reported that 100 or even
300 mg. is to be preferred. The recommended
daily dietary allowances of the National Research
Council (U.S.A.) are as follows: man (65 Kg.),
75 mg.; woman (55 Kg.), 70 mg.; during preg-
nancy (third trimester), 100 mg.; during lacta-
tion, 150 mg.; infants, 30 mg.; children (1 to
3 years old), 35 mg.; children (4 to 6 years old),
50 mg.; children (7 to 9 years old), 60 mg.; chil-
dren (10 to 12 years old), 75 mg.; girls from 13
to 20 years old, 80 mg.; boys from 13 to 20 years
old, 90 to 100 mg.

These recommendations find confirmation in
the report of Wilson and Lubschez (/. Clin. Inv.,
1946, 25, 428) that from 50 to 75 mg. was the
amount required daily by normal children averag-
ing seven years of age to maintain a level of 25
mg. per cent of ascorbic acid in the white cell-
platelet layer. They believe this level to be a
better criterion of habitual intake of the vitamin
than either plasma or urine levels. It is claimed
that a very considerable proportion of the popula-
tion is suffering from subclinical scurvy, that is,
from a partial deficiency of ascorbic acid
(J.A.M.A., 1942, 118, 944). From 1.4 to 1.8 mg.
per Kg. of body weight was required daily by
young women to produce saturation with the
vitamin as evidenced by urinary excretion of 50
per cent of a test dose of 400 mg. orally (Kline
and Eheart, /. Nutrition, 1944, 28, 413). How-
ever, both Crandon (loc. cit.) and Pijoan and
Lozner (New Eng. J. Med., 1944, 231, 14)
showed that saturation, as evidenced by overflow
in the urine, is not essential for health; from 12
to 25 mg. of ascorbic acid daily maintained a
normal concentration in the white cell-platelet
layer and permitted normal wound healing. Najjar
et al. (Bull. Johns Hopkins Hosp., 1944, 75, 315)
confirmed the adequacy of 18 to 25 mg. of ascor-
bic acid daily for young adults. In 20-year-old
male students in Iceland habitually on a diet of
about 20 mg. ascorbic acid daily, Sigurjonsson
(Brit. J. Nutrition, 1951, 5, 216) studied the
urinary excretion when 10 mg. per Kg. per day
was fed. A maximum output of 50 to 60 per cent
of the dose was reached on the second or third
day, decreasing thereafter despite continuation of
the high intake; this suggests an increased rate
of destruction. A diuretic effect has been reported
in man following large doses (700 mg.) by mouth,
but not intravenously; ascorbic acid has been
used effectively in the treatment of edema
(Shaffer, J. A.M. A., 1944, 124, 700).

Therapeutic Uses. — Ascorbic acid is used as
a specific curative in scurvy. In many different
diseases a deficiency of the vitamin may develop
due to anorexia, to fault of a special diet, to
failure of absorption as in diarrheal and other
disorders, or to increased requirements in hyper-
metabolism (Proc. S. Exp. Biol. Med., 1938, 39,
233; Bull. Johns Hopkins Hosp., 1938, 63, 31)
or during the course of infections. The correction,
or better the prevention, of any deficiency of
ascorbic acid will benefit such patients.

Detoxification. — Ascorbic acid has a detoxify-
ing action toward many toxins, drugs and indus-
trial chemicals (J. A.M. A., 1943, 121, 868; Arch.

Int. Med., 1943, 71, 315). Thus, it is of value
in connection with arsenicals, such as neoarsphen-
amine (J. A.M. A., 1941, 117, 1692; Am. J. Digest.
Dis., 1943, 10, 170; /. Pharmacol, 1944, 80,
81), benzene and trinitrotoluene (J -Lancet, 1943,
63, 349), bismuth and antimony compounds (Am.
J. Digest. Dis., 1943, 10, 170), the sulfonamides
(Arch. Int. Med., 1942, 69, 662), intravenous
procaine hydrochloride (J.A.M.A., 1951, 147,
1761); Arch. Dermat. Syph., 1952, 65, 39),
salicylates (/. Lab. Clin. Med., 1942, 28, 28),
diethylstilbestrol (J.A.M.A., 1943, 123, 113),
gold salts (New Eng. J. Med., 1943, 229, 773;
J.A.M.A., 1942, 120, 1331), and lead (/. Lab.
Clin. Med., 1941, 26, 1478). However, the bene-
ficial effect in lead poisoning has been denied
(J. A.M. A., 1943, 121, 501). The hypnotic action
of phenobarbital or pentobarbital is greater in
scorbutic guinea pigs (/. A. Ph. A., 1941, 30,
613); Greig (/. Pharmacol, 1947, 91, 317) de-
scribed a depression of oxidative metabolism in
the brain by barbiturates which was corrected,
in vitro, with ascorbic acid. McCormick (Arch.
Pediat., 1953, 70, 107) recommended use of
ascorbic acid to minimize the alleged undesirable
results to be expected from drinking public water
supplies to which fluoride has been added in a
"misguided" effort to prevent dental caries. Bour-
quin and Musmanno (Am. J. Digest. Dis., 1953,
20, 75) found that smoking of cigarettes or
addition of nicotine to blood, in vitro, decreased
the concentration of ascorbic acid in blood. In-
travenous injection of 1 Gm. of sodium ascorbate
at the time that a patient taking tetraethyl-
thiuram disulfide is given ethyl alcohol relieved
headache, restlessness, palpitation, weakness and
apprehension but did not prevent the increase in
acetaldehyde concentration in blood or the hypo-
tension, tachycardia and flushing of the skin
(Niblo et al, Dis. Nerv. System, 1951, 12, 340).
Greiner and Gold (J. A.M. A., 1953, 152, 1130)
did not find any decrease in the incidence of un-
toward effects when ascorbic acid was added to
meralluride administered by mouth as a diuretic.
Treatment of Various Disorders. — Ascorbic
acid, being related to the functioning of inter-
cellular substance, has come into consideration in
all phases of physiology and pathology and has
been tried in the treatment of almost all of the
disorders of mankind. Benefit has been reported
in: retinal hemorrhage (Am. J. Obst. Gyn., 1943,
46, 635), coronary thrombosis (Can. Med.
Assoc. J., 1941, 44, 114), hematuria (/. Urol,
1939, 41, 401), bleeding peptic ulcer (Ann. Int.
Med., 1940, 14, 588), peptic ulcer without hem-
orrhage (Am. Pract., 1952, 3, 117), rheumatic
fever, diphtheria, pneumonia and scarlet fever
(Am. J. Dis. Child., 1942, 64, 426), acute rheu-
matic fever (New Eng. J. Med., 1950, 242, 614)
(in doses of 1 Gm. by mouth 4 times daily),
healing of deep but not of superficial corneal
ulcers (Brit. M. J., 1950, 2, 1145), tuberculosis
(Am. Rev. Tuberc, 1941, 44, 596), grippe
(Laryn., 1938, 48, 327), dysentery (Clin. Proc,
1943, 2, 65), fractures (Klin.-therap. Wchnschr.,
1937, 16, 1313), prickly heat rash on the skin
(J.A.M.A., 1951, 145, 175), march hemoglobinuria

120

Ascorbic Acid

Part I

(Lancet, 1949, 1, 435), and dental caries (Ann.
Int. Med., 1944, 20, 1). The relation of ascorbic
acid to gastrointestinal disease seems to have sig-
nificance. Freeman and Hafkesbring (Fed. Proc,
1954, 13, 48) found that both blood and gastric
juice ascorbic acid concentrations were about one-
half that of healthy persons in patients with peptic
ulcer, gastritis, pernicious anemia, and carcinoma
of the stomach. The studies of Breidenbach and
Roy (ibid., 1953, 12, 182) indicated that ascorbic
acid retarded proteolysis in mixtures with crude
gastric juice; in cases of peptic ulcer such an
action would minimize the concentration of acid
and pepsin acting on the gastric mucosa.

The value of ascorbic acid in the following con-
ditions, among others, is controversial: hay fever
(Ann. Allergy, 1949, 7, 65), fatigue (J. -Lancet,
1943, 63, 355), hot environment (Science, News
Sup., June 19, 1942, p. 12; but see /. Allergy,
1945, 16, 14), and bleeding gums and gingivitis
(Am. J. Pharm., 1943, 115, 238; Lancet, 1943,

I, 640; but see Am. J. Obst. Gyn., 1951, 61,
1348; /. A. Dent. A., 1944, 31, 1323), in com-
bination with menadione in hyperemesis gravi-
darum (Am. J. Obst. Gyn., 1952, 64, 416), in
combination with procaine hydrochloride orally
in pruritus in allergic patients (Ann. Allergy, 1953.

II, 85), in virus infections in children (measles,
mumps, chicken pox, pneumonia, encephalitis and
poliomyelitis) (South. Med. Surg., 1951, 113,
101), and intravenously in combination with
desoxycorticosterone glucoside for temporary re-
lief in rheumatoid arthritis (Lancet, 1952, 1,
1280). In a carefully controlled study of ascorbic
acid and other vitamins, Cowan et al. (J.A.M.A.,
1942, 120, 1268) observed no benefit in the pre-
vention of the common cold. The relationship
between the blood plasma ascorbic acid level and
the titer of complement (J. A.M. A., 1939, 112,
1449) was not confirmed (/. Immunol., 1942, 44,
289). The addition of ascorbic acid did not en-
hance the effect of ferrous iron therapy in ele-
vating the blood hemoglobin level of school chil-
dren (Brit. M. J., 1944, 1, 76). Ruskin (Am. J.
Digest Dis., 1945, 12, 281), in experiments on
rabbit bronchiolar tissue, demonstrated ascorbic
acid to have antihistaminic activity. (Y)

Toxicology. — Untoward effects from either
oral use or proper parenteral administration of
appropriate solutions of ascorbic acid are almost
unknown. Cases of acute hemolytic anemia in
children ingesting a solution of ^-aminosalicylic
acid containing sodium ascorbate have been re-
ported (Lust, Scalpel, 1953, 106, 276; abstracted
in J.A.M.A., 1953, 152, 1281). Lowry et al. (Proc.
S. Exp. Biol. Med., 1952, 80, 361) fed four adult
humans 1 Gm. of ascorbic acid daily, in three
divided portions with meals, for three months
without untoward symptoms, and with no altera-
tion in the concentrations of the vitamin in blood
or urine at the end of the period as compared
with the first few weeks.

Parenteral Administration. — When intes-
tinal absorption of ascorbic acid is inefficient or
when a massive effect is desired sodium ascorbate
may be injected subcutaneously or intravenously
. (see above for description of preparation of solu-
tions of the salt). Because of the strong acidity of

ascorbic acid, which has been observed to cause
an increase in the blood pressure of animals, the
acid itself should not be used in this manner.
Under the name Cenolate (Abbott) a methyl
glucamine salt is available for intravenous, sub-
cutaneous or intramuscular injection.

Antioxidant Action. — The instability of as-
corbic acid in the presence of water is mainly
attributable to the ease of its oxidation, as by air.
Because of this, ascorbic acid may serve to pre-
vent oxidation of other substances. Since ascorbic
acid is available in large quantities, and is rela-
tively inexpensive, it is sometimes used for this
purpose. One ingenious application is the use of
ascorbic acid to prevent change of flavor or dis-
coloration of canned or frozen fruits, such as the
peach; 150 mg. of the acid per pound of fruit is
effective. Development of rancidity in butter, at
37°, was found to be retarded by addition of 0.01
per cent of L-ascorbyl stearate, palmitate, myris-
tate or laurate (Mukherjee and Goswami, /. In-
dian Chem. Soc, 1950, 27, 539; see also Watts
and Wong, Arch. Biochem., 1951, 30, 110).

Dose. — The usual therapeutic dose of ascorbic
acid is 150 mg. (approximately 2l/2 grains) daily,
by mouth, or by subcutaneous or intravenous ad-
ministration of sodium ascorbate injection; the
range of dose is 100 mg. to 1 Gm. The optimal
daily requirement in health is 75 mg. for an adult,
with a range of 25 to 75 mg.; for a child it is
50 mg. daily. An infant receiving a formula of
modified cow's milk should receive 5 mg. daily.
In severe illness the recommendation of Pijoan
and Lozner (New Eng. J. Med., 1944, 231, 14)
to take 1 Gm. daily for ten days is worthwhile.

The dose of ascorbic acid was formerly ex-
pressed in terms of units. The U.S. P. XII defined
its unit as follows: "One United States Phar-
macopoeial Unit of Ascorbic Acid (Vitamin C)
is the Vitamin C activity of 0.05 mg. of the U.S. P.
Reference Standard, and is equal to one Interna-
tional Unit of Vitamin C as defined and adopted
by the Conference of Vitamin Standards of the
Permanent Commission on Biological Standardiza-
tion of the League of Nations in June of 1934."
U.S.P. XII.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Ascorbic Acid Tablets, U.S.P.,
B.P.; Decavitamin Capsules; Decavitamin Tab-
lets, U.S.P.; Hexavitamin Capsules; Hexavitamin
Tablets, N.F.

ASCORBIC ACID INJECTION. U.S.P.

Sodium Ascorbate Injection, U.S.P. XIV

"Ascorbic Acid Injection is a sterile solution of
ascorbic acid in water for injection prepared with
the aid of sodium hydroxide, sodium carbonate, or
sodium bicarbonate. It contains not less than 95
per cent and not more than 115 per cent of the
labeled amount of C6Hs06." U.S.P.

For a discussion of methods of preparing this
injection see the preceding monograph. The
U.S.P. requires the pH of the injection to be be-
tween 5.5 and 7.0. The assay utilizes the method
described under Ascorbic Acid Tablets.

Storage. — Preserve "in single-dose containers,
preferably of Type I or Type II glass." U.S.P.

Part I

Aspidium 121

Usual Sizes.— 100 and 500 mg. in 2 ml.; 500
mg. and 1 Gm. in 5 ml.; 500 mg. in 10 ml.

ASCORBIC ACID TABLETS.

U.S.P. (B.P., I.P.)

Tabellas Acidi Ascorbici

"Ascorbic Acid Tablets contain not less than
95 per cent and not more than 115 per cent of the
labeled amount of CeHs06." U.S.P. The corre-
sponding limits of the B.P. are 88.0 per cent and
110.0 per cent; the I.P. limits are 90.0 and 110.0
per cent, respectively.

B.P. Tablets of Ascorbic Acid. I.P. Compressi Acidi
Ascorbici. Sp. Tabletas de Acido Ascorbico.

Assay. — Because the tablets will in all likeli-
hood contain other substances, besides ascorbic
acid, which reduce iodine it is not possible to de-
termine the content of ascorbic acid in the tablets
in the same manner as the pure acid is analyzed.
By using dichlorophenol-indophenol solution, how-
ever, the ascorbic acid may be oxidized — to dehy-
droascorbic acid, the same product as obtained in
the titration with iodine — without oxidizing any
other constituent that may normally be in the
tablet. Dichlorophenol-indophenol is blue in alka-
line solution, pink in acid and colorless when it is
reduced. For this titration the reagent is used in
alkaline solution; on addition to the ascorbic acid
solution it is decolorized and the end point is
taken to be the appearance of a rose-pink color in
the solution which persists for at least 5 seconds.
The formation of the pink color is due to the fact
that the titration medium contains acid, which
changes the blue color of the titrating solution
to pink. The dichlorophenol-indophenol solution
is standardized against pure ascorbic acid. U.S.P.

Ascorbic acid tablets are frequently yellowish
in color but this should not be interpreted as
necessarily indicating extensive decomposition.
Such discolored tablets may readily meet the offi-
cial assay requirement.

Under the name Sodascorbate (Van Patten)
there is available sodium ascorbate, in tablets, for
use in all conditions for which ascorbic acid is
given orally. The sodium salt has the advantage
of minimizing disturbance which may be caused
by the acidity of ascorbic acid, especially when
large doses of the latter are given.

Usual Sizes.— 25, 50, 100, 250 and 500 mg.

ASPIDIUM. U.S.P. (B.P, I.P.)

Male Fern, [Aspidium]

"Aspidium consists of the rhizome and stipes
of Dryopteris Filix-mas (Linne) Schott, known in
commerce as European Aspidium or Male Fern,
or of Dryopteris marginalis (Linne) Asa Gray,
known in commerce as American Aspidium or
Marginal Fern (Fam. Polypodiacece) . Aspidium
yields not less than 1.5 per cent of crude filicin."
U.S.P.

The B.P. recognizes Male Fern as the rhizome,
frond-bases and apical bud of Dryopteris filix-mas
(L.) Schott, collected late in the autumn, divested
of roots and dead portions and carefully dried,
retaining the internal green color; not less than
1.50 per cent of filicin is required. The I.P. defi-

nition and requirement of filicin content are prac-
tically the same as those of the B.P. except that
Dryopteris marginalis is also recognized as a
source of the drug.

B.P., I.P. Male Fern; Filix Mas. European Aspidium;
Basket Fern. Rhizoma Filicis; Filicis Maris Rhizoma. Fr.
Fougere male. Ger. Farnwurzel ; Johanniswurzel. It. Felce
maschio. Sp. Rizoma de helecho macho; Aspidio.

Since the term Dryopteris was first used by
Amman in 1739, and applied in 1763 by Adam-
son, as the name of the genus to which the
Aspidium was applied in 1800 by Swartz, the use
of the generic term Dryopteris is necessitated by
the rules of botanic nomenclature. The synonyms
for the male fern are extraordinarily numerous.
The following have been among those occasionally
used: Aspidium Filix-mas, of many authors;
Polypodium Filix-mas Linn.; and Polystichum
Filix-mas Roth.

The Male Fern is very widely distributed, oc-
curring in Greenland, Europe, Asia, Northern
Africa and in some of the Polynesian Islands;
in the Western Hemisphere it is found in the
Rocky Mountains in North America and the
Andes Mountains in South America. It has a
perennial, oblique rhizome, from which numerous
annual fronds arise, forming tufts from a foot
to four feet in height. The stipe, or petiole, and
midrib are thickly beset with brown, tough, trans-
parent scales; the frond itself is ovate-oblong in
outline, the pinnae being linear-lanceolate, taper-
ing from base to apex. The fructification is in
small dots on the back of each lobe, occurring
close to the midvein.

The leather wood jern or marginal fern, Dry-
opteris marginalis (L.) Asa Gray (Aspidium
marginale Sw. ; Polypodium marginale L.), differs
from the preceding by having the sori (fruit
bodies) on the margin of the leaves instead of
near the midrib. It is found in rocky woods and
on banks in eastern North America from Nova
Scotia to Alabama. Wilson (Thesis, Massachusetts
Coll. Pharm., 1925) found the oleoresin from the
marginal fern to yield from 22 to 24 per cent of
crude filicin.

It is probable that all of the species of this
genus possess more or less anthelmintic prop-
erties. According to Rosendahl (Pharm. J., 1911,
87, 35) the Dryopteris dilatata is indeed four
times as active a poison to the tapeworm as the
true aspidium. D. spinulosa Kuntze is often found
mixed with the male fern in Germany. Lauren
(Apoth.-Ztg., 1903) stated that this species is an
active taeniacide less liable to cause disagreeable
sensations. The D. rigida Underw. of the Pacific
coast is used in the western U. S. as a vermifuge.

The Athyrium Filix- jemina (L.) Bernh., or
Lady Fern, is also popularly ascribed with taenia-
fuge properties. Kiirsten (Pharm. J., 1891) found
in it pannic acid (or pannol) which is closely re-
lated to filicic acid; it differs in being soluble in
strong alcohol and in not yielding isobutyric acid
on hydrolysis. Under the name of inkomankomo or
uncomocomo, the rhizome of Aspidium athamanti-
cum (Hook.) Kuntze, has long been used by the
South African Kaffirs, and has entered European
commerce as pannum (Rhizoma Pannce). In it
Heffter (Arch. exp. Path. Pharm., 1897, 38, 458)

122 Aspidium

Part I

found three well characterized and crystallized
principles: flavopannin, albopannin and pannol
(pannic acid of Kiirsten). Both flavopannin and
albopannin are powerful muscle poisons, directly
affecting the heart.

Extracts of male fern undergo some chemical
change on standing which leads to a loss of filicin
content (Goris and Metin, Bull. sc. Pharmacol.,
May, 1924). According to Pedretti {them. Abs.,
1931, 25, 4658) physiologically active amorphous
filicic acid is changed into a crystalline inert form.

The rhizomes of other species of fern are fre-
quently substituted for the official, and in the
dried state it is difficult to distinguish them. The
varying results reported by physicians, when using
this drug, are no doubt due to use of spurious
male fern, or old rhizomes and stipe bases which
are devoid of any greenish color internally.

In collecting male fern, all the black, discolored
portions should be cut away, the fibers and scales
separated, and only the sound green parts pre-
served. Most of the drug is gathered in this coun-
try, especially in New Hampshire. Some supplies
of Male Fern from Dryopteris Filix-mas have
been imported from India.

Description. — "Unground Aspidium occurs as
unpeeled or peeled, entire or longitudinally split,
rhizomes with attached bases of stipes, or as sep-
arate pieces of rhizome and stipes. The rhizome is
6 to 15 cm. in length and 3 to 4 cm. in diameter,
cylindraceous and nearly straight, or curved and
tapering toward one end, usually split longitudi-
nally and showing large, angular stipe-scars, in
which the ends of vascular bundles are often visi-
ble, and occasionally, adhering feathery masses or
reddish brown ramenta. The stipes are nearly
cylindrical, but tapering toward one end, nearly
straight or somewhat curved, 3 to 5 cm. in length,
and up to about 10 mm. in thickness; externally
they are usually weak reddish brown to brownish
gray, or, if peeled, light brown to weak yellow;
the fracture is short. The transversely fractured
surface is pale green to weak greenish yellow or
brown, is spongy, and exhibits an interrupted
circle of from 2 to 13 vascular bundles. The odor
is slight. The taste is at first sweetish and astrin-
gent, then bitter and acrid." U.S.P. For histology
see U.S.P. XV.

Standards and Tests. — Aspidium contains
not more than 2 per cent of foreign organic
matter, and not more than 3 per cent of acid-in-
soluble ash. U.S.P.

Assay. — An ether extract of 40 Gm. of
aspidium is prepared and assayed as directed
under Aspidium Oleoresin. U.S.P.

Adulterants. — Powdered althea leaves have
been used as an adulterant of powdered aspidium,
giving the light-green tint indicative of a good
quality of drug. At other times the powder is said
to have consisted entirely of the chaff and other
inert material which the Pharmacopeia directs
should be rejected. Kraemer reported that much
of the aspidium formerly in the American market
consisted of the large rhizomes of Osmunda Clay-
toniana. This substitute has been frequently
offered on the American market. Capelle (Apoth.-
Ztg., 1907, p. 433) discussed the characteristics
"of genuine aspidium and the differentiation of

related species. The most recently offered sub-
stitute has been the rhizomes of the Christmas
Fern, Polystichum achrostichoides (Michx)
Schott.

Constituents. — The activity of male fern de-
pends on the presence of a number of related
compounds. These compounds include those desig-
nated as amorphous filicic acid, crystalline filicic
acid (also called filicin and filicinic acid), filic
acid, aspidinin, albaspidin, aspidin, aspidinol,
flavaspidinic acid, and filmaron. A green fixed oil,
a volatile oil, sugar, starch, resin and wax are
other substances which have been reported to be
present. Unfortunately, there is some confusion
in the naming of the compounds and several dif-
ferent chemical formulas have been assigned to
some of them, hence their exact chemical rela-
tionship is uncertain. It does appear, however,
that most of these substances are derivatives of
a methyl or a dimethyl-phloroglucinol. Robertson
and Sandrock (/. Chem. S., 1933, p. 819) verified,
through synthesis, that aspidinol, the simplest
phenolic constituent of the drug, is a monomethyl
ether of C-methylphloro-M-butyrophenone. The
same investigators (ibid., p. 1617) synthesized
filicinic acid (earlier shown to be a decomposition
product of several aspidium constituents) and
verified its formula as l:l-dimethylcyclohexane-
2:4:6-trione. For a review of the reports on the
constituents of aspidium, see Pabst and Bliss
(/. A. Ph. A., 1932, 21, 431).

Pabst and Bliss state that for purposes of
standardization of aspidium and its oleoresin by
chemical methods the active constituents have
been assumed to be crude filicic acid. The latter
is actually a mixture of complex composition and
no reliable methods have been devised by which
each of the constituents may accurately be de-
termined. It is further claimed that crude filicic
acid is accompanied by inert constituents in vary-
ing and unknown amounts.

Uses. — Because of its rapid deterioration pow-
dered aspidium is rarely employed. The more
stable oleoresin, prepared as soon as the drug is
harvested, is the preferred dosage form. For uses
of aspidium see under Aspidium Oleoresin. E

Dose, of powdered aspidium rhizome, 4 to 8
Gm. (approximately 1 to 2 drachms).

ASPIDIUM OLEORESIN. U.S.P.
(B.P., LP.)

Extract of Male Fern, Male Fern Oleoresin,
[Oleoresina Aspidii]

"Aspidium Oleoresin yields not less than 24 per
cent of crude filicin." U.S.P.

The B.P. requires that the Extract of Male
Fern contain 25.0 (limits, 24.0 to 26.0) per cent
of crude filicin. The LP. requires not less than
25.0 per cent and not more than 26.0 per cent of
filicin.

B.P. Extract of Male Fern; Extractum Filicis. LP.
Oleoresina Filicis Malis. Liquid Extract of Male Fern;
Oil of Fern. Oleoresina Filicis; Extractum (Oleum) Filicis
Maris; Extractum Filicis Maris ^Ethereum. Fr. Extrait de
fougere male; Extrait oleo-resineux de fougere male;
Extrait ethere de fougere male. Ger. Farnextrakt. It.
Estratto di felce Maschio etereo. Sp. Extracto de
helecho macho, etereo; Oleorresina de Aspidio.

Place 500 Gm. of aspidium, recently reduced to

Part I

Aspidium Oleoresin 123

coarse powder, in a cylindrical glass percolator
provided with a stopcock, and with a cover and a
receptacle arranged for safe use of volatile liquids.
Pack the powder firmly, and percolate slowly with
ethyl oxide added in successive portions until the
drug is exhausted. Recover the greater part of
the ethyl oxide from the percolate by distillation
on a water bath and, having transferred the resi-
due to a dish, allow the remaining ether to evapo-
rate spontaneously in a warm place remote from
a naked flame. U.S.P.

The process of extraction in the B.P. is essen-
tially the same as that in the U.S. P., except that
after the ether has been evaporated the extract
is assayed and sufficient arachis oil or other suit-
able official fixed oil is added to produce an ex-
tract of the required strength.

This is the only preparation of male fern which
should be used; in its making aspidium which is
internally green in color and recently collected
should be employed. The oleoresin is a thick, dark
green liquid having the odor of the fern and a
nauseous, bitter and somewhat acrid taste. It
usually contains a granular deposit of crystalline
material which is regarded as an active ingredient
and should not be separated. According to Hayes,
when an absolutely dry root and an anhydrous
ether (containing but little alcohol) of a specific
gravity below 0.728 are used, the oleoresin re-
mains clear. Aspidium oleoresin has been some-
times found in the market containing noticeable
proportions of copper, and in many cases it is
colored green artificially.

Description. — "Aspidium Oleoresin is a dark
green, thick liquid, usually depositing a granular,
crystalline substance, which must be thoroughly
mixed with the liquid portion before use. Aspidium
Oleoresin is insoluble in water; it is soluble in
alcohol and in ether. Not less than 85 per cent of
the Oleoresin is soluble in petroleum benzin. The
specific gravity of Aspidium Oleoresin is not less
than 1.00." U.S.P. The B.P. and the LP. both
require the oleoresin to have a refractive index,
at 40°, of not less than 1.492.

The requirement of the U.S.P. that not less
than 85 per cent of the oleoresin shall be soluble
in petroleum benzin is to exclude adulteration
with castor oil, which is only slightly soluble in
petroleum benzin. The presence of castor oil is
especially undesirable because it increases the
absorption of aspidium.

Assay. — After warming the aspidium oleoresin
on a water bath and stirring it until thoroughly
mixed, a sample of 3 Gm. is dissolved in ether,
and the phenolic and acidic constituents compris-
ing "crude filicin" removed by shaking the ether
with portions of 3 per cent barium hydroxide so-
lution. The barium hydroxide solutions are filtered,
combined, acidified to liberate the phenolic and
acidic substances, and these extracted with ether.
After filtration the ether solution is evaporated
and the residue of crude filicin dried at 105° for
2 hours and weighed. U.S.P.

The B.P. and LP. assays are practically the
same as that of the U.S.P.

Attempts have been made to standardize not
only aspidium but other anthelmintics as well by
biological methods. Sollmann (/. Pharmacol.,

1918, 12, 129) proposed use of the earthworm
for this purpose. His method is as follows: The
worms, which are kept in damp leaf mold before
being used, are washed with tap water and five of
them are placed in beakers containing 100 ml. of
tap water, to which are added varying quantities
of the anthelmintic substance. After 24 hours the
mobility of the worms is observed. Munch recom-
mends, for the purpose of determining life in the
worm, stimulation with faradic current. He found
close agreement, in his tests with aspidium oleo-
resin, between the toxicity to worms and chemical
assay. Other test animals which have been sug-
gested include the ascarides of either dogs or
pigs, various other helminths, and even goldfish.
Carlsson and Backstrom (Chem. Abs., 1944, 38,
2451) found that there is a linear relationship be-
tween the potency of aspidium extracts and their
extinction coefficient as calculated from optical
density readings using a photoelectric instrument.
They also reported that the activity of the ex-
tracts may be judged by their toxicity to earth-
worms; hexylresorcinol was used as the toxicity
standard. For a report on the chemical and bio-
logical standardization of aspidium oleoresin see
Pabst and Bliss (/. A. Ph. A., 1932, 21, 431).

Uses. — Aspidium oleoresin is used in medicine
almost solely for expulsion of the tapeworm
(Taenia solium or saginata, Diphyllobothrium
latum, and Hymenolepis nana). It is not used in
other forms of helminthiasis. It does not kill the
parasite, but paralyzes it so that it can be washed
out of the intestinal tract by an active purge.

Male fern was mentioned as a vermifuge in the
works of Dioscorides, Theophrastus, Galen, and
Pliny, as well as by some of the earlier modern
writers. It does not appear to have become gen-
erally known until about 1775, when the King
of France purchased from Madame Nouffer,
widow of a Swiss surgeon, a secret remedy for
tapeworm, which proved to be the powdered root
of the male fern. As first demonstrated by Straub
(Arch. exp. Path. Pharm., 1902, 48, 1) the prin-
ciples of aspidium paralyze the voluntary muscles
of higher animals, as well as the analogous con-
tractile tissue of invertebrates.

With adequate and careful preparation and
management of the patient, tapeworm is elimi-
nated in 90 per cent of cases following use of
aspidium oleoresin. It would appear that the use
of this drug will decrease in view of the demon-
strated efficacy of the less toxic quinacrine. For
purgation when aspidium oleoresin is administered
castor oil has been employed, but its use increases
the absorbability of the drug and adds to the
danger of poisoning. A saline cathartic, such as
magnesium sulfate or sodium sulfate, is prefer-
able. Also, a fat-free diet for two days preceding
use of aspidium is advisable.

When aspidium oleoresin is to be administered
a liquid diet is prescribed during the 24 hours
preceding administration of the drug. The evening
before the aspidium is given, the patient should
take 15 to 30 Gm. of magnesium sulfate to empty
the intestinal tract. In the morning a total dose of
4 Gm. of aspidium oleoresin, in capsules or dis-
persed in a mucilaginous vehicle, is given in one
or two divided doses, one hour apart. A saline

124 Aspidium Oleoresin

Part I

purgative is given 2 hours after the last dose; this
is followed by a soap-suds enema 2 hours later
to remove the scolex, should it now be free within
the intestine. By straining this material and any
feces passed the head may be identified. The
therapeutic course should not be repeated in less
than 7 to 10 days. The toxicity of aspidium ren-
ders its use in children hazardous.

Toxicology. — Aspidium is a violent poison,
the relative rarity of serious symptoms from its
use being due to its non-absorbability. When there
is a large amount of fatty matter in the bowel, it
may be absorbed and give rise to serious and even
fatal poisoning (see Hernandez Morales, Puerto
Rico J. Pub. Health Trop. Med., 1945, 21, 213;
also Lancet, 1882). It is highly irritant and may
produce vomiting and severe diarrhea. Stimulation
of the spinal cord may produce tremors and tonic
convulsions, followed by ascending depression, in-
volvement of the medulla, respiratory failure with
cyanosis and dyspnea. There may be headache,
cold sweats and mental disturbances. In nearly
half of the cases there has been disturbance of
vision, and even blindness, which in a few in-
stances remained permanently. According to Har-
nack {Munch, med. Wchnschr., 1912, 59, 1941),
the blindness is due to spasm of the retinal vessels
and subsequent optic atrophy. Prevost and Binet
found that in the lower animals the oleoresin,
given hypodermically, produces violent dyspnea
and death from arrest of the heart in systole;
Frohner found parenchymatous nephritis in ani-
mals fatally poisoned by it. Liver damage and
jaundice may occur.

Should symptoms of poisoning appear, use of
an emetic such as mustard or zinc sulfate fol-
lowed by vigorous catharsis with magnesium sul-
fate is indicated. Symptomatic and supportive
measures are required, including parenteral fluids,
electrolytes and dextrose, demulcents for the irri-
tated gastrointestinal tract, and stimulants, such
as caffeine, or sedatives, such as the barbiturates,
as indicated.

Contraindications. — Aspidium should not be
administered during pregnancy, nor to debilitated
adults or children. Parenchymal cardiac, hepatic,
and renal diseases are contraindications to its use;
so also is any ulcerative lesion of the gastrointesti-
nal tract. E

Filmaron, one of the active constituents of
aspidium, has been used as a clinical vermifuge,
as a 10 per cent solution in castor oil. The dose
of filmaron is 0.5 to 0.75 Gm. (approximately 7J4
to 12 grains).

The usual adult dose of aspidium oleoresin is
4 Gm. (approximately 60 grains), the range being
1 to 5 Gm. The maximum safe dose is usually 5
Gm., and the maximum dose in a period of 1 to 2
weeks should seldom exceed 5 Gm. For children
the dose is 250 mg. (approximately 4 minims)
per year of age, up to a maximum of 15 years.
Aspidium oleoresin may be administered by
mouth or duodenal tube, dispersed in a freshly
prepared mucilaginous vehicle; a typical formula
consists of aspidium oleoresin, 4 Gm.; acacia
mucilage, 30 ml.; cinnamon or other aromatic
water, to 45 ml. The oleoresin may also be given

in capsules or, especially to children, on a tea-
spoonful of sugar.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

CAPSULES OF EXTRACT OF
MALE FERN. B.P.

These are defined as flexible gelatin capsules,
the shells of which are colored black. Not less
than 95.0 per cent and not more than 105.0 per
cent of the prescribed, or stated, volume of ex-
tract is required to be present in each capsule of
average volume. B.P.

ATROPINE. N.F., B.P, LP.

[Atropina]

"Atropine is an alkaloid usually obtained from
Atropa Belladonna Linne, from species of Datura
and Hyoscyamus (Fam. Solanacece), or produced
synthetically. Caution. — Atropine is extremely
poisonous." N.F. The B.P. defines Atropine as
(±) -hyoscyamine and says that it is obtained
from Hyoscyamus muticus L, Duboisia species,
and other plants of the Solanacece. The LP.
defines it as DL-tropanyl-2 -hydroxy 1-1 -phenyl-
propionate.

I.P. Atropinurn. Fr. Atropine. Ger. Atropin. It. Atropina.
Sp. Atropina.

Atropine, discovered by Yaquelin in 1809, was
recognized as an alkaloid by Brandes in 1819. It
does not occur in plants to any appreciable extent
as such, but does occur as its levorotatory isomer
hyoscyamine, from which it is prepared by
racemization.

Hyoscyamine, the most commonly occurring
of the solanaceous alkaloids, and the one from
which atropine is prepared, occurs naturally only
as a levorotatory base. It melts at 108.5°, is
readily soluble in chloroform, benzene or alcohol,
less so in ether or cold water. The hydrobromide
and sulfate are official and are described elsewhere
in Part I.

Belladonna root, Hyoscyamus muticus, or H.
niger are common sources for the manufacture of
atropine. The powdered plant material is thor-
oughly moistened with an aqueous solution of
sodium carbonate and extracted by percolation
with ether or ethyl acetate. The bases are ex-
tracted from the ether with acetic acid, the acid
solution being shaken with ether as long as the
ether takes up coloring matter, then precipitated
with sodium carbonate. The precipitate of the
bases, after washing and drying, is dissolved in
ether, the solution dehydrated with anhydrous
sodium sulfate and filtered. Upon concentration
of the ether solution the bases crystallize upon
standing, the mixture being chilled in order to
hasten crystallization. The crude crystalline mass
consisting of a mixture of atropine and hyoscya-
mine, after filtering and drying, is mixed with
one-fourth of its weight of chloroform and heated
under a reflux condenser for 2 hours at from 116°
to 120°. This treatment racemizes the hyoscya-
mine into atropine. The racemization can also be
accomplished by treating the alcohol solution of

Part I

Atropine 125

the bases with some sodium hydroxide and allow-
ing to stand until the racemization is complete as
determined by optical measurement. The crude
atropine is purified by solution in acetone, treat-
ment with decolorizing carbon and, after filtration,
the solution is concentrated and cooled by means
of ice and salt. To hasten the crystallization the
solution is seeded with a few crystals of atropine.

The sulfate may be prepared from the base by
dissolving the latter in acetone and adding just
enough dilute sulfuric acid to furnish the neces-
sary amount of H2SO4.

Kraut demonstrated, in 1864, that atropine
undergoes hydrolysis, on heating either with hy-
drochloric acid or with barium hydroxide solution,
into tropic acid and tropine. Ladenburg (Ber.,
1880, 13, 376) succeeded in synthesizing atropine
from these two substances.

Tropic acid, a homologue of mandelic acid, is
alpha-phenyl-beta-hydroxypropionic acid, C6H5-
CH(CH2OH)COOH. Tropine, also called 3-tro-
panol, is a tertiary base containing a secondary
alcohol group which in atropine is esterified with
tropic acid; atropine is, accordingly, tropyltr opine.
Tropine is of interest also because it is the parent
substance of cocaine and most other coca alkaloids
(for formula of tropine see under Cocaine). On
oxidation, tropine is converted to the ketone
tropinone. Robinson (/. Chem. S., 1917, 111,
762), visualizing the latter as a possible starting
compound for the production not only of atro-
pine and hyoscyamine but cocaine, tropacocaine
and the artificial tropeines as well, prepared tro-
pinone by reacting succindialdehyde, methyla-
mine, and acetone (or acetonedicarboxylic acid).
Variants of this method have been the subject of
many patents and a number of synthetic substi-
tutes for atropine have been prepared utilizing
tropinone.

A large number of esters of tropine, to which
the general name of tropeines has been given, have
been synthesized. Some of these have pronounced
toxic effects, but one (homatropine) has found
use as a valuable substitute for atropine.

Description. — "Atropine occurs as white crys-
tals, usually needle-like, or as a white, crystalline
powder. Its saturated solution is alkaline to phe-
nolphthalein T.S. It is optically inactive, but
usually contains some levorotatory hyoscyamine.
One Gm. of Atropine dissolves in 460 ml. of water,
in 2 ml. of alcohol, in about 27 ml. of glycerin, in
1 ml. of chloroform, and in about 25 ml. of ether.
One Gm. of it dissolves in 90 ml. of water at 80°.
Atropine melts between 114° and 116°." N.F.

Standards and Tests. — Identification. — (1)
A yellow residue is obtained on evaporating a mix-
ture of 10 mg. of atropine and several drops of
nitric acid to dryness on a water bath. An intense
violet color is produced on adding a few drops of
alcoholic potassium hydroxide T.S. and a frag-
ment of potassium hydroxide to the cooled residue
(hyoscyamine and scopolamine respond similarly,
but other alkaloids obscure the effect). (2) A
lusterless precipitate forms on adding gold chlo-
ride T.S. to a 1 in 50 solution of atropine in di-
luted hydrochloric acid (hyoscyamine yields a lus-
trous precipitate). Residue on ignition. — Not over

0.1 per cent. Readily carbonizable substances. — A
solution of 200 mg. of atropine in 5 ml. of sul-
furic acid has no more color than matching fluid
A; this solution is colored no more than light yel-
low on adding 0.2 ml. of nitric acid. Other alka-
loids.— Platinic chloride T.S. produces no pre-
cipitate when added to a 1 in 75 solution of atro-
pine in N/ 15 hydrochloric acid. Addition of 2 ml.
of ammonia T.S. to a 5 ml. portion of the same
solution does not produce an immediate turbidity.
Limit of hyoscyamine. — The angular rotation of
a solution of 1 Gm. of atropine, previously dried
at 105° for 1 hour, in enough 50 per cent (by
weight) alcohol to make 20 ml. of solution at 25°,
and polarized in a 200-mm. tube, does not exceed
—0.70°. N.F.

The detection of small quantities of atropine
has been the subject of a number of investiga-
tions; a useful physiological test consists in plac-
ing the liquid to be tested in the eye of a cat, or
other animal, when, if the alkaloid be present,
dilatation of the pupil will occur. Vitali's test, in
which alcoholic potassium hydroxide solution is
added to atropine which has been oxidized with
nitric acid, is said to produce a violet color with
as little as 0.4 microgram of the alkaloid. This is
one of the U.S. P. tests for identification. For
microchemical reactions of atropine see Kleibs
(Chem. Abs., 1939, 33, 9201).

Uses. — The effects of atropine upon the system
are due to an action on certain medullary and
higher nerve centers, and a paralysis of secretory
glands and smooth muscle fibers innervated by
the parasympathetic division of the autonomic
nervous system (see monograph on Anticholinergic
Agents, in Part II, for comparison with related
compounds and the pharmacological basis for
their action).

Absorption-Excretion. — The absorption of
atropine is rapid. Within a few hours about one-
third of the dose is excreted by the kidney. The
remainder is hydrolyzed into tropine and tropic
acid. Tropine is related to ecgonine (see above),
the basic constituent of cocaine (Paul and Rhom-
berg, J. Iowa M. Soc, 1945, 35, 167).

Peripheral Action. — The parasympathetic
nerves carry impulses to numerous viscera, among
them being: the nerves for the salivary glands,
the secretory glands of the nasal and pharyngeal
mucous membranes and the bronchial tree and
stomach, the vagus nerve, which carries inhibitory
impulses to the heart and motor fibers to the
bronchi and a portion of the intestinal tract, and
the oculomotor nerve, which supplies the sphincter
pupillae and ciliary muscle. In addition, atropine
exerts an antispasmodic effect on smooth muscle
of the gall bladder and biliary ducts, as well as
on the smooth muscle of viscera supplied by the
sacral parasympathetic ganglia, as the ureter,
detrusor muscle of the urinary bladder, and, to a
slight extent, the uterine muscle. Also, the cho-
linergic nerves supplying the sweat glands are
inhibited by atropine. The action of atropine is,
therefore, as extensive and complex as are the
effects of the parasympathetic system which it
blocks. In general it is the muscarinic effects of
acetylcholine but not its nicotinic responses which

126 Atropine

Part I

are inhibited by atropine. In the presence of atro-
pine, nerve stimulation releases acetylcholine but
the effector cell fails to respond. Where the nerve
endings are within the cell, as seems to be the case
in the intestine and urinary bladder, atropine fails
to block the effects of stimulation of the para-
sympathetic nerves, but it blocks the effects of
injected acetylcholine (see Fulton, Physiology of
the Nervous System, 1938).

Central Action. — The central effects of atro-
pine may be attributed to central stimulation of
the vagus nerve and of the respiratory center.
There is also a primary depressant action on cer-
tain motor mechanisms. Toxic doses, however,
after causing restlessness, disorientation, and de-
lirium, ultimately will produce paralysis of the
medulla. Rarely, atropine is used as a respiratory
stimulant in doses of 0.5 to 1.5 mg. (approxi-
mately Vi2o to Vio grain), which should not be
repeated lest paralysis occur. Atropine is bene-
ficial in labyrinthine seasickness, but Holling et al.
(J.A.M.A., 1944, 125, 457) found it inferior to
scopolamine. Alexander and Portis (Psychosom.
Med., 1944, 6, 191) used atropine in the prophy-
lactic management of hypoglycemic fatigue but
its efficacy is questionable. Some features of both
the arteriosclerotic and postencephalitic forms of
paralysis agitans, or parkinsonism, are improved
by its use. Doses as large as 5 mg. (approximately
V12 grain) are employed to improve the tremor,
rigidity, salivation, oculogyric crises, etc. Some-
times it is used in conjunction with amphetamine
sulfate. From time to time various atropine-con-
taining plants have enjoyed a popular vogue in
such therapy. Often these effects have been at-
tributed to some peculiar character of drugs
grown in a particular locality — as the Bulgarian
belladonna — but it is now well established that
it is an action inherent to atropine and probably
other related alkaloids. The most plausible ex-
planation of this action is offered by the experi-
ments of Pollock and Davis {Arch. Neurol.
Psychiat., 1930. 23, 303) who observed that in
decerebrate cats atropine diminishes the rigidity
depending upon reflexes arising in the muscle
itself.

Ophthalmic Action. — In ophthalmology atro-
pine is used both for dilating the pupil and for
paralyzing the muscles of accommodation. Its
action is so slow and persistent that where only
temporary effects are desired, as, for example, in
the fitting of glasses, it has been largely aban-
doned for more rapidly acting drugs, but in in-
flammatory conditions of the eye, as in iritis,
keratitis, etc., the very persistence of its effect is
desirable. For this purpose one or two drops of a
1 per cent solution may be instilled into the eye
at such intervals as are found to be necessary.
The same purpose may be accomplished by in-
serting beneath the eyelid small gelatin disks con-
taining atropine (see Lamellce of Atropine'). The
mydriatic effect may last for ten days, though
the cycloplegic action remains only five days. It
is important to test the intraocular tension before
its instillation in order that glaucoma will not be
produced. Neblett (South. Med. & Surg., 1945.
107, 81) has called attention to this possible side
"effect in patients using atropine for gastrointesti-

nal tract disorders or in arthritis in conjunction
with neostigmine administration.

Respiratory Effects. — Atropine is used to
check the rhinorrhea of acute rhinitis and of hay
fever, as well as to diminish secretions in the
entire respiratory tract when given as part of pre-
anesthetic medication. It has been used in bron-
chial asthma, but it is less effective than epi-
nephrine in its relaxation of the bronchi and
bronchioles.

Cardiac Action. — The drug causes accelerated
heart rate by blocking vagal impulses at the pace-
maker or sinoauricular node. However, small doses
(less than 1 mg., approximately Yao grain; may
slow cardiac action by central vagal stimulation
(McGuigan, J. A.M. A., 1921, 66, 1338). It is
useful in preventing vagal syncope with brady-
cardia as a result of hyperactive carotid sinus
reflexes as described by Nichol and Strauss (Am.
Heart J., 1943, 25, 746). It counteracts the
bradycardia induced by pilocarpine. In complete
heart block large doses intravenously (2 mg., ap-
proximately Vso grain) may be beneficial. Its use
hypodermically in doses of 0.6 or 0.8 mg. (ap-
proximately ^oo or %o grain) is recommended by
Gilbert (Modern Concepts of Cardiovascular Dis-
ease, 1946, 15, No. 6) immediately on diagnosis
of coronary thrombosis in order to abolish reflex
arterial constriction, mediated by the vagus nerve,
in the uninvolved myocardium. Atropine produces
peripheral vasodilatation in the blush area by
means of a mechanism not fully understood.

Gastrointestinal Tract. — Atropine has an
exceedingly complex action upon the gastrointesti-
nal tract and its associated glands. It inhibits the
flow of saliva in doses as small as 0.5 mg. (ap-
proximately Yno grain). A similar dose was said
by Henderson and Sweeten (Am. J. Digest. Dis.,
1943, 10, 241) to decrease psychic (vagal) gastric
secretion more than that due to the hormone
gastrin, while a dose of 1.2 mg. (approximately Yso
grain) will abolish continuous secretion except
that seen in some cases of peptic ulcer. Nocturnal
gastric secretion is diminished by atropine, ac-
cording to Means (Surgery, 1943, 13, 214), as
are also free and total acidity in both normal and
ulcer patients. In general, muscular tonus and
peristalsis are decreased by its action, but the
effect depends upon the existing tonus and degree
of movements as well as the dose. Henderson and
Sweeten (loc. cit.) found that in pylorospasm of
infants a dose of 0.065 mg. (approximately a/looo
grain) before feedings may give some relief. It
is believed that atropine decreases the tonus of
the small intestine and decreases the motility in
the colon, where it antagonizes the hypertonicity
of morphine. The intestinal glands and the forma-
tion of bile are unaffected by atropine, as is the
production of pancreatic secretions, since the
latter is formed in response to the hormone
secretin.

Biliary and Urinary Tracts. — Other effects
of atropine on smooth muscle bring about its use
in conjunction with morphine in biliary colic and
ureteral colic. Its inhibition of tonus of the
detrusor muscle of the urinary bladder has led to
its use in treating some cases of nocturnal
enuresis. It has been used in dysmenorrhea, but

Part I

Atropine Sulfate 127

probably is of little value. Locally, atropine in
the form of an ointment and the belladonna plas-
ter is used in various painful conditions, but this
use does not seem rational. S

Toxicology. — Atropine poisoning may occur
from the ingestion of any of the numerous plants
of which it is the active principle, most frequently,
however, from either belladonna or the widespread
stramonium. Severe poisoning may follow external
applications. The symptoms are dryness of the
throat, dilatation of the pupil, rapid and hard
pulse, hurried respiration, warm and dry skin,
flushed face, and frequently a scarlatiniform rash.
The most striking symptom is the peculiar de-
lirium. In the earlier stages this manifests itself
simply by profuse and incoherent talkativeness;
later there is complete confusion, often with hal-
lucinations, sometimes maniacal in character.
After large doses a stage of depression may de-
velop, with stupor, rapid weak pulse, and respira-
tory failure. Though the condition is alarming,
recovery is usual. Alexander, Morris and Eslick
{New Eng. J. Med., 1946, 234, 258) report the
complete recovery of a patient severely poisoned
by the ingestion of 1 Gm. of atropine sulfate
orally. In case of doubt as to diagnosis, instilla-
tion of a drop or two of urine from the patient
into the eye of a cat will produce dilatation of
the pupil, if enough atropine is present. Dameshek
demonstrated that in atropine poisoning the usual
sweating, salivation, etc., following acetyl-P-
methylcholine chloride administration in doses
of 10 to 30 mg. (approximately Yq to Yi grain) is
absent. Atropine may cause fever, in children
particularly, by causing dryness of the skin and
inhibiting heat loss by evaporation.

In the treatment, after emptying the stomach
with the stomach tube (the dry mucosa requires
lubrication) or an emetic, 1.2 ml. (approximately
20 minims) of compound iodine solution should
be given as the best chemical antidote. Morphine
may be used to quiet the delirium, but there is
danger of respiratory paralysis, and cautious ad-
ministration of the barbiturates is recommended.
Pilocarpine, the physiological antagonist, should
be given in doses of 5 mg. (approximately Y12
grain) until the mouth becomes moist. Respira-
tory failure is treated with oxygen and carbon
dioxide inhalation and by the use of caffeine. Ade-
quate fluid intake is important.

Dose. — The usual hypodermic dose of atropine
(as sulfate) is 0.4 mg. (approximately Yiso grain) ;
the dose by mouth is 0.6 mg. (approximately Yioo
grain), although in serious cases these amounts
may be much exceeded. On the other hand in sus-
ceptible persons, 0.6 mg. (approximately Yioo
grain) will produce decided dryness of the throat,
and 1.2 mg. (approximately Ym grain) is alleged
to have caused toxic symptoms. As atropine itself
is nearly insoluble, the sulfate is preferred. For
application to the sound skin, an ointment may be
made by rubbing 65 mg. (approximately 1 grain)
of the alkaloid first with 0.25 ml. (approximately 4
minims) of alcohol, and then with 4 Gm. (approxi-
mately 1 drachm) of lard. The ointment of bella-
donna is, however, usually preferred.

When solution of atropine sulfate (1 or rarely
2 per cent) is used for dilating the pupil, it may

be dropped into the eye within the lower lid, or
introduced by means of minute circular disks of
gelatin, made by mixing the solution with gelatin
and evaporating so as to produce a thin film, which
is to be cut into circular pieces. (See Lamella of
Atropine.) An Eye Ointment of Atropine (Ocu-
lentum Atropines) of the B.P. contains 1 per cent
of atropine sulfate.

Solutions of atropine or its salts are very prone
to have developed in them a fungous growth with
consequent decomposition of the alkaloid; thus
Simon (J. A.M. A., 1915, 64, 705) showed that a
solution of atropine may become entirely inert in
three days.

Dose, of atropine, 0.3 to 1.2 mg. (approximately
Y200 to Y50 grain) .

Storage. — Preserve "in tight, light-resistant
containers." N.F.

ATROPINE SULFATE.
U.S.P. (B.P.) LP.

Atropinium Sulfate, [Atropinae Sulfas]

H
HjC— C

HNCH3

H2C— C-
2 H

•CH,

I * I

CH-O-CO-CH
I

■CH-

CH20H

-\J

SOf . H,0

"Caution. — Atropine Sulfate is extremely poi-
sonous." U.S.P.

B.P. Atropine Sulphate; Atropinae Sulphas. I. P. Atro-
pini Sulfas. Atropinum Sulfuricum; Sulfas Atropicus.
Fr. Sulfate d'atropine; Sulfate neutre d'atropine. Ger.
Atropinsulfat ; Schwefelsaures Atropin. It. Solfato di
atropina. Sp. Sulfato de atropina.

Atropine sulfate may be prepared by the inter-
action of a solution of atropine in ether and of
sulfuric acid in alcohol. For details of the for-
merly official method see U.S.D., 20th ed., p. 208.

Description. — "Atropine Sulfate occurs as
colorless crystals, or as a white, crystalline pow-
der. It is odorless. It effloresces in dry air, and is
affected by light. One Gm. of Atropine Sulfate
dissolves in 0.5 ml. of water, in 5 ml. of alcohol,
and in about 2.5 ml. of glycerin. One Gm. dis-
solves in 2.5 ml. of boiling alcohol. Atropine Sul-
fate, dried at 105° for 4 hours, melts at a tem-
perature not lower than 188°." U.S.P. The B.P.
gives the melting point of atropine sulfate, when
dried at 135° for 15 minutes, as between 191°
and 196°; the LP. specifies a melting range of
191° to 195° after drying at 110° for 4 hours.

Standards and Tests. — Identification. — Atro-
pine sulfate responds to the identification tests
given under atropine, and a 1 in 20 solution of the
salt also responds to tests for sulfate. Acidity. —
Not more than 0.3 ml. of 0.01 N sodium hydroxide
is required to neutralize a solution of 1 Gm. of
atropine sulfate in 20 ml. of water, using methyl
red T.S. as indicator. Water. — Not over 4 per
cent, when dried for 4 hours at 105°, or deter-
mined by the Karl Fischer method. Residue on
ignition. — Not over 0.2 per cent. Readily car-
bonizable substances. — This test is identical with
the corresponding test described under Atropine.

128 Atropine Sulfate

Part I

Other alkaloids. — This test is similar to the cor-
responding one described under Atropine, except
that a 1 in 60 solution of atropine sulfate is used.
Limit of hyoscyamine. — When the test is per-
formed as described under atropine the angular
rotation does not exceed — 0.60°. U.S.P.

Uses. — The effects of the salt on the system
are precisely the same as those of atropine, and
it may be used in the same dose. Its great advan-
tage over the alkaloid is its solubility in water.

The U.S. P. gives the usual dose as 0.5 mg. (ap-
proximately ^120 grain), and the range as 0.3 to
1.2 mg. Topically a 1 to 2 per cent solution is used.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

Off. Prep.— Atropine Sulfate Tablets, U.S.P.,
B.P.; Morphine and Atropine Sulfate Tablets,
N.F.; Lamellae of Atropine; Eye Ointment of
Atropine; Eye Ointment of Atropine with Mer-
curic Oxide, B.P.

ATROPINE SULFATE TABLETS.
U.S.P. (B.P., LP.)

[Tabellae Atropinae Sulfatis]

"Atropine Sulfate Tablets contain not less than
93 per cent and not more than 107 per cent of the
labeled amount of (Ci-H23N03)2.H2SO-iH20 for
tablets of 20 mg. or more; and not less than 90
per cent and not more than 110 per cent of the
labeled amount for tablets of less than 20 mg."
US. P. The corresponding limits of the B.P. and
LP. are 90.0 and 110.0 per cent, regardless of the
content of atropine sulfate.

B.P. Tablets of Atropine Sulphate; Tabellae Atropine
Sulphatis. LP. Compressi Atropini Sulfatis. Sp. Tabletas
de Sulfato de Atropina.

Tests. — Identification. — (1) When 1 drop of a
filtered solution of the tablets, representing 1 mg.
of atropine sulfate in 10 ml., is instilled into the
eye of a cat or other animal, the pupil shows
noticeable dilation within 2 hours. (2) Atropine
alkaloid obtained from the tablets responds to
identification test (1) under Atropine. (3) A
filtered solution of the tablets responds to tests
for sulfate. U.S.P.

Assay. — An aqueous extract of the tablets, pre-
pared with the aid of diluted sulfuric acid and rep-
resenting 60 mg. of atropine sulfate, is made alka-
line with ammonia and the liberated atropine
extracted with chloroform. Following evaporation
of the chloroform, the last traces of which are
expelled with the aid of neutralized alcohol, the
atropine is estimated by a residual titration using
20 ml. of 0.02 N sulfuric acid, the excess of acid
being titrated with 0.02 N sodium hydroxide, using
methyl red T.S. as indicator. Each ml. of 0.02 N
sulfuric acid represents 6.949 mg. of (C17H23-
N03)2.H2S04.H20. A variant of this method is
permitted if the tablets contain a very small
amount of atropine sulfate. U.S.P.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Usual Sizes. — In V200, -Kso, Vno, Vioo and Ho
grain (approximately 0.3, 0.4, 0.5, 0.6, and 1.2
mg.) tablets.

EYE OINTMENT OF ATROPINE.
B.P.

Oculentum Atropinae

This ointment contains, unless another strength
is specified, 1 per cent of atropine sulfate in a
base of 10 parts of wool fat and 90 parts of
yellow soft paraffin; the atropine sulfate is dis-
solved in the smallest quantity of water for injec-
tion before incorporating it with the base (see
Eye Ointments for further information).

EYE OINTMENT OF ATROPINE
WITH MERCURIC OXIDE. B.P.

Oculentum Atropinae cum Hydrargyri Oxido

This ointment contains, unless other concen-
trations are specified, 1 per cent of atropine sul-
fate and 1 per cent of yellow mercuric oxide in
a base of 10 parts of wool fat and 90 parts of
yellow soft paraffin; the atropine sulfate is dis-
solved in the smallest quantity of water for in-
jection before incorporating it with the base (see
Eye Ointments for further information). For the
therapeutic role of the ingredients of this oint-
ment see under both Atropine and Yellow Mer-
curic Oxide Ointment.

INJECTION OF ATROPINE
SULPHATE. B.P. (LP.)

Injectio Atropinae Sulphatis

The injection is a sterile solution of atropine
sulfate in water for injection, the solution being
sterilized by dissolving in it 0.2 per cent w/v of
chlorocresol or 0.002 per cent w/v of phenyl-
mercuric nitrate and heating it in its final con-
tainers at 98° to 100° for 30 minutes, or by
filtration through a bacteria-proof filter. No rubric
is provided. The LP. requires Injection of Atro-
pine Sulfate {Injectio Atropini Sulfatis) to con-
tain not less than 85.0 per cent and not more than
110.0 per cent of the labeled amount.

LAMELLiE OF ATROPINE. B.P.

Lamellae Atropinae

Discs of Atropine. Lamellae Ophthalmicae cum Atropino;
Gelatina Atropini. Fr. Disques d'atropine. Sp. Discos
oftalmicos con atropina.

Lamellae of atropine are discs of gelatin with
glycerin, each weighing about 1.3 milligrams (V»o
grain) and containing 0.065 milligram (^000
grain) of atropine sulfate, unless another amount
of the active ingredient is specified. The method
of preparation is discussed under Lamellce.

AUROTHIOGLUCOSE.

Gold Thioglucose

X.F.

1 0 1

AuS.CH.HCOH.HOCH.HCOH.HC.CH.2OH

"Aurothioglucose, dried over sulfuric acid for
24 hours, yields not less than 47.7 per cent and
not more than 53.0 per cent of Au. It contains
not more than 5 per cent of sodium acetate as
a stabilizer." N.F.

Solganal (Schering).

Aurothioglucose may be prepared by the inter-

Part I

Bacillus Calmette-Guerin Vaccine 129

action of aqueous solutions of gold bromide and
thioglucose, in the presence of sulfur dioxide; the
aurothioglucose is precipitated from the reaction
medium by addition of alcohol and is subsequently
purified by solution in water and precipitation
with alcohol. As indicated in the official defini-
tion, it contains sodium acetate as a stabilizer.

Description. — "Aurothioglucose occurs as a
yellow powder. It is odorless or nearly so and is
stable in air. An aqueous solution is unstable on
long standing. The pH of a solution of Auro-
thioglucose (1 in 100) is about 6.3. Aurothioglu-
cose is freely soluble in water. It is practically
insoluble in acetone, in alcohol, in chloroform,
and in ether." N.F.

Standards and Tests. — Identification. — (1)
The glucosazone prepared from aurothioglucose
melts between 189° and 194°. (2) A portion of
the filtrate obtained in the assay forms with
barium chloride T.S. a heavy white precipitate.
Specific rotation. — Not less than +65° and not
more than +75° when determined in an aqueous
solution containing 100 mg. of aurothioglucose,
previously dried over sulfuric for 24 hours, in
each 10 ml. Loss on drying. — Not over 1 per cent
when dried over sulfuric acid for 24 hours. N.F.

Assay. — About 1 Gm. of aurothioglucose,
previously dried over sulfuric acid for 24 hours,
is dissolved in water, reacted with nitric acid, and
the precipitate of metallic gold thereby obtained
is filtered off, washed with hot water, dried,
ignited, and weighed. N.F.

Uses. — This water-soluble, oil-insoluble or-
ganic compound with a gold-to-sulfur linkage is
injected intramuscularly as a suspension in sesame
oil for treatment of active rheumatoid arthritis
and nondisseminated lupus erythematosus. The
pharmacology, toxicology, and uses of gold com-
pounds are discussed under Gold Sodium Thio-
malate, in Part I.

The slow absorption of gold from aurothio-
glucose injection decreases incidence of untoward
reactions (Dawson et at., Trans. A. Am. Physi-
cians, 1941, 56, 330). Objective or subjective im-
provement in 88 per cent of 122 cases of rheu-
matoid arthritis, with toxic effects in only 11 per
cent of these, resulted from use of aurothioglu-
cose (Cohen and Dubbs, New Eng. J. Med., 1943,
229, 773). A dose of 200 mg. weekly was found
to be more effective than 100 mg., but the inci-
dence of toxic effects was too high (Ellman et al.,
Brit. M. J., 1940, 2, 314). A comparison of the
results of treatment of 102 early cases (within
one year of onset) of rheumatoid arthritis with
500 mg. or more of gold salt, usually aurothio-
glucose or gold sodium thiomalate, with 83 cases
not receiving gold therapy, reported by Adams
and Cecil {Ann. Int. Med., 1950, 33, 163), re-
vealed the following : complete remission occurred
in 66 per cent of patients receiving gold, in con-
trast with 24 per cent of the other group (who
were treated by other methods) ; no improvement
was reported by 3 per cent of patients receiving
gold and 18 per cent of those in the other group.
Gold therapy commenced within 6 months of the
onset of illness resulted in complete remission in
nearly 80 per cent of the patients but when it was

not started until the second 6 months such favor-
able response was observed in less than 50 per
cent of the patients.

Dose. — The usual dose of aurothioglucose in
rheumatoid arthritis is 50 mg. (about % grain)
weekly, injected intramuscularly, until a total
dose of 1 Gm. has been given. Preferably, a dose
of 10 mg. is given the first week, followed by 25
mg. the second and third weeks; if no untoward
effects appear, the full dose of 50 mg. may then
be given, with careful observation of the patient
(as described under Gold Sodium Thiomalate) .
After the total of 1 Gm. (rarely 1.5 Gm.) has
been given, maintenance doses of 50 mg. every
2 to 4 weeks may be continued if needed and
tolerated. Much smaller doses are employed
initially in the often hypersensitive cases of non-
disseminated lupus erythematosus, viz., 0.1, 0.5,
1, 2.5, 5 and 10 mg. at intervals of 2 to 3 days,
and then 25 mg. and eventually 50 mg. weekly.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

AUROTHIOGLUCOSE INJECTION.
N.F.

Gold Thioglucose Injection

"Aurothioglucose Injection is a sterile suspen-
sion of aurothioglucose, with or without a suit-
able thickening agent, in a suitable fixed oil for
injection, and yields an amount of aurothioglucose
equal to not less than 90 per cent and not more
than 110 per cent of the labeled amount of
CeHiiAuOsS." N.F.

Suspension Solganal in Oil (Schering).

Assay. — A volume of injection equivalent to
about 200 mg. of aurothioglucose is treated with
acetone to dissolve the oil while leaving the auro-
thioglucose and any thickening agent, such as
aluminum stearate, as an insoluble residue. The
insoluble material is separated by filtration, dried
at 65°, and weighed. This is treated with water to
dissolve the aurothioglucose, leaving the aluminum
stearate as an insoluble residue, which is weighed
after drying at 105°. The difference in the two
weights represents the aurothioglucose. N.F.

Storage. — Preserve "in either single-dose or
multiple-dose hermetic, light-resistant containers,
or in other suitable containers." N.F.

Usual Sizes.— 10, 25, 50, and 100 mg. (ap-
proximately V%, H, 2A, and I1/* grains) in 1 ml.

BACILLUS CALMETTE-GUERIN
VACCINE. B.P.

B.C.G. Vaccine

The B.P. defines this vaccine as a suspension of
living cells of an authentic strain of the bacillus
of Calmette and Guerin, the strain being main-
tained so as to preserve its power of sensitizing
man to tuberculin and its relative non-pathoge-
nicity to man and laboratory animals. The B.P.
vaccine, which is a liquid and deteriorates rapidly,
cannot be used more than 14 days after the com-
pletion of its manufacture.

130

Bacillus Calmette-Guerin Vaccine

Part I

Historical. — Attenuation of a highly virulent
bovine strain of tubercle bacillus, isolated from
the udder of a tuberculous cow in 1902, was
achieved by Calmette and Guerin by transplanting
cultures of the organism at 15-day intervals on
potato medium impregnated with beef bile and
glycerin. After 13 years and 230 transplantations,
a culture of the organism no longer produced
progressive tuberculosis in susceptible animals.
Despite the loss of virulence, the culture retained
its original cultural and antigenic characteristics,
including the ability to produce potent tuberculin.
This attenuated culture was designated BCG
(Bacillus Calmette and Guerin); all strains used
for the production of the vaccine are traceable to
this original culture, developed in the Pasteur
Institute, in Paris, France. The avirulent phase of
the culture was found to produce nodular lesions
in animals, with no evidence of progression; it
was also discovered that these tuberculin-positive
animals, when infected with virulent tubercle
bacilli, resisted to a great extent a progressive in-
fection (Calmette, Guerin et al., La vaccination
preventive contre la tuber culose par le BCG,
1927, Masson & Cie. Paris).

Preparation. — The culture used for produc-
tion of BCG vaccine must be directly traceable
to the Pasteur Institute of Paris. All work must
be done in completely isolated laboratories, re-
served for this purpose, by personnel in no way
associated with pathogenic bacteria. The technical
staff must be free of tuberculosis and undergo
roentgenological examination every 3 to 6 months.
To prepare the vaccine the BCG culture is grown
on protein-free Sauton medium containing aspara-
gin, glycerin, citric acid, dipotassium phosphate,
magnesium sulfate, ferric ammonium citrate and
water. The culture is grown at 37.5° C. for 7
days, after which the bacillary film is collected,
drained of excess medium and weighed. A weighed
amount of this mass is then suspended in buf-
fered phosphate solution, at pH 7.2, to produce a
concentration of 0.5 to 1.5 mg. per ml. if intended
for intracutaneous use, or 15 to 20 mg. per ml.
if intended for multiple puncture or scarification
use. BCG vaccine may be either a freshly pre-
pared suspension of the organisms or it may be
a dried culture (prepared from the frozen state)
in which case it is suspended just prior to use.
The volume recommended for restoration of a
dried vaccine is determined on the basis of the
use of the vaccine as indicated above.

Tests. — The time required to complete the
testing of BCG vaccine is longer than the period
(14 days) during which the liquid vaccine may
be used, for which reason the vaccine must be
used before the tests have been completed. Never-
theless, these tests must be made in order to
complete the production protocol. Potency is de-
termined by observation of the formation of in-
durations or nodules in normal guinea pigs fol-
lowing injection of 0.1, 0.01, 0.001, and 0.0001
mg. of BCG vaccine. At the end of 2 to 3 weeks,
the first two doses should produce definite non-
suppurating lesions, the third dose should produce
slight nodules, and the fourth dose should form
no nodules. The vaccine may also be tested by

the development of sensitivity, in guinea pigs, to
tuberculin, following multiple puncture. In addi-
tion, each lot must be tested in tuberculin-negative
persons. Further, each lot must be tested for
viable organisms (20,000,000 colonies per mg. of
growth), safety, and for sterility. A liquid vaccine
may be released after 24 hours on sterility test
if no growth other than of the bacillus of Cal-
mette and Guerin occurs.

Uses. — Bacillus Calmette-Guerin vaccine is
used to produce active immunization against tu-
berculosis, especially in persons likely to be
exposed to infection and in children.

Increased resistance to infection was first ob-
served by Marfan (Arch. gen. mid., 1886, 17,
423), who noted that pulmonary tuberculosis oc-
curred infrequently in persons who had evidence
of healed cervical adenitis, and also by Trean
(J.A.M.A., 1888, 10, 224), who noticed that
Sioux Indians of Dakota with scrofulous sores
and large glands did not as a rule have phthisis
pulmonalis.

The first human application of BCG vaccine
was instigated by Weill-Halle in Paris {Bull. soc.
med., 1925, 49, 1589). Since then it has been esti-
mated that approximately 50 million persons of
various ages, living in different parts of the world,
have received the vaccine.

Reluctance to accept BCG vaccination in the
United States can be attributed largely to the
tragedy in Liibeck, Germany, in which 77 of 271
infants vaccinated died of progressive tubercu-
losis. It was later proven by the Robert Koch
Institute of Berlin that the vaccine used was a
mixture of BCG and a virulent strain of tubercle
bacilli which was kept in the same incubator as
the BCG. For this malpractice, those responsible
were imprisoned. It can be stated unequivocally
that up to the present time there has been no
evidence that BCG vaccine has produced pro-
gressive tuberculosis in man or animals.

Calmette and his associates originally encour-
aged mass immunization of newborn infants by
the oral route. Wallgren (J. A.M. A., 1928, 91,
1876) subsequently demonstrated the superiority
of the intracutaneous route over the oral route.
Rosenthal et al. (J.A.M.A., 1948, 136, 73) and
Birkhaug (Acta med. Scandinav., 1944, 117, 274)
advocated the multiple puncture method, while
in some countries the scarification method is
used.

Despite the extensive use of BCG vaccine there
is a diversity of opinion regarding its value. This
is largely due to a lack of adequately controlled
investigations and to the difficulty of dissociating
the specific protective role of BCG vaccine from
an almost universal spontaneous decrease in the
morbidity and mortality from tuberculosis, ante-
dating the use of the vaccine (Aronson and Aron-
son, J. A.M. A., 1952, 149, 334). In order to ap-
praise as objectively as possible the specific
values of BCG vaccine in the control of tubercu-
losis, a joint investigation was undertaken by the
Henry Phipps Institute of the University of
Pennsylvania, and the Branch of Health, Bureau
of Indian Affairs, Department of the Interior, in
December 1935. The Indian population of eight

Part I

Bacitracin

131

different tribes, in five different geographical areas
of the United States and Alaska, were used in
the study. The Indian population was chosen be-
cause of the ease of observing the Indians over
a long period of time, their relatively low eco-
nomic and housing conditions, and the high mor-
bidity and mortality from tuberculosis in this
group. Fifteen years after initiation of the study,
12 of 1551 vaccinated persons and 65 of the 1457
controls had died of tuberculosis, corresponding
to rates of 0.56 and 3.32 per thousand persons
per year, respectively (Aronson and Aronson, loc.
cit.). The data observed in this study support the
concept that hypersensitivity (tuberculin-positive
reaction) developing after use of BCG vaccine is
closely correlated with resistance to reinfection.
Rosenthal et al. (J.A.M.A., 1948, 136, 73) con-
cluded that the vaccine was effective in prevent-
ing tuberculosis. Use of freeze-dried vaccine by
the multiple puncture method of application to
the skin is advocated (Rosenthal, ibid., 1955,
157, 801).

BCG vaccine is not recommended for those
who present evidence of tuberculous infections as
indicated by a positive tuberculin reaction. It is
recommended for those tuberculin-negative per-
sons whose professional duties may expose them
to tuberculous patients or to material that may
contain virulent tubercle bacilli and for tuberculin-
negative persons who may be exposed to infection
in their household. It is also recommended for
population groups, including newborn children,
where the morbidity and mortality from tubercu-
losis are high, and conditions favor the spread of
the disease.

Dose. — The dose recommended is 0.1 ml. intra-
cutaneously, of a suspension containing 0.5 to 1.5
mg. per ml. For the multiple puncture method, the
suspension used contains 15 to 20 mg. per ml. of
growth. One drop is spread over an area 1.5 by
2.5 cm. Thirty cutaneous punctures are made in
this area.

Regulations. — BCG vaccine is manufactured
under minimum requirements of the National
Institutes of Health, U. S. Department of Health,
Welfare and Education. The vaccine is not com-
mercially available, the entire supply being pro-
duced in state and institutional laboratories.

Storage. — Liquid BCG vaccine has an expira-
tion date of 10 days after the date of harvesting,
if kept constantly at 2° to 5° C. Dried BCG vac-
cine has a dating of 6 months, if kept constantly
at not over 5° C.

BACITRACIN. U.S.P.

"Bacitracin is an antibacterial substance pro-
duced by the growth of a Gram-positive, spore-
forming organism belonging to the Bacillus
licheniformis group (Fam. Subtilis). It has a
potency of not less than 40 U.S.P. Units per mg.,
except that when intended for parenteral use its
potency is not less than 50 Units per mg. and
when intended for the manufacture of ointments,
tablets and troches, it may have a potency of not

less than 30 Units per mg. Bacitracin conforms to
the regulations of the federal Food and Drug
Administration concerning certification of anti-
biotic drugs. Bacitracin not intended for paren-
teral use is exempt from the requirements of the
tests for Pyrogen and Sterility." U.S.P.

History. — Bacitracin is an antibiotic poly-
peptide or complex of polypeptides elaborated in
suitable culture media by the Tracy I strain of a
bacillus which many authorities consider to be a
strain of Bacillus licheniformis and others classify
as a variant of Bacillus subtilis. The organism
was isolated in 1945 during a study of bacterial
contaminants in civilian wounds. Johnson et al.
(Science, 1945, 102, 376) observed that broth
cultures of debrided tissues from a wound on a
child, Margaret Tracy, uniformly yielded a gram-
positive spore-former, whereas several additional
organisms appeared on plates prepared from the
same tissue. This suggested that the sporulating
species produced a substance which, in broth
where diffusion is not so important as on agar
plates, prevented growth of other wound con-
taminants. Thus, a new antibiotic was discovered.
It was named bacitracin to commemorate the
name of the patient (Tracy), and to indicate the
genus of organism (Bacillus).

Production. — At first produced only in sur-
face cultures, bacitracin now is obtained by sub-
merged fermentation. The yield of the antibiotic
is dependent on the composition of the nutrient
medium, and is greatest when the ratio of carbon
to nitrogn is about 15. Industrially, soybean meal
(or peanut granules), starch, calcium lactate, and
calcium carbonate are used as sources of essential
elements.

Recovery of the antibiotic from the fermented
broth is accomplished by countercurrent centrifu-
gal extraction with n-butyl alcohol and removal
of the alcohol by distillation at reduced pressure,
whereupon the residual aqueous concentrate is
treated with charcoal and the slurry so formed is
filtered. Bacitracin is in the clear filtrate.

Description. — "Bacitracin is a white to pale
buff powder, and is odorless or has a slight odor.
It is hygroscopic. Its solutions rapidly deteriorate
at room temperature. Bacitracin is precipitated
from its solutions and is inactivated by salts of
many of the heavy metals. Bacitracin is freely
soluble in water. It is soluble in alcohol, in
methanol, and in glacial acetic acid, the solution
in the organic solvents usually showing some in-
soluble residue. It is insoluble in acetone, in
chloroform and in ether." U.S.P.

Constitution. — The polypeptide character of
bacitracin soon became apparent when chemical
studies were initiated. Later it became clear that
the product present in crude fermented broth is
a complex of at least three polypeptides; these
have been called bacitracins A, B, and C. Subse-
quent investigation revealed the presence of a
fourth component, bacitracin F, which is rela-
tively inactive, if not inert, antibacterially and
which Codington (Antibiotics Annual, 1954-1955,
p. 1118) has suggested is a transformation product
of the antibacterially active bacitracin A and may
bear the following relation to it :

132

Bacitracin

Part I

C4H9-

-C—

I
NH,

S — CH

/
C

N— C-
H

-N —
H

Peptide

— 2H

Bacitracin A

H /

C4H9 — C — C

I V

NH2

-CH

N — C — C— N

& H

Peptide

Bacitracin F

Newton et al. {Brit. J. Pharmacol. Chemother.,
1951, 6, 417) showed that crude bacitracin and
ayfivin (produced by Bacillus licheniformis) are
identical. Among the amino acid components of
bacitracin are phenylalanine, leucine, isoleucine,
glutamic acid, aspartic acid, lysine, histidine,
cysteine; ammonia has also been obtained (see
Craig et al, J. Biol. Chem., 1952, 199, 259; New-
ton and Abraham, Biochem. J., 1953, 53, 597).
The molecular weight is 2700 if the compound is
a monomer; 5400 if it is a dimer.

Stability. — Bacitracin is stable at room tem-
perature (25°) when dry, i.e., when the content
of moisture is less than 1 per cent; at 37° there
is no loss of potency in 15 months, but at 56°
and above it loses its potency rapidly. Aqueous
solutions adjusted to a pH between 5 and 7 lose
about 10 per cent of their initial antibacterial
activity in from 2 to 3 months when refrigerated
(4°) but deteriorate rapidly at room temperature.
Bacitracin is destroyed by oxidizing agents and.
therefore, should not be formulated with them. It
is precipitated by the heavy metals and their salts;
it is claimed that if the metals are low in the
electromotive series, precipitation is accompanied
by inactivation, but that when the metals are high
in the electromotive series inactivation does not
result (Baker, Drug Cosmet. Ind., 1954, 75, 764).
Bacitracin in solution is incompatible also with
some organic acids such as tannic acid, benzoic
acid, and salicylic acid; also with high concentra-
tions of sodium chloride.

Some of the insoluble salts of bacitracin, e.g.,
zinc bacitracin and bacitracin methylenedisalicyl-
ate, are more stable, when dry, than bacitracin and
lack the bitterness of the natural antibiotic : being
more palatable, these preparations would seem to
have distinct pharmaceutical advantages. How-
ever, more work is necessary for their complete
clinical evaluation.

Standards and Tests. — Identification. — A
bluish green to dark green color is produced on
adding 1 drop of a 1 in 100 solution of sodium
nitrite to a mixture of 5 mg. of bacitracin and
5 ml. of />-dimethylaminobenzaldehyde T.S. Loss

on drying. — Not more than 5 per cent, when dried
in vacuum at 60° for 3 hours. pH .— The pH of
a solution containing 10,000 Units of bacitracin
per ml. is between 5.5 and 7.5. Pyrogen. — Bacit-
racin, used in a test dose of 1 ml. per Kg. of a
solution containing 300 units per ml., meets the
requirements of the test. Safety. — Bacitracin, used
in a test dose of 0.5 ml. of a solution in saline
T.S. containing 200 units per ml., given intra-
muscularly, meets the requirements of the test.
Sterility. — Bacitracin is required to be free of
bacteria, molds and yeasts. Content variation. —
The content of bacitracin in containers intended
for use with water vehicles for parenteral adminis-
tration is not less than 85 per cent of the labeled
unitage. U.S. P.

Assay. — Bacitracin is assayed by the official
microbial assay. U.S.P. For important contribu-
tions on the assay of bacitracin see Johnson et al.
(Science, 1945, 102, 376); Darker et al. (J. A.
Ph. A., 1948, 37, 156; Pinzelik et al., Appl.
Microbiol., 1953. 1, 293).

Unit. — The U.S.P. Unit of Bacitracin is de-
fined as the bacitracin activity exhibited by 23.8
micrograms of the dried master standard of the
federal Food and Drug Administration.

Uses. — When bacitracin first became available
from submerged fermentation it was a relatively
crude drug that caused a variety of untoward
effects when injected. Most important of these
was renal damage with tubular necrosis followed
by various sequelae. Therefore, use of the anti-
biotic generally was limited to topical application
or, for intestinal amebiasis, to the oral route. The
latter treatment can be used safely because
bacitracin is not absorbed from the gastrointes-
tinal tract.

Following intramuscular injection of bacitracin,
however, the drug is absorbed and relatively large
amounts occur in the blood and are excreted in
the urine at a rate corresponding to the rate of
glomerular filtration (Eagle et al., J. Clin. Inv.,
1947. 26, 919). In humans, blood levels may
reach 2 to 4 micrograms per ml. 1 to 2 hours after
a single injection of 1.5 mg. of bacitracin having
an activity of 0.03 unit per microgram. Concen-
trations in the blood remain above 0.5 microgram
for 5 to 6 hours (Eagle et al., loc. cit.). There-
fore, since antibacterially effective blood levels
can be attained and since bacitracin often is active
against gram-positive organisms resistant to peni-
cillin, efforts were made almost from the start to
render the drug suitable for parenteral use by
removing the nephrotoxic factors.

Meleney (/. Michigan Med. Soc, 1949, 48,
1154) reported that 87 per cent of a series of
more than 200 patients with localized surgical
infections responded favorably to injection of
bacitracin solutions and he and others recom-
mended parenteral administration on the basis of
results with 270 patients (Surg. Gyn. Obst., 1949,
89, 657). Seven of the patients in the series re-
ceived the drug prophylactically. The others were
treated for acute osteomyelitis, carbuncles, gan-
grene, infected wounds, staphylococcal meningitis,
etc. Ninety-six of the patients had had prior un-
successful treatment with one or more antibiotics;
of this group 23 had "excellent response" and 32

Part I

Bacitracin

133

"responded well" for a cure rate of about 57 per
cent. Of 119 patients without previous treatment,
78.1 per cent responded favorably to bacitracin.
In accord with the earlier study by Meleney, the
drug was found to be especially useful in cellulitis
or deeper surgical infections when incision was
unwise and cultures were not obtainable. Of the
cultures reported by this group 122 strains were
susceptible both to penicillin and to bacitracin,
104 resisted penicillin but were sensitive to baci-
tracin; only 11 were resistant to bacitracin while
being sensitive to penicillin. Bacitracin was as
effective in mixed infections, due to different
species of gram-positive organisms, as in infec-
tions due to a single species, rendering it espe-
cially efficacious in chronic conditions in which
the organisms had become penicillin-resistant.

Despite several successful parenteral trials,
many clinicians considered the risk of nephro-
toxicity to outweigh the benefits to be gained
from parenteral use of bacitracin (especially since
other effective antibiotics were available), and as
recently as 1953 the N.N.R. stressed that "it
[bacitracin] must never be administered intra-
muscularly or intravenously."

As methods of purification have been improved,
however, some of the nephrotoxic constituents
have been eliminated and reports of successful
parenteral applications of the drug with no un-
toward effects are becoming more common, espe-
cially when fluid intake is increased to at least
2^2 liters per day. Intramuscular injection of
bacitracin (10,000 to 20,000 units every six hours
until fever subsides) may afford satisfactory treat-
ment for infections caused by strains of gram-
positive organisms or of meningococci refractory
to penicillin (Teng, Arch. Neurol. Psychiat., 1950,
64, 861; Meleney et al, Surg. Gyn. Obst., 1952,
94, 401). The usual intramuscular dose is 10,000
to 20,000 units every 6 to 8 hours until fever
subsides. Since approximately two-thirds of pa-
tients with pneumococcal pneumonia respond to
bacitracin, it is useful if the clinical course is not
affected by penicillin. The drug enters the pleural
fluid readily. More recently Meleney and Johnson
{Antibiotics Annual, 1953-1954, p. 251) reported
on an additional 60 cases, half of whom were
given parenteral bacitracin prophylactically and
half for established infections. Bacitracin from
four different producers was used. A wide variety
of clinical entities, mostly surgical, was included.
Some cases were treated for periods up to 98 days
with only slight evidence of nephrotoxicity. Cases
showing kidney injury before treatment showed
no greater damage during treatment than did
those with normal kidney function, suggesting
that changes induced by bacitracin are not the
same as those occurring as the result of disease
or the degenerative changes of old age. In 75 per
cent of the patients there were slight signs of
nephrotoxicity; in only 2 of the 60 patients was
the toxicity disturbing.

Bacitracin may be administered intrathecally,
intracranially, or by subarachnoid injection for
meningococcal or pneumococcal meningitis two
to three times daily for periods up to two weeks
without causing any renal disturbance (Teng,
1950, loc. cit.). However, single intraspinal doses

should not exceed 1000 units in children under
2 years of age or 10,000 units in adults.

Teng et al. {Surgery, 1953, 33, 321) reported
on bacitracin treatment of 61 patients with intra-
cranial and cranial suppuration. The drug was
applied locally by dusting on exposed brain tis-
sue during surgery and also was injected intra-
thecally, intracerebrally, or intraventricularly.
Whether or not supportive intramuscular injec-
tion was used, the drug was uniformly successful
and there were no untoward effects. The authors
concluded that bacitracin is the antibiotic of
choice for neurologic infections. The same authors
later compared bacitracin with penicillin, strepto-
mycin, polymyxin B, and neomycin {Antibiotics
Annual, 1953-1954, p. 249). Bacitracin was the
least irritating and least toxic to components of
the central nervous system.

Topical Applications. — Despite the numerous
reports of successful systemic use of bacitracin,
its major therapeutic application is still in topical
or local medication as an adjunct to therapy with
other antibiotics. Eggers {Am. J. Ophth., 1951,
34, 1706) treated more than 400 cases of ocular
infections (conjunctivitis, blepharitis, dacryo-
cystitis, corneal ulceration, etc.) with bacitracin
ophthalmic solution (1000 units per ml.) by in-
stilling a few drops into the eye every l/i to 1
hour during the day. Patients generally were suffi-
ciently improved after treatment for 2 days to re-
turn to work. The drug was used prophylactically
with equal success following ocular surgery.

In dermatology, ointments containing 500 units
of bacitracin per Gm. of suitable base are ex-
tremely efficacious in eradicating many pyogenic
skin infections (Miller et al., Arch. Dermat.
Syph., 1949, 60, 106). Bacitracin is considered
especially useful in dermatology because of the
low incidence of local reactions to it and the rela-
tively high incidence of sensitization following
local application of penicillin or of sulfonamides
to the skin. Derzavis {J.A.M.A., 1949, 141, 191)
patch-tested 150 adults with a bacitracin ointment
for 48 hours; all were negative. A second appli-
cation in the same areas in 50 of the subjects two
weeks later revealed no allergenicity.

Only a small fraction of bacitracin is released
from grease bases, but practically all is available
from water-miscible bases. Bacitracin is readily
released from a base with the following composi-
tion and remains stable in it for at least two
weeks: cetyl alcohol, 10 Gm. ; glycerin, 10 Gm.;
sodium lauryl sulfate, 1 Gm.; distilled water,
74 ml.

Conditions treated successfully with bacitracin
formulated in the above ointment (Miller et al.,
loc. cit.) included impetigo (18 patients), fol-
liculitis (16 patients), infectious eczematoid der-
matitis (13 patients), vesiculopustular eruption
(10 patients) and ecthyma (5 patients). Derzavis
et al. reported similar satisfactory results in
138 patients with pyoderma of various origins
{J.A.M.A., 1949, 141, 191). Practical use of
bacitracin ointments in many types of skin in-
fections has been reviewed by Finnerty {New
Eng. J. Med., 1951, 245, 14) and by Wrong et al.
{Can. Med. Assoc. J., 1951, 64, 395).

In experimental dermatologic studies, mixtures

134

Bacitracin

Part I

of bacitracin with streptomycin and polymyxin
have proved useful in prophylaxis of skin infec-
tions with common bacteria and in the treatment
of chronic tropical ulcers due to bacteria and
treponemas (Loughlin et al., Antibiotics Annual,
1953-1954, p. 291). A lotion containing 500 units
of bacitracin and 10,000 units of polymyxin B
sulfate in each ml. has proved effective in super-
ficial skin infections caused by or secondarily in-
vaded by staphylococci or streptococci and in
sterilizing leg ulcers and in making possible sur-
gical closure of the ulcers (Philip, Antibiot.
Chemother., 1954, 4, 763). A suitable lotion can
be formulated with Carbowax, Veegum, sorbitol,
and lecithin. Such a bacitracin-polymyxin lotion
cannot be considered a dermatologic cure-all; but
it is highly efficacious in exudative skin diseases
where the lesions are invaded by pus-producing
bacteria and where there are avenues permitting
exudates to reach the surface of the skin and the
lotion to penetrate beneath the surface.

Formulated with vasoconstrictors or with other
antibiotics, or alone, bacitracin may be adminis-
tered as an aerosol or in nasal drops for treating
susceptible bacterial sino-respiratory infections.
Prigal and Furman (Am. Coll. Allergists Meet.,
1949) found among 100 patients with infections
of sinuses and respirator}' tract that 13 of 17
cases treated with bacitracin aerosol were mark-
edly improved and that similar results were
achieved with 12 of the remaining 83 patients
treated with bacitracin-penicillin aerosol.

A paste containing penicillin, streptomycin,
and bacitracin was used by Grossman (/. A.
Dent. A., 1951, 43, 265) to sterilize root canals
in pulpless teeth. Bacitracin-polymyxin mixtures
gave excellent results in a series of 89 cases of
otitis externa reported bv Graves {Eye, Ear, Nose
& Throat Monthly, 1952, 31, 32).

Vaginal suppositories containing bacitracin pro-
vide effective prophylaxis against contamination
by gram-positive organisms in hysterectomies
(Turner et al., Am. J. Surg., 1951, 82, 498).

Toxicology. — Bacitracin is virtually nontoxic
when administered locally as an ointment, solu-
tion, or aerosol or when injected intrathecally,
intra cranially, or intracerebrally. Intramuscular
injection, however, may be followed by the symp-
toms of nephrotoxicity mentioned above. Other
toxic effects from systemic administration occur
with varying frequency; these include local pain,
anorexia and nausea, urinary frequency, and
nocturia. Generally, the kidney damage from
bacitracin is completely reversible, but prudence
indicates withdrawal of the drug when symptoms
of toxicity begin to appear.

Bacitracins A and F have about the same
nephrotoxicity on a weight basis. But, as Coding-
ton (loc. cit.) has pointed out, "since F has no
potency against the test organism, an equal num-
ber of units of material containing a large propor-
tion of F would . . . produce a greater toxic effect
than material containing a small amount of F."
Differences in proportions of bacitracins A and F
probably account in part for the varying potency
of different fermentation batches of bacitracin.

Summary. — Bacitracin is a water-soluble poly-
peptide antibiotic that is elaborated by the Tracy I

strain of Bacillus licheniformis (or subtilis). The
drug is stable when dry but deteriorates when in
solution. Its antimicrobial activity is not affected
by serum, pus, or tissue debris.

Bacitracin closely resembles penicillin in the
range of its antimicrobial spectrum; it is active
against most cocci, whether aerobic or anaerobic;
against gram-positive rods; and several spiro-
chetes. It is not effective, in clinically practicable
doses, against gram-negative organisms but it is
Rot destroyed by them, as penicillin sometimes is,
and therefore can be used therapeutically for con-
trol of gram-positive pathogens in certain mixed
infections in which penicillin would be ineffective.
Among gram-positive organisms and cocci, fewer
strains are resistant to bacitracin than to peni-
cillin, possibly because the former antibiotic has
not been so badly abused by indiscriminate use.

Bacitracin has been used topically or locally
with eminent success in pyogenic skin infections,
ocular infections, sterilization of root canals in
pulpless teeth, and in treating oral lesions, espe-
cially those due to spirochetes.

In surgery, bacitracin has been used prophy-
lactically and therapeutically to control both sys-
temic and local infection, and in neurosurgery it
may prove to be the antibiotic of choice. It can
be applied directly to brain tissue without produc-
ing untoward effects. Intrathecal, intracranial,
and intracerebral injections are effective in con-
trolling meningococcal infections.

Intramuscular and intravenous injections of
solutions of bacitracin in saline or water are be-
coming safer as improved purification procedures
remove more of the nephrotoxic constituents.
However, it appears that not all the nephro-
toxicity can be ascribed to impurities; some of
the constituents of bacitracin itself are damaging
to the tubules. Consequently, parenteral adminis-
tration should be attempted only in a hospital
where there are proper facilities and then only
by personnel competent to recognize proteinuria
and other early symptoms of toxicity. Daily
urinalysis and frequent blood urea-nitrogen de-
terminations should be made. If fluid intake is
raised to at least 2500 ml. daily in adults (pro-
portionately in children) there is little risk of
nephrotoxicity. H

Dosage. — For external use the official oint-
ment, containing 500 units of bacitracin per Gm.,
is applied topically as required one or more times
daily; the concentration range in ointments is 250
to 1000 units per Gm. Solutions containing 250
to 1000 units per ml. have also been used
externally.

When administered orally, in treating intestinal
amebiasis, 20,000 to 30,000 units is given every
6 hours, after meals and at bedtime.

For intramuscular administration, in certain
circumstances (v.s.), a reasonable average daily
dose for an adult is 50,000 units given in equal
divided doses six to eight hours apart until fever
subsides. The safe range for a single dose is
10,000 to 20,000 units. The higher dose may be
increased slightly, but the total daily dose should
not exceed 100,000 units. For children the dose
should be reduced in proportion to weight. Usu-
ally a safe basis for calculation of doses for chil-

Part I

Barbital

135

dren or adults is 100 to 200 units per Kg. per
single dose. Meleney and Johnson (1953, loc.
cit.) recommended that (1) the concentration of
bacitracin in the injection should never exceed
10,000 units per ml. of sterile isotonic sodium
chloride solution for injection containing 1.5 per
cent monocaine hydrochloride or 2 per cent pro-
caine hydrochloride, (2) the total daily dose for
adults should never exceed 100,000 units nor
should a single dose exceed 25,000 units (pro-
portionately less for children), (3) fluids should
be forced to at least 2500 ml. daily for adults,
and (4) intake and urinary output should be
measured accurately every day. The daily output
should be about 1 liter; if it falls below 600 ml.
on a 2500 ml. intake, the drug should be discon-
tinued except in rare cases.

For intrathecal, intracisternal, etc., injection
a concentration of 1000 units per ml. of sterile
isotonic sodium chloride solution for injection is
used in a total daily dose of 10,000 units for a
patient over 15 years of age; for infants and
young children, the total daily dose varies from
250 to 5000 units according to size, site of injec-
tion and severity of the infection. Procaine
should not be used in this area.

For intraperitoneal injection in the prophylaxis
or treatment of peritonitis, 20,000 units in 20 ml.
of sterile isotonic sodium chloride solution for in-
jection is instilled or sprayed over the operative
site.

Storage. — Preserve "in tight containers, and
keep in a cool place." U.S.P.

BACITRACIN OINTMENT. U.S.P.

"Bacitracin Ointment is bacitracin in an anhy-
drous petrolatum base. Its potency is not less
than 85 per cent of the labeled potency. The
labeled potency is not less than 500 U.S.P. Units
per Gm. Bacitracin Ointment conforms to the
regulations of the federal Food and Drug Admin-
istration concerning certification of antibiotic
drugs.'; U.S.P.

Bacitracin ointment may be prepared by levi-
gating 500,000 U.S.P. Units of bacitracin with
65 Gm. of liquid petrolatum, and then incorporat-
ing the mixture with 925 Gm. of white petro-
latum. If a firmer preparation is desired up to
40 Gm. of liquid petrolatum may be replaced by
an equal amount of white petrolatum. U.S.P.

Bacitracin ointment contains not more than 1
per cent of water, when determined by the Karl
Fischer method.

For uses of this ointment see the preceding
monograph.

Storage. — Preserve "in collapsible tubes, pref-
erably in a cool place." U.S.P.

ADHESIVE ABSORBENT BANDAGE.
U.S.P.

Adhesive Absorbent Compress, Adhesive Absorbent

Gauze, Adhesive Bandage, [Carbasus Absorbens

Adhaesiva]

Sp. Gasa Absorbente Adhesiva.

Description. — "Adhesive Absorbent Bandage
is a sterile individual dressing prepared by affixing
a plain absorbent compress to a strip of film or

fabric coated with a pressure-sensitive adhesive
composition. One or more colors or bacteriostatic
agents or both, if nontoxic and harmless in the
concentration employed, may be added to the
compress. The weight of the compress is not less
than that of a compress of the same area com-
posed of four layers of Type I Absorbent Gauze.
The compress is substantially free from loose
threads or ravelings. The adhesive strip may be
perforated over the compress, and the back may
be coated with a water-repellent film. The ad-
hesive surface is protected by overlapping strips
of crinoline or other protective material of a
width not less than that of the dressing. Sterility.
— Adhesive Absorbent Bandage meets the re-
quirements of the Sterility Tests for Solids."
U.S.P.

Adhesive absorbent bandage is the official title
for the convenient dressings available on the
market under various trade-marked names, such
as band-aids and quick-aids. Such bandages, which
sometimes contain bacteriostatic agents, are use-
ful for dressing minor wounds.

Storage and Labeling. — "Each Adhesive
Absorbent Bandage not exceeding 15 cm. (6
inches) in width is packaged individually in such
manner that sterility is maintained until the indi-
vidual package is opened. One or more individ-
ual packages are packed in a second protective
container. The label of the second protective con-
tainer bears a statement that the sterility of the
Adhesive Absorbent Bandage cannot be guaran-
teed if the individual package has been damaged
or previously opened. If the compress is colored
with a dye which is not claimed to be a bacterio-
static agent, the label shall bear a statement that
the compress is colored, but the coloring agent
does not render the Bandage antiseptic. If the
compress contains one or more bacteriostatic
agents, the label shall bear the name of each such
agent. Each container indicates the name of the
manufacturer, packer or distributor, and each
protective container indicates also the address
of the manufacturer, packer or distributor." U.S.P.

BARBITAL. N.F. (B.P.), LP.

Diethylbarbituric Acid, BarSitone, Diethylmalonylurea,
[Barbitalum]

The B.P. defines Barbitone as 5:5-diethylbarbi-
turic acid and indicates that it may be obtained
by condensing ethyl diethylmalonate with urea.

B.P. Barbitone; Barbitonum. Veronal (W'inthrop) .
Acidum diaethylbarbituricum. Fr. Diethylmalonyluree.
Ger. Diathylbarbitursaure ; Diathylmalonylharnstoff. It.
Acido dietilbarbiturico. Sp. Acido dietilbarbiturico;
Barbital.

Barbital, prepared by Conrad and Guthzeit in
1882 but not used in medicine until 1904, was the
first of the now extensive series of synthetic
hypnotic drugs derived from barbituric acid (so
named by Baeyer, in 1863, in honor of a friend,

136

Barbital

Part I

Fraulein Barbara). It is that derivative of bar-
bituric acid or malonylurea (for structural for-
mula and discussion see under Barbiturates, Part
II) in which the two hydrogen atoms attached to
the carbon atom in number five position have
been replaced by two ethyl radicals. Most bar-
biturates differ chemically only in the nature of
the substituent groups attached to this particular
carbon atom.

Conrad and Guthzeit prepared barbital by the
action of ethyl iodide on the silver derivative of
barbituric acid. Commercially it is made by the
condensation of diethylmalonic ester with urea in
the presence of sodium ethoxide or metallic so-
dium. The ester may be prepared from mono-
chloroacetic acid by intermediate conversion to
cyanoacetic acid and ethyl malonate, the latter
ultimately yielding diethylmalonic ester. Many
alternative methods of manufacturing barbital
have been proposed and used.

Because of enol formation, in which the
— NH.CO.NH — group of barbital functions as
— N:COH.NH — , it is possible to replace the
hydrogen of the hydroxyl group by sodium
through interaction with sodium hydroxide, form-
ing the official barbital sodium. Other bases func-
tion similarly.

Description. — "Barbital occurs as colorless or
white crystals, or as a white, crystalline powder.
It is odorless, has a slightly bitter taste, and is
stable in air. Its solutions are acid to litmus paper.
One Gm. of Barbital dissolves in 130 ml. of water,
in about 15 ml. of alcohol, in 75 ml. of chloro-
form, and in 35 ml. of ether. One Gm. dissolves
in about 13 ml. of boiling water. It is soluble in
acetone and in ethvl acetate. Barbital melts be-
tween 188° and 192°." N.F. The B.P. states that
barbital is soluble in aqueous solutions of alkali
hydroxides and of alkali carbonates.

Standards and Tests. — Identification. — (1)
Ammonia is evolved on boiling 200 mg. of bar-
bital with 10 ml. of sodium hydroxide T.S. (2)
About 300 mg. of barbital is shaken with 1 ml.
of 1 N sodium hydroxide and 5 ml. of water for
2 minutes and the mixture filtered. On adding
mercuric nitrate T.S. to one-half of the filtrate
a white precipitate, soluble in ammonia T.S., is
produced; on adding silver nitrate T.S. dropwise
to the remainder of the filtrate a white precipi-
tate, at first redissolving, is produced with an
excess of the precipitant. Loss on drying. — Not
over 1 per cent, when dried at 105° for 2 hours.
Residue on ignition. — Not over 0.1 per cent.
Readily carbonizable substances. — A solution of
500 mg. of barbital in 5 ml. of sulfuric acid has
no more color than matching fluid A. Benzene
derivatives. — No yellow color develops on shaking
500 mg. of barbital with 5 ml. of nitric acid. U.S.P.

The B.P. includes a test for the limit of neutral
and basic substances; this consists in dissolving
1 gram of barbitone in a slight excess of sodium
hydroxide solution, extracting with ether and.
after evaporating the solvent, weighing the resi-
due— which should be not more than 2 mg. The
LP. has a similar test but the limit is half that
of the B.P.

Incompatibilities. — Barbital is unstable in

the presence of alkali, undergoing hydrolytic
cleavage of the molecule to form therapeutically
inactive products (see also Incompatibilities under
Barbital Sodium) .

Uses. — Action. — Barbital is a hypnotic. It de-
presses the intellectual function and produces
sleep. After small doses this effect merges into
normal sleep, according to the encephalographic
studies of Brazier and Finesinger (Arch. Neurol.
Psychiat., 1945, 53, 51). The respirations may be
somewhat slowed and the blood pressure reduced
slightly. At this stage there is very little, if any,
reduction in pain perception (Hale and Grabfield,
/. Pharmacol., 1923, 21, 77) and, therefore, bar-
bital does not replace the analgesics though it may
enhance their effect. Gardner (Pennsylvania M. J.,
1944, 47, 451) cautioned against substitution of
barbiturates for opiates for relief of pain. Indeed,
its utility is much diminished unless attending
pain is attended by an analgesic agent. Following
sleep induced by barbital the patient awakens in
a normal condition, though a sense of heaviness
may persist for an hour or two.

With large doses the sleep may pass into com-
plete coma resembling surgical anesthesia, and
there occur a variety of functional changes which
van.' with dosage and individual susceptibility.
Respiration is steadily depressed. The effect on
general metabolism is not much greater than
would be expected from the pronounced muscular
relaxation. Gruber (/. Pharmacol., 1936, 56, 432)
demonstrated that barbital and many of its de-
rivatives directly depress intestinal musculature.
Porter and Allamon (/. Pharmacol., 1936, 58,
178) found that it lowers the threshold of reflex
excitability in the spinal cord, which may explain
its beneficial effect in certain convulsive disorders.
For a review of the general physiologic action of
barbital see Wagner (J.A.M.A., 1933, 101, 1787)
and Tatum (Physiol. Rev., 1939, 19, 472).

In addition to its use as a hypnotic barbital has
been used in small doses in anxiety states, sea-
sickness, and similar conditions. It is decidedly
inferior to phenobarbital in treatment of the con-
vulsive state, lacking the specific corticomotor
depressant action of the latter drug. It has been
used prior to local applications of cocaine to pre-
vent reactions. H

Metabolism. — The major portion of barbital
is excreted unchanged through the kidneys ; elimi-
nation may require several days even in normal
animals. Argy et al. (J. Pharmacol., 1936, 57,
258) reported that rapidity of excretion provided
an accurate index of kidney function; in renal
disease elimination is as slow as 3.2 per cent in
24 hours. Qualitative and quantitative methods
of determining barbital were reported by Kozelka
and Tatum (/. Pharmacol., 1937, 59, 54). Masson
and Bleland (Anesth., 1945, 6, 483), reporting on
the inactivation and ehmination of 29 different
barbiturates in partially hepatectomLzed or com-
pletely nephrectomized rats, suggested that they
be classified into four groups, depending on the
site of detoxication : (1) those detoxified by the
kidney, including barbital and phenobarbital:
(2) those detoxified by the liver, including amo-
barbital, aprobarbital, hexethal, hexobarbital,

Part I

Barbital

137

pentobarbital sodium, probarbital, propallylonal,
and secobarbital; (3) those detoxified by both
liver and kidney, including butethal, cyclobarbital,
diallylbarbituric acid, and vinbarbital; (4) those
detoxified by all body tissues, including thiopental
and other thiobarbiturates.

Toxicology. — Although barbital is a useful
drug, it is capable of doing harm when improperly
employed. The conference on distribution of bar-
biturates held by the Committee on Legislation
of the American Pharmaceutical Association
(J.A.M.A., 1945, 129, 1264) recommended uni-
form state laws to govern its dispensing. Curran
(/. Nerv. Ment. Dis., 1944, 100, 142) called at-
tention to the fact that from 0.3 to 1 per cent of
all psychiatric admissions to hospitals in the
United States are attributable to use of drugs.

Habituation. — Brownstein and Pacella {Psych.
Quart., 1943, 17, 112) noted that convulsive
seizures may ensue from sudden withdrawal of
barbiturates in individuals who manifest no such
tendency clinically or by electroencephalographic
examination. Green and Koppanyi (Anesth., 1944,
5, 329) demonstrated that dogs develop cross-
tolerance for various barbiturates after receiving
one of them; they believe this to be a true cellu-
lar tolerance, though of brief duration. Psychic
dependence rather than true addiction, as in the
case of morphine, is more common. Seevers and
Tatum (7. Pharmacol., 1931, 42, 217) showed
that prolonged use of barbital in animals may
cause pathological alteration of the cerebral struc-
ture. Robinson (/. Missouri M. A., 1937, 34,
374) believed that analogous changes may occur
in human addition. Work (Arch. Neurol. Psychiat.,
1928, 19, 324; pointed out that habitual use may
lead to paranoid states. In individuals with per-
sonality abnormalities, Isbell and White (Am. J.
Med., 1953, 14, 558) described barbiturate addic-
tion often associated with abuse of both alcohol
and amphetamine and rarely with opiates. These
cases consumed more than 800 mg. of one of the
potent and moderate-duration barbiturates such
as pentobarbital, amobarbital, etc., by mouth
daily. Injection of the contents of a capsule causes
severe irritation. Although some tolerance exists,
an increase of only 100 mg. above the individual's
usual daily dose causes acute barbiturate poison-
ing. A definite abstinence syndrome is described
in such individuals (Isbell et al., Arch. Neurol.
Psychiat., 1950, 64, 1). During the first few hours
after discontinuing the drug, the sedative effects
of the barbiturate diminish but within 8 to 16
hours anxiety, nervousness, headache, twitching
of muscle groups, tremor, weakness and impaired
circulatory responses to changes in body posture
and other stimuli appear. There is progressive
slowing of the abnormally rapid electroencephalo-
graph pattern in these cases and then bursts of
spike and dome complexes appear; a convulsive
seizure of grand mal type often occurs within 16
to 48 hours after the last dose of barbiturate.
Confusion follows the convulsion and in some
cases progresses into a delirium resembling de-
lirium tremens of alcoholism; severe exhaustion
may develop. Fraser et al. (Ann. Int. Med., 1953,
38, 1319) reported a death. Usually after several

days the agitation subsides, the patient sleeps and
recovers.

Suicide. — In recent years poisoning by barbital
and allied substances has become very frequent.
While many cases occur as the result of unex-
pected sensitiveness to the drug or injudicious
dosage for therapeutic purposes, the majority of
the serious cases have been suicidal. In fact, in
1936 more than 300 suicides in the United States
were produced by barbiturates (Hambourger,
J. A.M. A., 1939, 112, 1340). The popularity of
barbiturates for suicidal use continues despite
increasing restrictions on their sale.

Symptoms. — The chief symptom of acute poi-
soning is stupor, merging into deep coma which
may persist for days. The respiration is slowed,
in some cases markedly so, and accompanied by
cyanosis and even by Cheyne-Stokes breathing.
The anoxemia leads to a fall in blood pressure as
a result of capillary dilatation. The body tem-
perature may be increased, but if shock ensues
the skin becomes cold and moist, and the pulse
weak and rapid. Lowered blood pressure together
with the antidiuretic action of barbital may lead
to urinary suppression. The urine may contain
hematoporphyrin. The pupils may be either
dilated or contracted. The deep tendon reflexes
are not altogether absent until coma is profound.
Death may occur in a few hours from acute
respiratory failure or later from pulmonary edema
or hypostatic pneumonia. According to Quastel
and Wheatley (Proc. Roy. Soc. Med., 1932, B
112, 60), barbiturates inhibit oxidation of glucose,
lactate, and pyruvate, though not of succinate,
within brain tissue.

The fatal doses reported for barbital have
ranged from 2 Gm. (30 grains) to as high as 16
Gm. (240 grains), according to Hambourger
(J.A.M.A., 1940, 114, 2015). The effects of bar-
biturate intoxication have been summarized by
Billow (/. Lab. Clin. Med., 1944, 27, 265) as
follows :

Dose in Gm.

Producing

Severe Intoxi-

cation with

Fatal Dose

Recovery

in Gm.

Allonal

More than 15

Amobarbital

1.5 to 2

2 to 3

Barbital

3 to 10

5 to 20

Butallylonal

0.5 to 1

More than 1

Diallylbarbituric

Acid

2 to 2.5

More than 2.5

Pentobarbital So-

dium

More than 1

More than 2

Phanodorn

1.2

More than 10

Phenobarbital

4 to 7

6 to 9

Differential diagnosis from poisoning by other
aliphatic narcotics is almost impossible without
the history or chemical examination. The absence
of odor on the breath distinguishes it from alcohol
or paraldehyde narcosis, but it must be remem-
bered that in many instances patients are under
the influence of alcohol when they take barbital.

In chronic poisoning with barbital the mental

138

Barbital

Part I

features resemble paresis (Curran. /. Nerv. Ment.
Dis., 1944, 100, 142; Isbell and White, loc. cit.),
there being silly euphoria and disorientation even
to the point of hypomania, despite drowsiness.
There is impaired mentation, loss of emotional
control, poor judgment, confusion and rarely a
toxic psychosis. Nystagmus, dysarthria, ataxia,
adiadokokinesis and an abnormally fast electro-
encephalogram pattern is found. Respiration and
nutrition are usually normal. Bromide intoxica-
tion, on the other hand, presents a delirium with
hallucinations, confabulation, and vestibular phe-
nomena; there may be nystagmus, convulsive
movements, a positive Babinski reflex, intention
type tremors, a positive Romberg sign with cere-
bellar dysfunction and unsteady gait in association
with vestibular derangement.

Idiosyncrasy to barbiturates may be acquired,
especially in individuals otherwise allergic; doses
as low as 300 mg. (5 grains) may cause fever,
scarlatiniform eruptions with desquamation or
angioneurotic edema.

Treatment of Acute Poisoning. — In view of the
extensively disordered physiology of the organism
produced by barbiturate poisoning active therapy
is of paramount importance. In addition to these
symptomatic measures two basic considerations
should guide the treatment of profound barbital
intoxication: (1) the compound is poorly excreted
or metabolized; thus it may be necessary to
watch the patient carefully for several days fol-
lowing withdrawal of the drug in order to main-
tain adequate cardiovasculorespiratory function.
(2) Because of the depressed respiratory excur-
sions over many hours, adequate chemothera-
peutic prophylaxis against the development of
pneumonia is a justifiable precaution until the
patient is out of clanger. Burdick and Rovenstine
(Ann. Int. Med., 1945. 22, 819) and Dorsey
(/. Nerv. Ment. Dis., 1944, 99, 367) recommend
early and adequate symptomatic use of picrotoxin.
Dorsey recommended the following plan of
treatment: On establishing diagnosis the patient's
head is lowered, external heat is applied, an air-
way maintained, and gastric lavage performed
with a quart of warm water each of three times.
Sixty grams of magnesium sulfate solution are
instilled to hasten bowel elimination. Continuous
intravenous administration of 5 per cent dextrose
in normal saline is begun. Through the tubing a
picrotoxin solution containing 3 mg. per ml. is
injected at the rate of 1 ml. per minute until it
produces tremors and twitching of the eyes or
lips, at which level the maximum beneficial effect
on cardiac and respiratory centers obtains. A 1-ml.
dose must be repeated about every 5 minutes to
maintain this effect. The patient becomes restless
as improvement begins, and the frequency of in-
jections may be reduced to each 10 or 15 minutes.
Picrotoxin administration is discontinued when
the patient moves about the bed. Since picrotoxin
disappears in 30 minutes, its use must be continued
for an adequate time, the usual total requirement
being about 300 mg. Amphetamine sulfate (q.v.)
or pentylenetetrazol (q.v.) are also used. Ad-
juncts to this specific stimulation include injec-
tion of 500 mg. (~y2 grains) of caffeine and
'sodium benzoate intravenously each hour, the

inhalation of a mixture of 5 per cent carbon
dioxide and 95 per cent oxygen, or artificial res-
piration as necessary, and the administration of
plasma or blood transfusion for shock. The pa-
tient's position is changed hourly and the bladder
is catheterized every 6 hours.

Soskin and Taubenhaus (/. Pharmacol., 1943,
78, 49) used a 10 per cent aqueous succinate
solution intravenously with success in a patient
who failed to respond after 3 days of treatment
with picrotoxin. so maintaining brain metabolism
until the barbiturates were destroyed and elimi-
nated. This use of sodium succinate could not be
substantiated bv others (/. Pharmacol., 1944, 81,
202; 1949, 96, 315).

Dose. — The dose of barbital is from 300 to
600 mg. (approximately 5 to 10 grains), one to
two hours before bedtime.

Barbital Elixir, X.F. IX, is prepared by dis-
solving 35 Gm. of barbital in a mixture of 335 ml.
of alcohol, 30 ml. of compound vanillin spirit, and
600 ml. of glycerin, then adding 20 Gm. of cara-
mel and enough glycerin to make 1000 ml. of
product. The average dose of 4 ml. (approxi-
mately 1 fluidrachm) contains about 140 mg.
(approximately 2}i grains) of barbital.

Storage. — Preserve "in well-closed contain-
ers." Nf.

BARBITAL TABLETS.
N.F. (B.P.) (I.P.)

Tabellae Barbitali

"Barbital Tablets contain not less than 94 per
cent and not more than 106 per cent of the labeled
amount of CSH12X2O3." NJ7. The corresponding
B.P. limits are 95.0 and 105.0 per cent, while
those of the I.P. are 94.0 and 106.0 per cent.

B.P. Tablets of Barbitone; Tabellae Barbitoni. I.P.
Tablets of Barbital; Compressi Barbitali. Sp. Tobletas
de Barbital.

Assay. — A representative sample of powdered
tablets, equivalent to about 300 mg. of barbital,
is treated with an alkaline sodium chloride solu-
tion to dissolve barbital and this solution is ex-
tracted with ether to remove lubricants other than
stearic acid or stearates. The aqueous solution is
then acidified to liberate barbital, which is ex-
tracted with chloroform ; the chloroform solutions
are washed with acidified water, filtered, and the
chloroform evaporated. The residue of barbital is
dried at 105° for 2 hours and weighed. If stearic
acid or a stearate has been used as a lubricant for
the tablets the residue will contain stearic acid.
To remove this the residue is dissolved in alcohol,
and barium hydroxide is added to precipitate
barium stearate while dissolving the barbital. The
mixture is filtered, the filtrate is acidified, and
the precipitated barbital is extracted with chloro-
form as before, and finally weighed. X.F. The I.P.
uses the same assay, with minor variations. In the
B.P. assay a portion of powdered tablets repre-
senting about 300 mg. of barbital is extracted with
ether in a continuous extraction apparatus: the
ether is evaporated and the residue of barbital is
dried to constant weight at 105°.

Usual Size. — 5 grains (approximately 300
mg.).

Part I

Barium Sulfate

139

BARBITAL SODIUM. N.F. (B.P.) LP.

Soluble Barbital, Barbitone Sodium,
[Barbitalum Sodicum]

"Barbital Sodium, dried at 105° for 3 hours,
contains not less than 98.5 per cent of CsHn-
N2Na03." N.F. The B.P. recognizes Barbitone
Sodium as the monosodium derivative of 5:5-di-
ethylbarbituric acid, the substance being required
to contain not less than 98.0 per cent and not
more than the equivalent of 101.0 per cent of
C8HnN2Na03, calculated with reference to the
material dried at 105°. The LP. requires not less
than 98.0 per cent of C8HnN2Na03, no reference
being made to drying it, or calculating to the dried
substance.

B.P. Barbitone Sodium; Barbitonum Sodium. LP.
Barbitalum Natricum. Sodium Barbital; Sodium Diethyl-
malonylurea; Sodium Diethylbarbiturate; Medinal (Scher-
ing & Glatz); Veronal Sodium (Winthrop) . Natrium
Diaethylbarbituricum. Ger. Diathylbarbitursaures Nat-
rium; Veronal Natrium. It. Dietilbarbiturato di sodio.
Sp. Barbital Sodico.

Barbital sodium is produced by the interaction
of barbital and sodium hydroxide, in the presence
of water, from which solution the sodium deriva-
tive is precipitated with alcohol. In this reaction
the — NH.CO.NH — group of barbital is probably
first converted to the isomeric — N:COH.NH —
group, which subsequently reacts with sodium
hydroxide to form — N:CONa.NH— .

Description. — "Barbital Sodium occurs as a
white powder. It is odorless, has a bitter taste,
and is stable in air. Its solutions are alkaline to
litmus paper and to phenolphthalein T.S. One Gm.
of Barbital Sodium dissolves in about 5 ml. of
water and in 2.5 ml. of boiling water. It is slightly
soluble in alcohol and is insoluble in ether." N.F.

Standards and Tests. — Identification. — (1)
The barbital obtained in the assay melts between
188° and 192° and responds to identification tests
for barbital. (2) A white precipitate of barbital
is obtained on adding diluted hydrochloric or
sulfuric acid to a 1 in 20 solution of barbital
sodium. (3) The residue resulting from the igni-
tion of barbital sodium responds to tests for
sodium. Loss on drying. — Not over 1 per cent,
when dried for 3 hours at 105°. Heavy metals. —
The limit is 20 parts per million. Readily carbon-
izable substances. — A solution of 500 mg. of bar-
bital sodium in 5 ml. of sulfuric acid has no more
color than matching fluid A. Uncombined barbital.
— 500 mg. of barbital sodium shaken with 20 ml.
of absolute ether for 10 minutes yields not more
than 3 mg. of soluble matter. N.F. The B.P. and
the LP. limit the content of lead to 10 parts per
million; the LP. also provides a heavy metals
limit of 20 parts per million.

Assay. — A sample of 500 mg. of barbital so-
dium is dissolved in water, acidified with hydro-
chloric acid, and the liberated barbital extracted
with chloroform. The filtered chloroform extract
is evaporated to dryness, the residue is dried at
105° for 2 hours, and then weighed. The weight
of the residue multiplied by 1.119 represents the
weight of CsHnN2Na03. N.F. The B.P. and LP.
assays are similar in principle, except that ether
is employed for extracting barbital.

Incompatibilities. — In aqueous solution, bar-

bital sodium undergoes hydrolysis, diethylmalon-
uric acid, diethylacetylurea and possibly further
decomposition products being produced (see Niel-
son, Quart. J. P., 1938, 11, 150, and Aspelund
and Skoglund, ibid., 1938, 11, 291). The reaction
is accelerated by an increase in temperature but
is appreciable even at room temperature; this is
emphasized by the fact that solutions of barbital
sodium have been known to decompose as much
as 50 per cent during a period of a few months,
even when stored at room temperature. Since
hydrolysis of barbital sodium is accompanied by
loss of therapeutic value, aqueous solutions of
this compound should be freshly prepared. Bar-
bital sodium is precipitated as barbital by acids
and acid-reacting salts. Because of its alkalinity
it should not be prescribed along with chloral
hydrate, which it decomposes to form chloroform
and sodium formate, with simultaneous precipita-
tion of barbital.

Uses. — Because of its solubility, this drug acts
somewhat more promptly than does barbital
(q. v.). Being soluble in water it can be given by
intravenous injection but has largely been replaced
for that purpose by some of the newer sodium
barbiturates. For discussion of uses and toxicology
see under Barbital. S

Dose, from 300 to 600 mg. (approximately 5
to 10 grains).

Storage. — Preserve "in tight containers." N.F.

BARBITAL SODIUM TABLETS.

N.F. (B.P.) (LP.)

Tabellae Barbitali Sodici

"Barbital Sodium Tablets contain not less than
94 per cent and not more than 106 per cent of the
labeled amount of CsHii^OsNa." N.F. The
corresponding B.P. limits are 92.0 and 105.0 per
cent, while those of the LP. are 94.0 and 106.0
per cent.

B.P. Tablets of Barbitone Sodium; Tabellae Barbitoni
Sodii. LP. Tablets of Barbital Sodium; Compressi Bar-
bitali Natrici. Sp. Tabletas de Barbital Sodico.

Usual Size. — 5 grains (approximately 300
mg.).

BARIUM SULFATE. U.S.P. (B.P.) LP.

[Barii Sulfas]

BaS04

"Caution. — When Barium Sulfate is prescribed,
the title should always be written out in full to
avoid confusion with the poisonous barium sidfide
or sulfite." U.S.P.

B.P. Barium Sulphate; Barii Sulphas. Blanc Fixe; Syn-
thetic or Artificial Barytes; Artificial Heavy Spar; Snow,
New or Permanent White. Terra Alba; Terra Ponderosa.
Fr. Sulfate de baryum; Blanc fixe. Ger. Bariumsulfat ;
Schwefelsaures Barium. It. Solfato di bario. Sp. Sulfato
de bario.

A native barium sulfate, known as barytes,
heavy spar, barite or tiff, is the most abundant
of the natural salts of barium and is mined ex-
tensively in the United States. It occurs as a
heavy, lamellar, brittle mineral, usually translu-
cent, sometimes transparent or even opaque;
color white or pale pink. Sometimes it occurs in
flat rhombic prisms.

140

Barium Sulfate

Part I

The medicinal salt, however, is obtained by the
interaction of barium hydroxide or soluble barium
salts with sulfuric acid or soluble sulfates. Much
barium sulfate is made, by the same reactions, for
industrial usage; as this grade is not as pure as
the medicinal variety it is imperative that the
industrial grade not be used medicinally. Barium
sulfate is often a by-product in the manufacture
of other chemicals.

Description. — "Barium Sulfate is a fine,
white, odorless, tasteless, bulky powder, free from
grittiness. Barium Sulfate is insoluble in water,
in organic solvents, and in solutions of acids and
of alkalies." U.S.P.

Standards and Tests. — Identification. — (1)
Tests for sulfate are given by barium sulfate
when 500 mg. of it is fused with 2 Gm. each of
anhydrous sodium carbonate and anhydrous po-
tassium carbonate, the fused mass leached with
hot water, and the tests performed on the filtered
liquid. (2) Tests for barium are given by the
well-washed residue from the preceding test after
solution in acetic acid. Bulkiness. — 5 Gm. of
barium sulfate, previously passed through a No.
60 sieve, and mixed with enough water to make a
volume of 50 ml. in a glass-stoppered graduated
cylinder having the 50-ml. graduation about 14
cm. from the bottom does not settle below the
11 -ml. graduation within 15 minutes. Acidity or
alkalinity. — 1 Gm. of barium sulfate shaken with
20 ml. of water for 5 minutes leaves the water
neutral to litmus paper. Sulfide. — Lead acetate
paper is not darkened when exposed to the vapors
of a mixture of 10 Gm. of barium sulfate, 10 ml.
of diluted hydrochloric acid and 90 ml. of water
boiled for 10 minutes in a 2 50-ml. Erlenmeyer
flask. Acid-soluble substances. — Not more than
15 mg. of residue, dried at 105° for 1 hour, is
obtained from 50 ml. of filtrate from the insolu-
ble residue of the preceding test (the soluble
portion of barium sulfate is largely eliminated by
evaporating the filtrate, dissolving it in 10 ml. of
hot water and 2 drops of hydrochloric acid, and
filtering). Soluble barium salts. — No turbidity
develops within 30 minutes after the addition of
diluted sulfuric acid to a solution of the residue
obtained in the preceding test. Phosphate. — No
yellow precipitate is formed on adding ammonium
molybdate T.S. to the filtrate obtained from 1 Gm.
of barium sulfate boiled for 5 minutes with 3 ml.
of nitric acid and 5 ml. of water. Arsenic. — The
limit is 1 part per million. Heavy metals. — The
limit is 10 parts per million. U.S.P.

The B.P. and LP. require that the loss on dry-
ing to constant weight, at 105° and 110° re-
spectively, not exceed 2.0 per cent.

Uses. — Barium sulfate, by virtue of its opacity
to x-rays and its insolubility in the fluids of the
gastrointestinal tract, is used in medicine for
obtaining roentgenograms of the alimentary canal.
For this purpose it has quite generally replaced
bismuth salts, over which barium sulfate has the
advantages of greater opacity, lesser effect on the
bowel, and lower cost. Barium sulfate is com-
monly administered in aqueous suspension, the
amount employed depending on the portion of the
tract to be examined and the technic to be em-
ployed. Various formulations call for from 30 to

360 Gm., and sometimes more, of barium sulfate.
These may be given orally or, if the examination
is to be of the colon, by enema.

A homogeneous suspension, free of lumps in
order that the barium sulfate itself may have uni-
form opacity to x-rays, is obviously desirable. In
addition, a thin film of barium sulfate should be
deposited on the mucosal surface and persist there
even after most of the suspension has passed the
area to be examined (Hodges, J. A.M. A., 1953,
153, 1417). Ideally, it should be possible to vary
opacity (to x-rays) and viscosity independently.
For oral administration suspensions should pref-
erably be flavored. Various suspending agents
have been employed in formulating barium sulfate
preparations, these including bentonite, kaolin
(Haenisch, Munch, med. Wchnschr., 1911, 58,
2375), starch (Potter, Radiology, 1953, 60, 500),
flour, acacia, agar, gelatin (Abel, ibid., 1944, 43,
175), lecithin, pectin, tragacanth, malted milk,
and aluminum hydroxide gel (Swallow, Pharm. J.,
1950, 2, 434). More recently methyl cellulose
(Marks, Am. J. Surg., 1951, 81, 6) and sodium
carboxymethylcellulose (Bactowsky and Presto,
Bull. Am. Soc. Hosp. Pharm., 1950, 7, 65) have
been used; silicones and tannic acid have been
included in certain formulations. Saccharin and
vanillin are commonly employed for sweetening
and flavoring suspensions to be taken orally; other
flavoring agents, including cocoa, are also used.
The particle size of the barium sulfate is obvi-
ously an important factor; very minute par-
ticles improve suspension stability and facilitate
coating of the mucosa. Hodges alleges that the
designation "colloidal," as applied to the suspen-
sions, is often a misnomer.

A barium sulfate suspension enema,, accom-
panied by fluoroscopic observation, has been used
therapeutically to reduce intussusception (Ravitch
and Morgan, Ann. Surg., 1952, 135, 296). Fawcitt
(Brit. M. J., 1943, 1, 352) recommended use of
cotton "sandwiches" impregnated with barium
sulfate to entangle sharp foreign bodies within the
intestinal tract and to permit their visualization, [vj

Toxicology. — It should be remembered that
the soluble barium salts are actively poisonous,
being very active stimulants to the entire bodily
musculature. As little as 800 mg. of a soluble
barium salt has proved fatal. The safety of barium
sulfate in large doses is due to its insolubility.
Karaoglanow {Pharm. Weekblad., 1918, 55, 47)
found that from 2.5 to 4.3 milligrams of barium
sulfate dissolve in a liter of water, according to
the degree of fineness of the powder. The solu-
bility is decreased by the presence of sulfate ion
and increased by nitric or hydrochloric acid.

Barium Sidfide. — A number of fatal cases of
poisoning by other salts, especially the sulfide of
barium, but including even the carbonate (Mor-
ton, Lancet, 1945, 2, 738), which have been mis-
takenly used for x-ray work have been recorded.
In a case reported by Bensaude and Antoine
{Bull. soc. med., 1919, 43, 369), the patient was
poisoned immediately after drinking the suspen-
sion of barium and was dead in 10 minutes. In
other cases the appearance of symptoms has been
delayed as much as an hour and death until the
following day. The characteristic symptoms are:

Part I

Beef, Iron and Wine

141

burning pain in the stomach, nausea and vomit-
ing, the latter often bilious, followed by diarrhea
with violent abdominal cramps. The pulse is usu-
ally slow and frequently irregular, the blood pres-
sure being elevated. There are often vertigo and
ringing in the ears. Death may occur suddenly
with convulsions, or may be delayed for 10 or 12
hours. Post-mortem examination shows intense
congestion of the alimentary canal, with some-
times minute hemorrhages, also congestion of the
liver and kidney.

The proper treatment consists in the immedi-
ate administration of large quantities of mag-
nesium or sodium sulfate followed by repeated
washings of the stomach. Intravenous adminis-
tration of calcium or magnesium salts may be
tried to counteract the action of barium on
muscles. Morphine and atropine are indicated for
the pain.

Caution. — In view of the considerable number
of fatalities that have been recorded from the
substitution of barium sulfide for sulfate it is
imperative that both in writing prescriptions, and
in labeling containers, for barium sulfate the name
should be written out in full — never abbreviated.

Dose. — The usual dose is 300 Gm. (approxi-
mately 10 ounces), by mouth, in a suitable sus-
pension (about 50 per cent w/v in water) or 360
Gm. (approximately 12 ounces) in appropriate
suspension as an enema.

Storage. — Preserve "in well-closed contain-
ers" U.S.P.

BEEF EXTRACT. N.F.

Extractura Carnis

"Beef Extract is a concentrate from beef broth
obtained by extracting fresh, sound, lean beef by
cooking with water and evaporating the broth at a
low temperature, usually in a vacuum, until a
thick pasty residue is obtained." N.F.

Fr. Extrait de boeuf. Ger. Fleischextrakt.

Description. — "Beef Extract occurs as a yel-
lowish brown to dark brown, slightly acid, pasty
mass, having an agreeable meat-like odor and
taste. Twenty-five Gm. of Beef Extract, dissolved
in sufficient water to make 250 ml., yields a nearly
clear solution, free from sediment." N.F.

Standards and Tests. — Total solids. — Not
less than 75 per cent, as determined by drying 10
ml. of a 1 in 100 solution over sand or asbestos
at 105° for 16 hours. Residue on ignition. — Not
less than 30 per cent of the total solids when the
residue from the preceding test is incinerated at
a dull red heat. Chlorides as sodium chloride. —
Not over 6 per cent of the total solids. Alcohol-
insoluble solids. — Not over 10 per cent of the total
solids. Nitrate. — No blue color develops when
1 drop of a 1 in 10 solution of beef extract, previ-
ously decolorized by boiling with animal charcoal,
is added to 3 drops of a 1 in 100 solution of di-
phenylamine in sulfuric acid. N.F.

Assay. — For nitrogen content of alcohol-sol-
uble substances. — An aliquot portion of the alco-
hol filtrate remaining from the test for alcohol-
insoluble substances, equivalent to 1 Gm. of
alcohol-soluble solids, is digested with sulfuric

acid, in the presence of potassium sulfate, until
a pale yellow or nearly colorless liquid results.
The resulting solution of ammonium sulfate is
alkalinized with sodium hydroxide and the liber-
ated ammonia distilled into 50 ml. of 0.1 N sul-
furic acid; the excess acid is titrated with 0.1 N
sodium hydroxide, using methyl red T.S. as indi-
cator. Each ml. of 0.1 N sulfuric acid represents
1.401 mg. of N. The amount of nitrogen thus
found is not less than 60 mg. For nitrogen as
ammonia. — The ammonia in 100 ml. of a 1 in 10
solution of the extract is distilled into 50 ml. of
0.1 TV sulfuric acid after adding 5 Gm. of barium
carbonate to the sample; the excess of acid is
titrated with 0.1 N sodium hydroxide using methyl
red T.S. as indicator. Each ml. of 0.1 N sulfuric
acid represents 1.703 mg. of NH3. The amount
of ammonia does not exceed 0.35 per cent of the
total solids in the solution taken. N.F.

Uses. — Years ago beef extract was a very pop-
ular nutritional adjunct. In large part because of
the uncertainty of and variation in its composition
— notwithstanding the many tests which were de-
vised for its nutritional evaluation together with
the development of relatively pure forms of many
nutritional factors — the popularity of beef extract
has waned. That it contains hydrolysis products
of proteins and small amounts of proteins them-
selves, together with vitamins and certain miner-
als, is certain — but it is extremely unlikely that
any material benefit can arise from the ingestion
of the small amounts of extract usually taken.
It is official as an ingredient of Beef, Iron and
Wine.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

Off. Prep.— Beef, Iron and Wine, N.F.

BEEF, IRON AND WINE. N.F

Caro, Ferrum et Vinum

"Beef, Iron and Wine contains, in each 100 ml.,
an amount of ferric ammonium citrate corre-
sponding to not less than 750 mg. and not more
than 975 mg. of Fe." N.F.

Dissolve 30 Gm. of beef extract in 60 ml. of
purified water with the aid of heat, cool, and add
a mixture of 1 ml. of compound orange spirit,
100 ml. of syrup and 50 ml. of alcohol. Dissolve
50 Gm. of ferric ammonium citrate in 750 ml. of
sherry wine, and add this solution to the other
one. Add enough diluted ammonia solution to
make the mixture neutral or slightly alkaline.
Finally add sufficient sherry wine to make 1000
ml. Set the solution aside for 2 days and filter.
N.F.

Assay. — A 10-ml. portion of beef, iron and
wine is evaporated to dryness and the residue
ignited until free from organic matter, finally in
the presence of sulfuric acid. The residue of iron
oxide is dissolved in hydrochloric acid, the solu-
tion oxidized by means of hydrogen peroxide T.S.
and the excess of the latter expelled by heating.
The amount of ferric iron present is finally deter-
mined by having it liberate iodine from potassium
iodide, the halogen being estimated by titration
with 0.1 N sodium thiosulfate, using starch T.S.

142 Beef, Iron and Wine

Part I

as indicator. Each ml. of 0.1 N sodium thiosulfate
represents 5.585 mg. of Fe. N.F.

Alcohol Content. — From 17 to 25 per cent,
by volume, of C2H5OH. N.F.

Use. — This tonic preparation provides a thera-
peutic dose of ferric ammonium citrate in the
recommended average dose of 8 ml. (approxi-
mately 2 fiuidrachms) of beef, iron and wine;
this represents 400 mg. (approximately 6 grains)
of ferric ammonium citrate. The presence of
beef extract and wine may tend to stimulate the
appetite through the flavor they give to the
preparation.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

BELLADONNA LEAF. U.S.P. (B.P., LP.)

Belladonna Herb, Deadly Nightshade Leaf,
Belladonna; Folium

"Belladonna Leaf consists of the dried leaf and
flowering or fruiting top with branches of Atropa
Belladonna Linne or of its variety Acuminata
Royle ex Lindley (Fam. Solanacece). Belladonna
Leaf vields not less than 0.35 per cent of the alka-
loids 'of Belladonna Leaf." U.S.P.

The B.P. recognizes as Belladonna Herb the
leaves, or leaves and other aerial parts, of Atropa
Belladonna L. and Atropa acuminata Royle ex
Lindley (the validated name for Indian Bella-
donna; see under Belladonna Root), collected
when the plants are in flower and dried. An
alkaloidal content of not less than 0.30 per cent,
calculated as hyoscyamine, is required. The LP.
definition and rubric are identical with those of
the B.P.

The B.P. recognizes also a Prepared Belladonna
Herb (Belladonna Prceparata) and the LP. a
Standardized Powdered Belladonna Herb (Pulvis
BelladonncB Herbce. Standardisatus), both being
Belladonna Herb reduced to a fine powder and
adjusted, if necessary, to contain 0.30 per cent
of alkaloids (limits, 0.28 to 0.32); adjustment to
this potency may be made either by the admixture
in suitable proportions of powdered belladonna
herb of lower or higher alkaloidal content or by
the addition of powdered exhausted belladonna
herb (powdered lactose or rice starch is also per-
mitted to be used by the LP.). This is the prep-
aration to be dispensed when belladonna leaf or
belladonna herb is prescribed.

B.P., LP. Belladonna Herb; Belladonnas Herba. Bella-
donna Leaves; Black Cherry Leaf; Dwale; Dwayberry Leaf.
Belladonnas Folia; Herba Solani Furiosi. Fr. Belladone;
Feuilles de belladone. Ger. Tollkirschenblatter; Bella-
donnablatter; Tollkraut; Tollkirschenkraut. It. Foglie di
belladonna. Sp. Hoja de belladona.

For account of the botany and chemistry of
this drug see Belladonna Root.

Description. — "Unground Belladonna Leaf
usually occurs as partly matted together, crumpled
or broken leaves, together with some smaller
stems and a number of flowers and fruits. The
leaves are thin and brittle, mostly light green to
moderate olive green. The lamina is mostly from
5 to 25 cm. in length and from 4 to 12 cm. in
width and possesses an ovate-lanceolate to broadly
ovate outline, an acute to acuminate apex, an
-entire margin, an acute to somewhat decurrent

base and slightly hairy surface, the hairs being
more abundant along the veins; when broken
transversely, it shows numerous light-colored dots
(crystal cells) visible with a lens. The petiole is
slender and usually up to 4 cm. in length. The
flowers possess a campanulate corolla with 5 small,
reflexed lobes which are purplish to yellowish
purple, becoming faded to brown or dusky yellow,
a green, 5-lobed calyx, 5 epipetalous stamens, and
a superior, bilocular ovary with numerous ovules.
The fruit is subglobular, dark yellow to yellowish
brown to dusky red or black, up to about 12 mm.
in width and sometimes subtended by the per-
sistent calyx and containing numerous flattened,
somewhat reniform seeds, the latter up to about
2 mm. in width. The stems are more or less
flattened and hollow and finely hairy when young.
When moistened, its odor is slight, somewhat
tobacco-like. Its taste is somewhat bitter and
acrid." U.S.P. For histology see U.S.P. XV.

"Powdered Belladonna Leaf is fight olive brown
to moderate olive green in color. The following
are among the elements of identification: the
separate microcrystals, the dark gray crystal cells,
the cuticular striping of the epidermal cells, the
vessels with ellipsoidal, bordered pits, the fibers
of the stem, and occasional hairs and pollen grains.
Rosette aggregates of calcium oxalate and frag-
ments of the seed occur when the drug contains
belladonna fruits. Examine Belladonna Leaf for
hairs having a papillose cuticle and for raphides
of calcium oxalate: their presence indicates adul-
teration." U.S.P. For features distinguishing leaf
from the two sources recognized by the pharma-
copeias see under Belladonna Root.

Standards and Tests. — Belladonna leaf con-
tains not over 3 per cent of belladonna stems ex-
ceeding 10 mm. in diameter; the acid-insoluble
ash is not over 3 per cent. U.S.P. The B.P. allows
not over 2.0 per cent of foreign organic matter;
the LP. permits not more than 15.0 per cent of
ash (total).

Assay. — A 10-Gm. portion of leaf, in moder-
ately coarse powder, is inserted in the thimble of
a Soxhlet, or similar, extractor; after maceration
with a mixture of ammonia, alcohol and ether, the
drug is extracted with ether. Alternatively, the
drug may be extracted in a percolator with a mix-
ture of 3 volumes of ether and 1 volume of chloro-
form. The extract, concentrated if necessary, is
shaken with approximately 0.5 N sulfuric acid to
remove alkaloids, and these are then transferred
to chloroform after alkalinization of the aqueous
solution. After evaporating the chloroform the
residue of alkaloid is heated to expel non-alka-
loidal amines, then dissolved in 15 ml. of 0.02 N
sulfuric acid and the excess acid titrated with
0.02 N sodium hydroxide, using methyl red T.S.
as indicator. Each ml. of 0.02 N acid represents
5.788 mg. of belladonna leaf alkaloids, calculated
as hyoscyamine (or atropine). U.S.P.

The B.P. belladonna assay is different in several
details from the method of the U.S.P. In the B.P.
method the drug is shaken well with a solvent
composed of 4 volumes of ether and 1 volume of
95 per cent alcohol for ten minutes, then dilute
ammonium hydroxide solution is added and the
mixture shaken frequently during one hour. This

Part I

Belladonna Leaf Fluidextract 143

mixture is then transferred to a percolator, the
drug packed firmly, and extracted, first with a
small amount of the first solvent (4 ether and 1
alcohol) and, finally, with ether alone until all
the alkaloids are removed. The percolation must
not take more than 3 hours. The percolate, which
contains the alkaloids of the belladonna, is con-
centrated to a small volume, mixed with chloro-
form, and shaken out with a hydrochloric acid
solution until the alkaloids are completely ex-
tracted. The acidulated alkaloidal solution is
washed with chloroform to remove chlorophyll,
then rendered alkaline with dilute ammonia water,
and the alkaloids again extracted with chloroform.
The chloroform is evaporated, the alkaloidal resi-
due dissolved in dehydrated alcohol, evaporated
and dried at 100° until two successive weighings,
at one hour intervals, do not differ by more than
1 mg. This residue is dissolved in an excess of
0.02 N sulfuric acid, and the excess of acid titrated
with 0.02 N sodium hydroxide, using methyl red
or cochineal as indicator.

The LP. assay is identical with that of the B.P.
but at the point where the alkaloids are in hydro-
chloric acid solution, prior to alkalinization and
extraction with chloroform, the LP. permits an
alternative method of determining the alkaloids
by hydrolyzing the acid solution, after it has been
made alkaline with sodium hydroxide, so as to
yield tropic acid (see under Atropine) ; the aque-
ous solution is acidified, the tropic acid is ex-
tracted with a mixture of chloroform and iso-
propyl alcohol and, following evaporation of the
solvent, the acid is dissolved in water and titrated
with 0.02 N sodium hydroxide, using phenol-
phthalein indicator. Each ml. of 0.02 N sodium
hydroxide represents 5.788 mg. of alkaloids, calcu-
lated as hyoscyamine.

Uses. — For description of the physiological
and therapeutic actions of this, see under Bella-
donna Root, [v]

The dose of prepared or standardized bella-
donna leaf is from 30 to 200 mg. (approximately
Yz to 3 grains).

Storage. — Preserve in "well-closed contain-
ers." U.S.P.

BELLADONNA EXTRACT. N.F. (B.P.)

[Extractum Belladonnas]

"Belladonna Extract yields, from each 100 Gm.,
not less than 1.15 Gm. and not more than 1.35
Gm. of the alkaloids of belladonna leaf." N.F.

The B.P. Dry Extract of Belladonna contains
1.0 per cent (limits 0.95-1.05) of the total alka-
loids of belladonna leaf calculated as hyoscyamine.

B.P. Dry Extract of Belladonna; Extractum Bella-
donna Siccum. Extract of Belladonna Leaves. Fr. Extrait
de belladone. Ger. Tollkirschenextrakt. It. Estratto idro-
alcoolico di belladonna. Sp. Extracto de belladona.

The N.F. recognizes this extract in two forms,
Pilular Extract and Powdered Extract, so that
the pharmacist may select the form best suited
for dispensing. The pilular extract is used officially
in the ointment. Both forms of the extract, how-
ever, are of the same strength. The B.P. recog-
nizes only the "dry" extract.

Pilular Belladonna Extract. — Prepare the

extract by percolating 1000 Gm. of belladonna
leaf, using a menstruum of 3 volumes of alcohol
and 1 volume of water. Macerate the drug during
16 hours, then percolate at a moderate rate.
Evaporate the percolate to a pilular consistence
under reduced pressure at a temperature not over
60°, and adjust the residue, by addition of liquid
glucose, so that the finished extract contains 1.25
Gm. of belladonna leaf alkaloids in 100 Gm. of
extract. N.F.

Powdered Belladonna Extract. — Prepare the
extract by percolating 1000 Gm. of belladonna
leaf, using alcohol as the menstruum. Macerate
the drug during 16 hours, then percolate slowly.
Evaporate the percolate to a soft extract under re-
duced pressure at a temperature not over 60°, add
50 Gm. of dry starch, and continue evaporation
until a dry product results. Powder the residue
and adjust it to contain, by the addition of suffi-
cient starch, 1.25 Gm. of belladonna leaf alkaloids
in 100 Gm. of extract. The extract may be de-
prived of fat by treating either the soft extract
first obtained, or the dry and powdered extract, as
directed under Extracts. N.F.

The B.P. percolates the moderately coarse
powder of belladonna herb with 70 per cent alco-
hol. The percolate is tested for the amount of
alkaloids and also for the proportion of total
solids. To the remaining percolate is added slightly
less than the amount of finely ground belladonna
herb (which has been assayed for its alkaloidal
content) required to produce a dry extract con-
taining 1 per cent of alkaloids. The solvent is re-
moved under reduced pressure at a temperature
not exceeding 60°. The residue is dried in a cur-
rent of air at 80°, powdered, the remainder of the
belladonna herb added, and the whole is passed
through a No. 22 sieve and mixed.

Uses. — There is no difference in the thera-
peutic effects of pilular and powdered belladonna
extracts. The former may be used in the prepara-
tion of pills or ointments, the latter in powders,
capsules or tablets. For conditions in which these
extracts are useful, see under Atropine.

The usual dose is 15 mg. (approximately K
grain), with a range of 10 to 40 mg. (approxi-
mately % to % grain).

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 30°." N.F.

Off. Prep. — Belladonna Ointment; Aloin,
Belladonna, Cascara and Podophyllum Pills, N.F.

BELLADONNA LEAF FLUID-
EXTRACT. N.F.

Fluidextractum Belladonna: Folii

Belladonna Leaf Fluidextract yields, from each
100 ml., not less than 270 mg. and not more than
330 mg. of the alkaloids of belladonna leaf." N.F.

Liquid Extract of Belladonna Leaf. Extractum Bella-
donna: Folii Liquidum; Extractum Belladonnas Fluidum.
It. Estratto fluido di belladonna.

Prepare the fluidextract from belladonna leaf,
in moderately coarse powder, either by Process A,
as modified for assayed fluidextracts, or by Proc-
ess E (see under Fluidextracts). By Process A
use a menstruum of 3 volumes of alcohol and 1
volume of water; macerate the drug during 48

144 Belladonna Leaf Fluidextract

Part I

hours, and percolate at a moderate rate. By Proc-
esa E use a menstruum of 2 volumes of alcohol
and 1 volume of water; macerate 1000 Gm. of
the drug with 400 ml. of menstruum, allow to
stand 1 hour, pack into a cylindrical percolator or
a series of percolators having a length about 30
times the diameter, saturate the drug with men-
struum under 6 to 15 pounds air pressure and
macerate during 48 hours, then percolate under
pressure at a rate of about 1.5 ml. per minute
until 950 ml. have been collected. In either case,
adjust the liquid to contain 300 mg. of belladonna
leaf alkaloids in 100 ml. and 60 per cent, by vol-
ume, of C2H5OH. X.F.

Alcohol Content. — From 57 to 63 per cent,
by volume, of C2H5OH. X.F.

This preparation is, fortunately, little used in
the United States. Its potency is relatively great
and. since only very small volumes would be used
in the usual prescription mixture, a potentially
large variation in dosage may arise unless extra
care is taken to insure accuracy of the volume
measured. The tincture lends itself to greater
accuracy, and precision, of measurement.

The official usual dose of the X.F. preparation
is 0.06 ml. (approximately 1 minim).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or excessive heat." X.F.

BELLADONNA OINTMENT. N.F.

Unguentum Belladonnas

''Belladonna Ointment yields not less than 0.110
per cent and not more than 0.140 per cent of the
alkaloids of belladonna leaf.*' X.F.

Pomatum cum Extracto Belladonnas; Pomatum Bella-
donna;. Fr. Pommade belladonee. Ger. Tollkirschen-
salbe. It. Unguento di belladonna; Pomato di belladonna.
Sp. Pomade de belladona; Ungilcnio de Beiladona.

Triturate 100 Gm. of pilular belladonna extract
with 50 ml. of diluted alcohol until a smooth mix-
ture is obtained, then incorporate it with 850 Gm.
of yellow ointment. X.F.

Belladonna ointment is a convenient form for
the external application of belladonna. The most
important use of the ointment is as a local appli-
cation in hemorrhoids. Formerly it was used to
check secretion of breast milk but at present the
estrogens_have replaced belladonna for this
purpose. v.

Storage. — Preserve "in tight containers and
avoid prolonged exposure to temperatures above
30°." X.F.

BELLADONNA TINCTURE.
U.S.P. (B.P.. I.P.i

Belladonna Leaf Tincture, Tinctura Belladonnae

"Belladonna Tincture yields, from each 100 ml.,
not less than 2 7 mg. and not more than 33 mg.
of the alkaloids of belladonna leaf." U.S.P. The
B.P. requires 0.03 per cent w v of the alkaloids
of belladonna herb (leaf), calculated as hyos-
cyamine (limits. 0.028 to 0.032). The corre-
sponding LP. limits are 0.02 7 and 0.030 per cent,
respectively.

B.P. Tincture of Belladonna. Tincture of Belladonna
Leaves. Tinctura Belladonnae Foliorum. Fr. Teinture de
Belladone. Ger. Tollkirschentinktur. It. Tintura di bella-
* donna. Sp. Tintura de belladona.

Prepare the tincture, by Process P, as modified
for assayed tinctures (see under Tinctures), from
100 Gm. of belladonna leaf, in moderately coarse
powder, using a menstruum of 3 volumes of alco-
hol and 1 volume of water. Adjust the volume
of the product so as to contain 30 mg. of bella-
donna leaf alkaloids in 100 ml. of tincture. U.S.P.

The B.P. prepares the tincture from 100 Gm. of
belladonna herb (leaf; by percolation with 70 per
cent alcohol to produce 1000 ml. of percolate
which is diluted, if necessary, to a preparation of
the required strength.

Alcohol Content. — From 65 to 70 per cent,
by volume, of C2H5OH. U.S.P.

The usual dose is 0.6 ml. (approximately 10
minims) three times a day, with a range of 0.3
to 2.4 ml. The maximum single dose is 2.4 ml. and
not more than 10 ml. should be given in 24 hours.

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." U.S.P.

BELLADONNA ROOT. X.F, B.P, IP.

Deadly Nightshade Root, Belladonnae Radix

"Belladonna Root is the dried root of Atropa
Belladonna Linne (Fam. Solanacece). Belladonna
Root yields not less than 0.45 per cent of the
alkaloids of Belladonna Root." X.F.

The B.P. and LP. recognize the dried root, or
or root and rootstock of Atropa belladonna L.. or
of Atropa acuminata Royle ex Lindley or of a
mixture of both species; not less than 0.40 per
cent of alkaloids, calculated as hyoscyamine. is
required.

Fr. Racine de belladone. Ger. Tollkirschenwurzel; Bella-
donnawurzel ; Tollwurz. It. Radice di belladonna. Sp. Raiz
de belladona.

Atropa Belladonna is an herbaceous perennial,
with a fleshy root system, from which rise sev-
eral erect, round, purplish, branching stems, to
the height of about three feet. The leaves, which
are attached by short footstalks to the stem, are
alternate, broadly ovate to ovate, pointed, entire,
of a dusky green on their upper surface, and paler
beneath. The flowers are large, tubular-bell-
shaped, axillary, pendant, of a brownish-purple
color, with solitary peduncles. The fruit is a sub-
globular berry with a longitudinal furrow, at first
green, afterward red, ultimately deep purple to
black and containing, in two loculi, numerous
seeds and a sweetish violet-colored juice. The
5-cleft calyx adheres to the base of the fruit.

The plant is a native of central and southern
Europe, where it grows in shady places, along
walls, and amid rubbish, flowering in June and
July, and ripening its fruit in September. It grows
vigorously under cultivation in England. France
and the United States. For a number of years
there has been very great interest in the cultiva-
tion of belladonna in the United States. This in-
terest has been intensified in recent years owing
to the greatly reduced imports from abroad, as
the result of the World Wars, and considerable
quantities are now produced in this country.
Plants cultivated in California are very rich in
active constituents. The yield per acre of stems
and leaves is somewhat less than one ton. The ex-

Part I

Belladonna Root

145

periments in California seemed to show that the
alkaloidal content of belladonna stems may equal
that of the leaves, ranging from 0.51 to 0.82 per
cent of total alkaloids. Belladonna leaves grown
in the shade are uniformly larger, though some-
what thinner. It is quite likely that the percent-
age of alkaloids can be increased through selection.

All parts of the plant are active. The leaves
and roots, including branches (which are prob-
ably not less effective when young), are recog-
nized in the official compendia of the United
States and Great Britain. The leaves should be
collected in June or July, when the plant is in
flower, the roots in the autumn or early in the
spring, and from plants three to four years old.
Leaves which have been kept long should not be
used, as they undergo change through absorption
of atmospheric moisture, emitting ammonia, and
probably losing a portion of their active alkaloids.
Todd (Pharm. J., 1930, 124, 94) has shown that
loss of alkaloid in the leaves does not take place
to any extent during careful drying, but if the
drying process is unduly prolonged, up to one-
fifth of the total alkaloid may disappear. Enzymes
appear to be the causative agents in this loss.
E. Kopp {Pharm. Zentr., 1931, 72, 113) found
that wild and cultivated belladonna plants had
the same alkaloidal content when dried in the sun
as when dried in the shade. Specimens which con-
tain much stem or are musty should always be
rejected, as weak in active principle.

Both herb and root drugs are obtained for the
most part from plants cultivated in the United
States, central Europe and England. A total of
125,394 pounds of belladonna was imported into
the U. S. A. during 1940 and only 12,387 pounds
in 1952. During and since World War II most of
the belladonna leaf and root drugs used in this
country have been obtained from plants culti-
vated in the U. S. A. and some of the American-
grown Belladonna is exported to Europe.

Atropa lutes cens Jacquem. more properly
Atropa acuminata Royle, or Indian Belladonna,
is not generally recognized as a good species by
botanists (see Index Kewensis, also Hooker's
Flora of British India, 4, 241). It grows in the
Himalaya Mountains from Kashmir to Simla.

Two names have been given the plant yielding
Indian belladonna, the earlier, Atropa acuminata
Royle, having been applied to it by Royle in his
"Illustrations of the Botany of the Himalaya"
1839, 279. No description accompanied it and
hence Royle's name is a nomen nudum. However,
Lindley, in /. Hort. Soc. Lond. (1846), validated
Royle's name by giving a brief description of
A. acuminata plants raised in the Society's garden
in 1845 from seeds collected at Kumaun, India,
in 1844.

The name Atropa lutescens Jacquem. appeared
in manuscripts of Jacquemont and was used by
Aitchison in his account of the flora of Kurrum
Valley (/. Linn. Soc, 1881, 18, 82) and some
other writers. Clarke, in Hooker f., Flora of
British India, 1885, 4, 241, cited A. lutescens
Jacquem. Mss. as well as A. acuminata Royle
as synonyms for A. Belladonna L. The Index
Kewensis also equates A. lutescens and A. acu-
minata to A. Belladonna L. Youngken and Hassan

showed that the A. acuminata is only a variety
of A. Belladonna and named it Atropa Belladonna
L. var. acuminata (for details see /. A. Ph. A.,
1948, 37, 450).

Melville (/. Botany, 1942, 80, 54) investigated
the botanical source of Indian belladonna and
found the leaves of Atropa acuminata to be ovate
elliptic to elliptic lanceolate, acuminate, with a
gradually tapering base, as contrasted with the
ovate acute to acuminate leaves of A. Belladonna
which are stated to have a typically abruptly
rounded base. He also found the general direc-
tion of the main lateral nerves made a more acute
angle with the midrib in A. acuminata than in
A. Belladonna. Comparing the second and third
lateral nerves from the base of the leaf, the
angles were found to be about 30-45° in A. acu-
minata and 60-75° in A. Belladonna.

Corfield, Kassner and Collins investigated some
of the macroscopical characters and the alkaloidal
content of Indian belladonna (Atropa acuminata).
They found that on home-grown plants the leaves
were oblong-elliptical, tapering gradually at both
the apex and base, and on the flowering tops they
were more pointed at the apex and less tapering
at the base, that the flower was yellow to slightly
greenish yellow, its corolla campanulate to funnel-
shaped, and the ripe fruit black. The first year
rootstock was found to be hard and woody, the
dried root wrinkled longitudinally, tough, and not
breaking with a short mealy fracture. For home-
grown plants, the total alkaloid by weight after
heating on a water-bath for 30 minutes was found
to be, for leaves and flowering tops, 0.456 per
cent, and for root, 0.613 per cent (for further
details see Quart J. P., 1943, 16, 108). Youngken,
Sr., found branches bearing brownish purple and
yellow flowers and both black and yellow fruits
on the same plants of Atropa Belladonna he had
under cultivation at Jamaica Plain, Mass.

According to Rowson (Chem. Drug., 1943, 140,
150), the leaves of Atropa lutescens (A. Bella-
donna var. acuminata) can be readily distinguished
microscopically from those of A. Belladonna,
even in powdered form, by the stomatal index of
the lower epidermis, it being 21.6 for A. Bella-
donna, the standard deviation from the mean
being 1.30, and 17.6 for A. lutescens, the stand-
ard deviation from mean being 0.71.

Bulgarian belladonna root, which has received
considerable publicity during recent years and
which has been used in the forms of a decoction
and a wine in the treatment of parkinsonian syn-
drome, does not differ structurally from ordinary
belladonna root grown in other countries. Bailey
(Pharm. J., 1938, 140, 77) did not find any dif-
ference in chemical constituents.

Description. — "Unground Belladonna Root is
cylindrical or tapering, slightly branched, often
split longitudinally or broken transversely; from
0.5 to 4 cm. in thickness; weak brown to mod-
erate yellowish brown externally, light yellowish
brown to pale yellow internally; somewhat
wrinkled longitudinally, the soft periderm being
frequently abraded. The fracture is short and
mealy, emitting a puff of dust consisting chiefly
of starch grains. Belladonna Root is nearly odor-
less when dry but has a characteristic odor when

146

Belladonna Root

Part I

moistened; it has a sweet, then bitter and acrid
taste." N.F. For histology see N.F. X.

"Powdered Belladonna Root is pale brown to
weak yellow. It contains numerous simple and
compound starch grains, the single grains up to
30 n in diameter and showing a distinct, some-
what eccentric hilum, the polarizing bands in-
creasing in distinctness in direct ratio to the size
of the grains; numerous sphenoidal microcrystals
from 3 to 10 fi in length; a few fragments of
vessels, tracheids and wood fibers and occasion-
ally long, thin-walled pericyclic fibers from bella-
donna stem. Old fibrous roots contain an excess
of lignified tissue." N.F.

Standards and Tests. — Belladonna root con-
tains not over 10 per cent of its stem-bases and
woody crowns, not more than 2 per cent of for-
eign organic matter other than stem-bases and
woody crowns, and not more than 4 per cent of
acid-insoluble ash. Neither acicular crystals of
calcium oxalate nor Vessels with diamond-shaped
bordered pits, indicative of the presence of Phyto-
lacca root, are seen. N.F.

Assay. — A sample of 10 Gm. of belladonna
root is assayed in the same manner as the leaf is
assayed. N.F. The B.P. and I. P. assays are the
same as these pharmacopeias respectively specify
for belladonna herb (leaf).

Constituents. — Belladonna contains members
of the group of solanaceous alkaloids. The latter
term, which may be applied to all alkaloids from
solanaceous plants, is generally limited to the fol-
lowing: Atropine and hyoscyamine (C17H23NO3),
apoatr opine and belladonnine (C17H21NO2), nor-
hyoscyamine and nor-atropine (C16H21NO3),
scopolamine or hyoscine (C17H21NO4), tropa-
cocaine (C15H19NO2), meteloidine (C13H21NO4),
and some recently discovered minor alkaloids.
Members of the group are esters of tropic, atropic,
benzoic, tiglic or other acid with a basic alcohol
tropine, nor-tropine, atropine, teloidine or sco-
pine (Henry, Plant Alkaloids, 1949).

The chief alkaloid of belladonna is hyoscyamine
with, possibly, some atropine being present. It is
questionable whether the optically inactive atro-
pine exists as such, or is produced by racemiza-
tion of the naturally occurring levorotatory-
hyoscyamine in the process of extraction (see
Gorio and Coty, Bull. sc. Pharmacol., 1921, 28,
545).

For a description of hyoscyamine and atropine
see under Atropine. Apoatropine is the anhydride
of atropine and is prepared by the action of
dehydrating agents upon atropine or hyoscyamine.
Hesse reported having isolated this alkaloid, under
the name atropamine, from belladonna root. Bella-
donnine, obtained naturally from henbane berries,
is an isomeride of apoatropine from which latter
it may be prepared by heating. Nor-hyoscyamine
is the demethylated derivative of hyoscyamine.
and has been found naturally in certain plants of
the Solanaceae. Nor-atropine, the demethylated
derivative of atropine, is obtained by racemiza-
tion of nor-hyoscyamine. For a discussion of the
other alkaloids mentioned above, see elsewhere
in this work.

Adulterants. — The usual adulterants of bella-
donna leaves are the leaves of Phytolacca and

Ailanthus and the leaves and tops of Solanum
nigrum and Scopola carniolica. Phytolacca leaves
may be detected by the presence of numerous
raphides as well as crystal sand. Scopola leaves
and tops show characteristic barrel-shaped reticu-
late tracheae as well as short calyx tubes, each
having a contained pyxis. Solanum nigrum or
black nightshade has ovate, wavy-toothed leaves
and a white rotate corolla. For distinction between
belladonna and scopola leaves see article by
Kraemer (Proc. A. Ph. A., 1908, p. 819). Guerin
and Guillaume describe the anatomical difference
in the leaves of belladonna, Phytolacca and
ailanthus (Bull. sc. Pharmacol., 1908, p. 213).

Belladonna root is not infrequently of inferior
quality because of the presence of large quanti-
ties of the stem-bases of the plant. The root is
sometimes adulterated with Phytolacca or sco-
pola. Rusby reported the presence of 25 per cent
of some inert root, apparently wild althea, or a
relative of that plant. Youngken reported the
main adulterants of belladonna root as roots of
Phytolacca decandra, unpeeled roots of Althaa
officinalis and rhizomes of Scopola carniolica.
Phytolacca roots possess a tough fibrous fracture
and exhibit in transverse sections series of con-
centric circles of open collateral fibrovascular
bundles; the diagnostic tracheas have diamond-
shaped bordered pores; as in the case of the
leaves, raphides and crystal sand are present.
Althea roots show numerous mucilage sacs,
sclerenchyma fibers, ellipsoidal starch grains and
a few rosettes of calcium oxalate. Scopola rhi-
zomes possess characteristic reticulate tracheae.

Scopola rhizome has been largely used by manu-
facturers of belladonna plasters in the place of
belladonna root.

Uses. — All parts of the belladonna plant are
poisonous. It is not uncommon in countries where
it grows wild for children to pick and eat the
berries, allured by their fine color and sweet taste.
The symptoms of belladonna poisoning are pre-
cisely the same as those of atropine poisoning.

The conclusion that the active principle of
belladonna is hyoscyamine, rather than atropine,
harmonizes with clinical experience which has
shown that, although qualitatively indistinguish-
able in its action from atropine, belladonna is
often efficacious in doses considerably smaller than
might be expected from its content of alkaloid if
the latter were atropine (see also Hyoscyamine
Hydrobromide) . For description of the physio-
logical and therapeutic properties of belladonna,
see under Atropine. An important use of bella-
donna alkaloids has been in the treatment of
Parkinson's disease (see monograph on Skeletal
Antispasmodic Compounds, in Part II).

In the past belladonna root preparations were
employed topically as in the following instances;
today they have little more than historic interest.
Rubbed upon the areola of the breast, belladonna
has been believed to arrest the secretion of milk
and was frequently employed in mastitis; its
utility is questionable. Spasmodic stricture of the
urethra, anal fissures and painful uterine affections
have been relieved through local use of the ex-
tract, either smeared upon bougies or adminis-
tered by injection or by suppositories. It was

Part I

Bentonite

147

claimed also to be useful in paraphimosis. The
inhalation of fumes from burning belladonna
leaves has been employed to relieve the asthmatic
paroxysm. For this purpose, 8 Gm. (approxi-
mately 2 drachms) of the leaves was smoked in
the form of a cigarette or in a pipe, or the
coarsely broken leaves, mixed with a little potas-
sium nitrate, ignited to smolder and emit dense
fumes to be deeply inhaled. ©

Dose. — The range of dose is 30 to 120 mg.
(approximately Yi to 2 grains).

Storage. — Preserve "against attack by in-
sects." N.F.

BELLADONNA ROOT FLUID-
EXTRACT. N.F. (B.P.)

Fluidextractum Belladonnas Radicis

"Belladonna Root Fluidextract yields, from
each 100 ml., not less than 405 mg. and not more
than 495 mg. of the alkaloids of belladonna root."
N.F. Liquid Extract of Belladonna of the B.P.
contains 0.75 per cent w/v of the alkaloids of
belladonna root calculated as hyoscyamine (limits
0.70 to 0.80).

B.P. Liquid Extract of Belladonna; Extractum Bella-
donnas Liquidum.

Prepare the fluidextract from belladonna root,
in coarse powder, by Process A, as modified for
assayed fluidextracts (see under Fluidextracts) ,
using a menstruum of 4 volumes of alcohol and
1 volume of water. Macerate the drug during 48
hours, and percolate at a moderate rate. Adjust
the liquid to contain 0.45 Gm. of belladonna root
alkaloids in 100 ml. and 69 per cent, by volume,
of C2H5OH. N.F.

Under the name of Liquid Extract of Bella-
donna, the B.P. recognizes a product of consider-
ably higher potency than the corresponding prep-
aration of the N.F. The B.P. liquid extract of
belladonna root is prepared by percolating 1000
Gm. of moderately coarse belladonna root with
80 per cent alcohol. A 400-ml. portion of the
percolate is reserved; the remainder is evaporated
to a soft extract under reduced pressure, and the
residue dissolved in the reserved portion. This
liquid is assayed for alkaloidal content, adjusted
to the proper strength, and, after standing at least
12 hours, filtered.

Alcohol Content. — From 66 to 71 per cent,
by volume, of C2H5OH. N.F.

Belladonna root fluidextract, having a reddish-
brown color, is markedly different in appearance
from belladonna leaf fluidextract, which is a deep
green; the N.F. fluidextract from the root also
contains half again as much alkaloid (0.45 per
cent w/v) as the corresponding N.F. preparation
from the leaf (0.3 per cent w/v). Belladonna root
fluidextract, even as the preparation from the
leaf, is little used internally. When called for on
a prescription special care must be observed to
measure accurately the volume required; because
this volume is small, as a rule, it is susceptible to
relatively large variation. The fluidextract is em-
ployed externally, for its supposed local anodyne
effect, in various liniment formulations. The
N.F. IX recognized Belladonna Liniment prepared

by dissolving 50 Gm. of camphor in sufficient
belladonna root fluidextract to make 1000 ml.

The official usual dose of the N.F. preparation
is 0.05 ml. (approximately Ya minim) ; the B.P.
formerly gave as the dose for its stronger prep-
aration 0.015 to 0.06 ml. (approximately Y to 1
minim) but the B.P. 1953 makes no mention of
a dose.

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

BELLADONNA PLASTER.

Emplastrum Belladonnas

N.F.

"Belladonna Plaster is a mixture of adhesive
plaster mass and an extract prepared from bella-
donna root, spread evenly upon fine cotton cloth
or other suitable backing material. The plaster
mass yields not less than 0.25 per cent and not
more than 0.30 per cent of the alkaloids of bella-
donna root. Each 100 square centimeters of the
spread plaster contains at least 2.5 Gm. of the
belladonna plaster mass." N.F.

Fr. Emplatre d'extrait de belladone. Get. Tollkirschen-
pflaster. Sp. Emplasto de belladona.

No method for preparing this plaster is given
by the N.F. ; for information concerning the
nature of the adhesive plaster mass which is used
in this preparation see under Plasters and Ad-
hesive Plaster.

Uses. — Although belladonna plaster is widely
used it is essentially an irrational preparation.
Sufficient of the active principle may be absorbed
through the skin to produce constitutional symp-
toms, but this is manifestly an uncertain and un-
satisfactory mode of obtaining the general effects
of belladonna and is never employed for this pur-
pose. The plaster is used purely as a local anodyne
in lumbago and other myalgias, but belladonna is
not an analgesic. Such benefit as has followed the
employment of belladonna plaster is probably
attributable more to the mechanical action of the
plaster than to the therapeutic effect of the bella-
donna. A popular type of belladonna plaster is one
in which capsicum is also present.

Storage. — Preserve "in well-closed containers
at a temperature which does not exceed 30°.
Protect it from direct sunlight." N.F.

BENTONITE. U.S.P., B.P.

[Bentonitum]

"Bentonite is a native, colloidal, hydrated alu-
minum silicate." U.S.P.

Wilkinite; Soap Clay; Mineral Soap. Sp. Bentonita.

Bentonite, so named because of its discovery
in the Fort Benton formation of the Upper
Cretaceous in Wyoming, was first described by
Knight in 1897, though it is said to have been
used at the posts of the Hudson Bay Company
as a detergent in the washing of woolen materials.
It is a clay mineral of the class of hydrous alumi-
num silicates but its composition is quite variable,
depending on the locality where it is mined. The
United States Geological Survey defined bentonite
as "a transported, stratified clay, formed by the

148

Bentonite

Part I

alteration of volcanic ash, shortly after deposi-
tion." Of the many available varieties of benton-
ite, that produced in the Black Hills region of
Wyoming and South Dakota is reported to be
of the highest quality; it is variously known as
northern bentonite, "true" bentonite, and sodium
bentonite, the last name referring to its contain-
ing somewhat more sodium than other bentonites
(though the content of NasO averages only about
2.5 per cent). The chief mineral constituent of
this variety is the mineral montmorillonite, hav-
ing the approximate formula H20.(Al203.Fe2C»3.-
3MgO).4Si02.nH20, and comprising about 90 per
cent of the bentonite. The remaining 10 per cent
consists of a feldspar, gypsum, the clay mineral
beidellite, calcium carbonate, remnants of altered
volcanic glass, some crystals of quartz, and a few
fragments of mica and of a manganese carbonate.
A relatively small, and variable, proportion of
the cations of bentonites are exchangeable by
certain other ions and it is possible to modify
bentonites by replacing the exchangeable cations
with others. These exchangeable cations have a
great deal to do with determining certain physi-
cal properties of bentonites, notably their hydra-
tion. A predominance of sodium in the exchange-
able cation fraction imparts a high degree of
hydration, while predominance of calcium results
in lowered degree of hydration. Barr and Guth
(J. A. Ph. A., 1951, 40, 9) prepared five different
cation-saturated (sodium, potassium, calcium,
magnesium, and hydrogen) bentonites from the
same sample of a natural bentonite by appro-
priate cation-exchange reactions (see further ref-
erence to a practical application under Uses).
Bentonite is chemically similar to kaolin and china
clay, but it differs physically from these in the
fineness of its particles, which gives it a greater
total surface area that is at least partly responsible
for its pronounced adsorptive capacity.

Bentonite is insoluble in water but when mixed
with eight to fourteen parts of the latter it swells
to produce a slippery paste resembling petroleum
jelly. The consistency of the gel may be regu-
lated by varying the amount of water added. Sus-
pensions containing smaller amounts of bentonite
are quite permanent, particularly if a fine-particle
variety of the clay is used. In aqueous suspen-
sions, the individual particles of bentonite are
negatively charged, this resulting in a strong at-
traction for positively charged particles and being
responsible for the ability of bentonite to clarify
such liquids as contain positively charged par-
ticles of suspended matter.

La Rocca and Burlage (/. A. Ph. A., 1945, 34,
302) demonstrated that the pH of the medium
in which bentonite is dispersed has a marked
effect on the stability of the suspension; above
about pH 7 the suspensions are considerably more
stable than below. They also confirmed an earlier
finding that bentonite, after washing with acid,
loses its suspending properties because of neu-
tralization of hydroxyl ions on the surface of the
bentonite. These hydroxyl ions appear to be essen-
tial for the formation of the large lattice-like
structure characteristic of bentonite magmas. For
other data on bentonite see Ewing et al. (J. A.
"Ph. A., 1945, 34, 129).

Description. — "Bentonite occurs as a very
fine, odorless, pale buff or cream-colored powder,
free from grit, and has a slightly earthy taste. Ben-
tonite is insoluble in water, but swells to approxi-
mately twelve times its volume when added to
water. It is insoluble and does not swell in
organic solvents." U.S.P.

Standards and Tests. — Gel formation. — A
mixture of 6 Gm. of bentonite and 300 mg. of
magnesium oxide is added, in divided portions,
to 200 ml. of water in a 500-ml. glass-stoppered
cylinder, and agitated thoroughly for 1 hour. A
100-ml. portion of the mixture is transferred to
a 100-ml. cylinder, and allowed to remain undis-
turbed for 24 hours: not more than 2 ml. of
supernatant liquid appears on the surface. Swell-
ing power. — A 2-Gm. portion of bentonite is
added, in divided portions, to 100 ml. of water in
a glass-stoppered cylinder, allowing each portion
to settle before adding the next. The mass at the
bottom of the container gradually swells until it
occupies an apparent volume of not less than
24 ml. Fineness of powder. — A suspension of 2
Gm. of bentonite in enough water to make 100 ml.
leaves no grit which can be felt with the fingers
when poured through a No. 200 standard mesh
sieve, the latter being thoroughly washed with
water. Loss on drying. — Not less than 5 per cent
and not more than 8 per cent, when dried at 105°
for 2 hours. pH. — The pH of a 2 per cent aqueous
suspension is between 9 and 10. U.S.P.

Uses. — Bentonite is used for many industrial,
pharmaceutical, and cosmetic purposes (see re-
view by Goodman, Arch. Dermat. Syph., 1944,
49, 264). The better grades are excellent for
stabilizing many varieties of industrial emulsions
and other dispersions, such as of latex, various
oils and waxes, asphalt, etc. It exerts detergent
effects, being used in soaps, dentifrices, shaving
creams, and cleaners. Turbid waters and many
other liquids can be clarified with bentonite, and
it has marked adsorptive powers for dyes and
other coloring matter.

Bentonite is utilized in the preparation of a
number of pharmaceutical preparations for ex-
ternal use. Griffon (/. pharm. chim., 1938, 27,
159) prepared bentonite gels of yellow mercuric
oxide, mercury, zinc oxide, calomel, sulfur, coal
tar, etc., simulating the pomades of the French
Codex but differing from these in not having a
fatty base. Bentonite has been used as a facial
pack for cosmetic purposes, and as an adherent
dressing or an adsorbent powder in dermatology.
Fantus and Dyniewicz (/. A. Ph. A., 1938, 27,
878) were able to reduce the rapid sedimentation
rate of calamine lotion by incorporating ben-
tonite in the formula. They incorporated bentonite
also in other dermatological formulas (ibid., 1939,
28, 548). Hubbard and Freeman (/. A. Ph. A.,
Prac. Ed., 1941, 2, 78) employed a 6 per cent
stock suspension of bentonite in effecting emulsi-
fication of troublesome olive oil and lime water
mixtures, and also in producing improved dis-
persions of such substances as bismuth subnitrate,
zinc oxide, sulfur, camphor, etc. Both oil-in-water
and water-in-oil emulsions were prepared. When
using bentonite it is essential that it be added to
water and thoroughly agitated, preferably with

Part I

Benzaldehyde 149

an electric mixer, to permit maximum hydration;
water should not be added to bentonite.

Kulchar (Arch. Dermat. Syph., 1941, 44, 43)
found a 15 per cent suspension of bentonite in
water to be a satisfactory base, particularly for
formulations to be used in the treatment of
dermatitis and pruritus of the anogenital area.
The bentonite base dries to a film which keeps
the medication in situ. Salicylic acid, ichthammol,
ammoniated mercury, resorcinol, sulfur, Naf talan,
coal tar, Peru balsam, and juniper tar were in-
corporated in the base.

Pillsbury, Sulzberger and Livingood (Manual
of Dermatology, 1942) indicated the multiple
utility of a powder containing 50 Gm. of zinc
oxide, 50 Gm. of talc, and 10 Gm. of bentonite
for preparing a lotion with water, for use as a
simple dusting powder in which antipruritic agents
may be incorporated, and for preparing an oint-
ment by addition of petrolatum to the powder.

Hopkins (/. Invest. Dermat., 1946, 7, 7)
treated over 500 cases of fungus skin disease and
allied conditions using a bentonite gel base (20
Gm. of bentonite, 15 Gm. of talc, 55 ml. of water,
5 ml. each of liquid petrolatum and glycerin, and
5 Gm. of white petrolatum) for various water-
soluble drugs and also for fatty acids, salicylic
acid, and other medicaments which may be dis-
solved in propylene glycol, alcohol, or other sol-
vent, prior to incorporation with the base. Sulfur,
ammoniated mercury, zinc oxide, and other in-
soluble powders were readily incorporated. Thin
layers only of base are to be applied, as harshly
acting granules may remain if thick layers are
used on intertriginous areas or wounds.

Hollander and McClenahan (ibid., 1948, 11,
127) devised emulsified ointment bases contain-
ing petrolatum and bentonite; their formulations
contained from 10 to 32 per cent of oil phase
and from 13 to 17 per cent of bentonite. Formulae
containing higher proportions of oil had greater
emollient properties and tended to dry less
readily. These investigators emphasized the non-
irritating character of the components and the
rare appearance of allergic skin reactions follow-
ing use of such ointment bases. The bases were
especially useful in treating diseases of the lower
extremities, the bentonite component absorbing
moisture and removing obnoxious debris from the
skin.

Barr and Guth (/. A. Ph. A., 1951, 40, 13),
taking advantage of the ability of bentonite to
exchange a portion of its cations, prepared five
different bentonites, saturated with sodium, po-
tassium, calcium, magnesium, and hydrogen ions,
respectively, and used these to prepare bases for
various ointments. These bases were found to be
superior to certain official fatty bases as carriers
for various anti-infective medicaments, judging
from results of tests utilizing the F.D.A. cup-
plate method for testing antiseptic ointments.
They observed that the hydrogen ion-saturated
bentonite produced ointment bases in which sulfa-
thiazole, ammoniated mercury, and phenol showed
greater antibacterial activity than when incor-
porated in bases containing any of the other
modified bentonite or the original bentonite from
which the modified forms were prepared.

In the form of a gel, bentonite has been used
as a bulk laxative. Among many other uses it has
also been employed as a carrier for barium sulfate
in a preparation administered internally for x-ray
delineation.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

BENTONITE MAGMA.

[Magma Bentoniti]
Sp. Magma de Bentonita.

U.S.P.

Sprinkle 50 Gm. of bentonite, in divided por-
tions, upon 800 ml. of hot purified water and
allow the mixture to stand, with occasional stir-
ring, for 24 hours to permit hydration of the
bentonite to be completed. Stir until a uniform
magma is obtained, add enough purified water to
make 1000 ml., and mix thoroughly. U.S.P.

This is a convenient form in which to have
bentonite available for immediate use as a sus-
pending and emulsifying agent (see under Ben-
tonite). As hydration of the bentonite is complete
in the magma, its maximum viscosity has been
attained and it will therefore be immediately
effective.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Calamine Lotion, U.S.P.; Chalk
Mixture, N.F.

BENZALDEHYDE.

Benzaldehydum

CeHs.CHO

N.F.

"Benzaldehyde contains not less than 98 per
cent of C7H60." N.F.

Benzoic Aldehyde; Artificial Essential Oil of Almond.
Oleum Amygdalarum yEthereum Artificiale. Fr. Aldehyde
benzoique. Ger. Benzaldehyd; Kiinstliches Bittermandelol.
Sp. Benzaldehido; Bencilal.

As pointed out elsewhere (see under Bitter
Almond Oil) benzaldehyde is one of the products
of the hydrolysis of amygdalin. The commercial
supply, however, is mostly obtained by synthesis.
It may be made from toluene by a variety of
processes. Thus, benzyl chloride, C6H5CH2CI,
obtained by the chlorination of toluene, yields
benzaldehyde when treated with water and a mild
oxidant. If toluene is chlorinated to benzal chlo-
ride, C6H5CHCI2, this is easily hydrolyzed in the
presence of either acid or lime to give benzalde-
hyde. It may also be prepared by the oxidation
of benzyl alcohol, C6H5CH2OH, as well as by
other processes.

Exposed to air, benzaldehyde rapidly oxidizes
to benzoic acid, the latter frequently contami-
nating benzaldehyde.

Description. — "Benzaldehyde is a colorless,
strongly refractive liquid, having an odor resem-
bling that of bitter almond oil, and a burning
aromatic taste. It is affected by light. Benzalde-
hyde dissolves in about 350 volumes of water,
and is miscible with alcohol, with ether, and with
fixed or volatile oils. The specific gravity of
Benzaldehyde is not less than 1.041 and not more
than 1.046." N.F.

Standards and Tests. — Refractive index. —

150 Benzaldehyde

Part I

Not less than 1.5440 and not more than 1.5465,
at 20°. Hydrocyanic acid. — No greenish blue color
or blue precipitate (the Prussian blue test) forms
within 15 minutes after mixing 0.5 ml. of benzal-
dehyde, 5 ml. of water, 0.5 ml. of sodium hy-
droxide T.S. and 0.1 ml. of ferrous sulfate T.S.,
warming gently, then acidifying slightly with
hydrochloric acid. Chlorinated compounds. — A
roll of copper gauze is heated in a Bunsen burner
to form a coating of copper oxide; a total of six
drops of benzaldehyde is ignited on the gauze and
the latter then heated in the outer edge of a
Bunsen flame. No green color, due to copper chlo-
ride vapor, should be seen in the flame. This test
is commonly known as the Beilstein test for halo-
gens. Nitrobenzene. — No purplish color is ob-
tained on treating benzaldehyde with zinc and
diluted sulfuric acid (whereby nitrobenzene, if
present, is reduced to aniline) and heating with
potassium dichromate T.S. AT.F.

Assay. — Benzaldehyde is assayed in the same
manner as this constituent is determined quanti-
tatively in Bitter Almond Oil. Each ml. of 1 N
sodium hydroxide represents 106.1 mg. of C7H6O.
N.F.

Uses. — Benzaldehyde is used chiefly as a
flavoring agent, having the aroma of bitter al-
monds without their poisonous qualities. While
not completely harmless, the toxic powers of
benzaldehyde are relatively feeble (Viehoever
and Mack, Am. J. Pharm., 1935, 107, 397).

The N.F. gives the average dose as 0.03 ml.
(approximately Yz minim), although it has no
recognized medicinal action.

Storage. — Preserve "in wTell-filled, tight, light-
resistant containers." N.F.

Off. Prep. — Compound Benzaldehyde Elixir,
N.F.

COMPOUND BENZALDEHYDE
ELIXIR. N.F.

[Elixir Benzaldehydi Compositum]

Dissolve 0.5 ml. of benzaldehyde and 1 Gm. of
vanillin in 50 ml. of alcohol; add 400 ml. of syrup,
150 ml. of orange flower water, and enough puri-
fied water, in portions and shaking the mixture
after each addition, to make 1000 ml. Filter the
product, if necessary, until it is clear. N.F.

Alcohol Content. — From 3 to 5 per cent, by
volume, of C2H5OH. N.F.

This elixir is used solely as a pleasant vehicle,
particularly for administering bromides.

Storage. — Preserve "in tight containers." N.F.

Off. Prep. — Three Bromides Elixir, N.F.

BENZALKONIUM CHLORIDE. U.S.P.

Alkyldimethyl-benzylammonium Chloride,
[Benzalkonii Chloridum]

"Benzalkonium Chloride is a mixture of alkyl-
dimethyl-benzylammonium chlorides of the gen-
eral formula, [C6H5CH2N(CH3)2R]C1, in which
R represents a mixture of the alkyls from CsHu
to C18H37. It contains, when calculated on the
anhvdrous basis, not less 97 per cent and not more
than 103 per cent of [C6H5CH2N(CH3)2R]C1."
U.S.P.

Zephiran Chloride (JWinthrop). Sp. Cloruro de Bengal-
konio.

The particular compound which Domagk, in
1935, called attention to in pointing out the anti-
septic and detergent properties of certain quater-
nary ammonium compounds was zephirol, now
called zephiran chloride, and assigned the title
benzalkonium chloride by the U.S.P.

Benzalkonium chloride possesses the structural
requirements (see also Benzethonium Chloride)
for a quaternary ammonium compound having
high germicidal activity, namely, the presence of
a long alkyl hydrocarbon chain, one short aro-
matic-substituted alkyl group (benzyl), and two
lower alkyl groups (methyl). The long alkyl
hydrocarbon chain is supplied by the fatty acids
of coconut oil; as the composition of coconut oil
is reasonably constant a uniform composition of
the product is assured.

Description. — "Benzalkonium Chloride occurs
as a white or yellowish white, amorphous powder,
or in the form of gelatinous pieces. It has an
aromatic odor, and a very bitter taste. Its solu-
tions are alkaline to litmus and foam strongly
when shaken. Benzalkonium Chloride is very solu-
ble in wrater, in alcohol, or in acetone. It is almost
insoluble in ether, and is slightly soluble in ben-
zene." U.S.P.

Standards and Tests. — Identification. — (1)
A white precipitate, soluble in alcohol, is pro-
duced on adding diluted nitric acid or mercuric
chloride T.S. to a 1 in 100 solution of benzal-
konium chloride. (2) Dissolve 200 mg. of ben-
kalkonium chloride in 1 ml. of sulfuric acid, add
100 mg. of sodium nitrate, and heat on a steam
bath for 5 minutes. Cool, dilute with water to
10 ml., add 500 mg. of zinc dust, and warm for
5 minutes on a steam bath. To 2 ml. of the clear
supernatant liquid add 1 ml. of 1 in 20 sodium
nitrite solution, cool in ice water, then add 3 ml.
of a solution of 500 mg. of betanaphthol in 10 ml.
of ammonia T.S. : an orange-red color is pro-
duced. (3) A solution of benzalkonium chloride
in dilute alcohol responds to tests for chloride.
Water. — Not over 15 per cent, wThen deter-
mined by the Karl Fischer method. Residue on
ignition. — Not over 0.2 per cent. Ammonium
compounds. — Ammonia is not evolved on heating
to boiling a mixture of 5 ml. of 1 in 50 solution
of benzalkonium chloride and 3 ml. of sodium
hydroxide T.S. U.S.P.

Assay. — To a solution representing 1 Gm. of
benzalkonium chloride buffered with sodium ace-
tate and acetic acid is added an excess of 0.05 M
potassium ferricyanide which precipitates the
ferricyanide of benzalkonium; after standing for
an hour the precipitate is filtered off and the
excess ferricyanide in an aliquot of the filtrate
estimated by oxidation of potassium iodide and
titration with 0.1 N sodium thiosulfate in the
presence of zinc sulfate. A blank titration is per-
formed on the potassium ferricyanide solution.
Each ml. of 0.05 M potassium ferricyanide repre-
sents 54.0 mg. of alkvldimethyl-benzylammonium
chlorides. U.S.P.

Incompatibilities. — Benzalkonium chloride is
a cationic detergent, i.e., one whose antiseptic

Part I

Benzalkonium Chloride

151

and detergent properties reside in the cation, and
as such is incompatible with any anionic detergent,
such as soap, in which the detergent effect is
exhibited by the anion. Soap should be completely
removed from tissue to which benzalkonium chlo-
ride solution is to be applied. Solutions of local
anesthetics, of epinephrine and of ephedrine, as
well as of most other substances with which
benzalkonium chloride is likely to come in con-
tact, are compatible with the antiseptic.

Uses. — Benzalkonium chloride is a powerful
and rapidly acting germicide for many pathogenic
nonsporulating bacteria and fungi. Solutions of
the substance have low surface tension (37.4
dynes per centimeter for a 1:1000 solution at
25.3°) and possess detergent, keratolytic and
emulsifying properties, all of which favor wetting
and penetration of surfaces to which they are
applied. In vitro tests demonstrated that Strepto-
coccus haemolyticus is killed in 10 minutes (but
not in 5 minutes) by a 1:40,000 solution at 20°,
and by a 1:95,000 solution at 37°; for Staphylo-
coccus aureus the corresponding dilutions are
1:20,000 and 1:35,000; for Eberthella typhosa
they are 1:20,000 and 1:70,000; and for Esche-
richia coli, 1:12,000 and 1:40,000 (see Dunn,
Proc. Soc. Exp. Biol. Med., 1936, 35, 427; ibid.,
1938, 37, 661; Am. J. Surg., 1938, 41, 268; also
Hoyt et al., Surgery, 1942, 12, 786). In the pres-
ence of serum the effective concentrations were
approximately 10 times greater. As with other
disinfectants it has little sporicidal activity. It is
less injurious to human leukocytes than are the
mercurial antiseptics (Herrell and Heilman, Am.
J. Med. Sc, 1943, 206, 221).

On the skin, under the usual conditions of use,
the disinfectant action of benzalkonium chloride
is not as great as has been generally supposed
(Price, Arch. Surg., 1950, 61, 23), principally
because residual soap on the skin inactivates
the detergent (see under Incompatibilities) . Thor-
ough rinsing of the area to which benzalkonium
chloride is to be applied, with water, will ma-
terially enhance its effectiveness. Price has demon-
strated that the "tincture" of benzalkonium chlo-
ride— in which the solvent is composed of 50 per
cent ethyl alcohol, 10 per cent acetone, and 40
per cent water — is not only a more effective skin
disinfectant than an aqueous solution of equal
concentration, but also is less affected by soap
than is the aqueous solution. The strongest dis-
infectant action, according to Price, is produced
by 1 per cent iodine in 70 per cent alcohol; the
next strongest is 70 per cent (by weight) alcohol
by itself; third is the tincture of benzalkonium
chloride. He suggests that the quaternary com-
pound may be as effective as iodine if dissolved
in 70 per cent alcohol.

Miller et al. {Proc. Soc. Exp. Biol. Med., 1943,
54, 174) reported that certain cationic antiseptics
of the type of benzalkonium chloride deposit an
invisible film on the skin which is difficult to re-
move. This film may be sterile on the outside but
underneath it the skin may hold viable bacteria;
it is readily removed by alcohol or by application
of an anionic detergent, such as soap.

Effective concentrations of benzalkonium chlo-

ride are relatively nonirritating — indeed they are
said to have an emollient action. A 1:1000 solu-
tion was given orally to guinea pigs as their only
source of fluid for months without harmful effect;
injections intraperitoneally of as much as 6 ml.
daily of the same solution for several months also
showed no apparent reaction. Single doses of 1.2
ml. of a 10 per cent solution per Kg. of body
weight produced little or no effect in rabbits when
injected subcutaneously or intraperitoneally; when
the dose was increased to 1.5 ml. per Kg. death
occurred in 24 hours due to local destruction of
tissue rather than systemic toxicity. In reporting
the death of a woman following artificial abortion
with benzalkonium chloride Arnold and Krefft
{Deutsche Ztschr. ges. gerichtl. Med., 1952, 41,
297) stated that in animals the substance is ex-
tremely toxic following intraperitoneal or intra-
venous injection. It produced, according to these
investigators, a curare-like effect with paralysis of
neuromuscular junctions of all striated muscles,
which effect was similar to that observed in the
woman. Extreme caution is advised by Arnold
and Krefft in using benzalkonium chloride for
washing body cavities, especially if the solution is
to be kept in place for a long time.

Aqueous or alcohol-acetone-water solutions of
benzalkonium chloride may be employed in nearly
all cases where skin and mucous membrane anti-
sepsis is required. Where the skin has been washed
with soap and water, careful rinsing with water,
then with 70 per cent alcohol, is to be followed
by application of the "tincture" of benzalkonium
chloride. Aqueous solutions of the antiseptic are
employed on areas where soap is not ordinarily
used or where alcohol would produce irritation.

The concentrations of benzalkonium chloride
recommended for the several uses to which it is
put are as follows: For preoperative disinfection
of unbroken skin or treatment of superficial in-
juries and fungous infections, the 1 :1000 tincture
is preferable; for preoperative disinfection of
mucous membranes and denuded skin, concentra-
tions from 1 : 10,000 to 1 :2000 may be employed;
for widely denuded areas, from 1 : 10,000 to
1 :5000 is better; for urinary bladder and urethral
irrigation, the concentration should not exceed
1:20,000; for retention lavage of the bladder, the
maximum strength is 1:40,000; for application to
the eye or the vagina, solutions ranging from
1:5000 to 1:2000 may be used. Therapeutic dis-
infection of deep lacerations may be effected with
the 1 : 1000 aqueous solution, but for irrigation of
infected deep wounds, the maximum concentration
should be 1:3000. For wet dressings solutions of
1 : 5000 or less are employed.

A 1:1000 solution of benzalkonium chloride is
an effective sterilizing agent for surgical instru-
ments when applied for 30 minutes; for storing
the sterile instruments a 1:5000 solution suffices
but it must also contain at least 0.1 per cent
sodium nitrite to prevent rusting of metal instru-
ments. Rubber articles may be similarly sterilized
and stored.

Benzalkonium chloride is available only under
the trade-marked name Zephiran Chloride, manu-
facture of the substance being protected by letters

152 Benzalkonium Chloride

Part I

patent. It is available in the form of a 1:1000
aqueous solution and a 12.8 per cent concentrated

leous solution (see Benzalkonium Chloride So-
lution), as an ophthalmic jelly 1:2000, and as a
tincture 1:1000, stainless or tinted.

Storage.— Preserved "in tight, light-resistant
containers." U.S. P.

BENZALKONIUM CHLORIDE
SOLUTION. U.S.P.

Liquor Benzalkonii Chloridi

"Benzalkonium Chloride Solution contains not
less than 93 per cent and not more than 107 per
cent of the labeled amount of benzalkonium chlo-
ride. It may be buffered by the addition of am-
monium acetate in a quantity not exceeding 40
per cent of the weight of the benzalkonium chlo-
ride. It may contain a suitable coloring agent."
U.S.P.

Sp. Solution de Cloruro 4e Benzalkonio.

Description.— "Benzalkonium Chloride Solu-
tion is a clear liquid, colorless unless a color has
been added. It has an aromatic odor, and a bitter
taste." U.S.P.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

Usual Sizes. — Aqueous solution 1:1000, 8 fl.
oz. and 1 gallon; concentrated 12.8 per cent solu-
tion, 4 fl. oz. and 1 gallon.

GAMMA BENZENE HEXA-
CHLORIDE. U.S.P, B.P.

Benzene Hexachloride, Hexachlorocyclohexane

CI CI

c"wCI

ci a

"Gamma Benzene Hexachloride is the gamma
isomer of hexachlorocyclohexane. It contains not
less than 99 per cent of CeHeCle." U.S.P.

The B.P. defines Gamma Benzene Hexachloride
as the Y-isomer of 1 :2:3:4:5:6-hexachlorocyc/o-
hexane and requires it to contain not less than
99.0 per cent of CeHeCle.

B.P. Gamma Benzene Hexachloride. Lindane. Gam-
mexane (Imperial Chemical Industries).

Benzene hexachloride was first prepared by
Michael Faraday in 1825, but it has been only
recently that the outstanding insecticidal prop-
erties of the gamma isomer were discovered by
British and French investigators. Prepared by the
interaction of chlorine and benzene, the product
benzene hexachloride consists of five isomers,
designated alpha, beta, gamma, delta, and epsilon;
these differ in the stereochemical configuration of
the chlorine atoms of the molecule. The isomers
may be fairly well separated by differences in
their solubility in various liquids. The gamma
isomer almost exclusively possesses insecticidal
activity; since it is present in the reaction prod-
ucts only to the extent of about 12 per cent it
must be separated from the other isomers to ob-
tain a product of maximum activity.

The name lindane was adopted by the U.S.
Department of Agriculture, Bureau of Entomol-
ogy and Plant Quarantine, to designate the gamma
isomer of 1,2,3,4,5, 6-hexachlorocyclohexane hav-
ing a purity of not less than 99 per cent.

Description. — "Gamma Benzene Hexachloride
is a white, crystalline powder having a slight,
musty odor. Gamma Benzene Hexachloride is
practically insoluble in water and is slightly solu-
ble in ethylene glycol. One Gm. dissolves in about
15 ml. of alcohol, in about 3.5 ml. of chloroform,
and in about 40 ml. of ether." U.S.P.

Standards and Tests. — Identification. — A
few mg. of benzene hexachloride is ignited, on a
clean copper wire, above the non-luminous flame
of a Bunsen burner; on subsequently holding the
wire in the flame a bright green color is imparted
to the flame. Loss on drying. — Not over 0.5 per
cent, when dried over phosphorus pentoxide at
60° at a pressure of 10 mm. of mercury for 4
hours. Chloride. — 100 mg. of benzene hexachlo-
ride is shaken with 10 ml. of water and the mix-
ture is filtered: on adding 1 ml. of nitric acid
and 3 ml. of silver nitrate T.S. to the filtrate no
turbidity develops. Limit of isomers. — The con-
gealing temperature is not less than 112.0°. U.S.P.
As a test for identification the B.P. directs that a
mixture of 1 ml. of 0.5 per cent alcoholic solution
of benzene hexachloride, 3 ml. of alcohol, and
1 ml. of alcoholic potassium hydroxide solution
shall show, after standing for 10 minutes, reac-
tions characteristic of chlorides.

Assay. — About 400 mg. of gamma benzene
hexachloride is warmed with alcohol to effect solu-
tion, then saponified with an alcoholic potassium
hydroxide, whereby trichlorobenzene is formed
and three chloride ions are released; the chlo-
ride is estimated volumetrically by the Yolhard
method. Each ml. of 0.1 N silver nitrate repre-
sents 9.695 mg. of CeHeCle. U.S.P.

Uses. — Both technical benzene hexachloride
and lindane are effective insecticides against the
same species that DDT kills except that the
former are toxic in smaller dose and in a shorter
period of time. They are employed in the same
kinds of formulations as DDT (see under Chloro-
phenothane). The objectionable off-flavor im-
parted to certain agricultural crops and processed
foods by the technical product and. to a lesser
extent, by lindane is a disadvantage of these
insecticides.

The pure gamma isomer of hexachlorocyclo-
hexane is of therapeutic interest because of its
effectiveness as a local application in the treat-
ment of scabies. Cannon and McRae (J.A.M.A.,
1948, 138, 557) and Kornblee and Combes (Arch.
Dermat. Syph., 1950, 61, 407) treated nearly two
hundred patients with scabies with a preparation
(Kwell, Commercial Solvents Corp.) containing
1 per cent of the gamma isomer in a vanishing
cream base; every patient was cured, with no
evidence of irritation or sensitivity except in one
patient. A few patients with pediculosis corporis
and pubis were also treated similarly, by Cannon
and McRae, with good results. Pflug (U. S. Armed
Forces Med. J., 1951, 2, 399) employed an
emulsion containing 1 per cent of the same sub-
stance as a more rapid means of applying the

Part I

Benzethonium Chloride

153

agent to military personnel afflicted with scabies.

Toxicology. — Technical benzene hexachloride
is about equal to DDT in acute toxicity to man
and other warm-blooded animals. The gamma
isomer is the most toxic of the isomers, being
about twice as toxic as DDT. It has been esti-
mated that approximately 600 mg. per Kg. of
body weight, or about an ounce of technical
benzene hexachloride containing 15 per cent of
the gamma isomer, could be fatal in a single dose
for an adult; the corresponding dose for the
gamma isomer is probably of the order of one-
quarter this amount. While the acute toxicity of
the beta isomer is about one twenty-fourth that
of DDT, the former plays the most important
role in chronic intoxication with technical ben-
zene hexachloride because it is stored in fat tissue
longer than are other isomers and it is also the
most stable of the isomers. For these reasons the
chronic oral toxicity of essentially pure gamma
isomer is not as great as that of the technical
product. Liver degeneration and nutritional dis-
turbances, however, have been induced in dogs
exposed to the gamma isomer over long periods
of time.

While cutaneous absorption of both oily and
aqueous suspensions of the gamma isomer have
resulted in fatalities in laboratory animals, it is
believed to be safe to apply the substance in 1 per
cent concentration to the skin, as in the treatment
of scabies, if prolonged or repeated applications
are avoided. The vapor and dust hazards of the
mixture of isomers appear to be of a low order.

Not only does the mode of action of technical
benzene hexachloride and its gamma isomer in
general resemble that of DDT, but the symptoms
of poisoning and its treatment are also essen-
tially the same for these insecticides; reference
should be made to the monograph on Chloro-
phenothane for this information. A detailed dis-
cussion of the pharmacology and toxicology of
technical benzene hexachloride and its principal
isomers mav be found in J.A.M.A., 1951, 147,
571.

Pure benzene hexachloride is applied topically
in 1 per cent concentration, in lotion or ointment
form.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

BENZETHONIUM CHLORIDE. U.S.P.

Benzyldimethyl{2-[2-(p-l,l,3,3-tetramethylbutyl-
phenoxy)ethoxy]ethyl}ammonium Chloride

On the basis of a study of a large group of
quaternary ammonium compounds for germicidal
activity Rawlins et al. (/. A. Ph. A., 1943, 43,
11) concluded that for pronounced activity it is
essential to have in the cation one long alkyl
hydrocarbon chain of 12 to 16 atoms (which
may, however, be modified by the inclusion of
an aromatic group and of one or more oxygen
atoms), one short aromatic-substituted alkyl
group (such as C6H5CH2— ), and two lower alkyl
groups (such as CH3— ). One such compound is
benzethonium chloride (note the structural
formula) .

Benzethonium chloride may be synthesized by
reacting />-£er£-octylphenol with .rym-dichloroethyl
ether in the presence of an alkaline condensing
agent; the product obtained in this reaction is
subsequently reacted with dimethylamine, the re-
sulting tertiary amine being converted to the
quaternary ammonium salt by treatment with
benzyl chloride. For further information see U.S.
Patent 2,115,250.

Description. — "Benzethonium Chloride occurs
as colorless crystals. It is odorless and has a very
bitter taste. Its 1 in 100 solution is slightly alkaline
to litmus. Benzethonium Chloride is soluble in
water, in alcohol, and in chloroform. It is only
slightly soluble in ether. Benzethonium Chloride,
dried at 105° for 4 hours, melts between 160°
and 165°." U.S.P.

Standards and Tests. — Identification. — (1)
A white precipitate, insoluble in diluted nitric
acid but soluble in diluted ammonia solution, is
produced on adding 2 ml. of alcohol, 0.5 ml. of
diluted nitric acid and 1 ml. of silver nitrate T.S.
to 1 ml. of 1 in 100 benzethonium chloride solu-
tion. (2) A 1 in 100 solution of benzethonium
chloride forms a precipitate with diluted nitric
acid, and with mercuric chloride T.S., both
soluble in alcohol. (3) Benzethonium chloride,
reacted with sulfuric acid and sodium nitrate, the
resulting nitro-derivative reduced with zinc and
diazotized with sodium nitrite, and finally coupled
with 2-napthol-6,8-sodium disulfonate (G salt),
produces an orange-red compound which may
change to a brown precipitate. Water. — The limit
is 5 per cent, when determined by drying at 105°
for 4 hours. Residue on ignition. — Not over 0.1
per cent. Ammonium compounds. — The odor of
ammonia is not perceptible when a mixture of
5 ml. of a 1 in 50 solution of benzethonium chlo-
ride and 3 ml. of sodium hydroxide T.S. is
boiled. U.S.P.

(CH3)3C-CH2C(CH3)2

-0--

CH2CH2-0-CH2CH2

■CHS

ci:h2o

"Benzethonium Chloride contains not less than
97 per cent and not more than 103 per cent of
C27H42CINO2.H2O." U.S.P.

Phemerol Chloride (Parke, Davis). Hyamine 1622 (Rohm
& Haas). ^-tcri-Octylphenoxyethoxyethyldimethylbenzylam-
monium Chloride.

Assay. — Benzethonium chloride is assayed,
using essentially the same procedure as for ben-
zalkonium chloride, by precipitating benzethonium
ferricyanide with a measured excess of 0.01 M
potassium ferricyanide, then determining the ex-
cess of the latter through liberation of iodine

154

Benzethonium Chloride

Part I

from iodide, followed by titration with 0.01 N
sodium thiosulfate. A residual blank titration is
performed. Each ml. of 0.01 M potassium ferri-
cvanide represents 13.98 mg. of CyrHiaClNOs.-
HjO. In the assay 3 moles of benzethonium chlor-
ide react with 1 mole of potassium ferricyanide,
the excess of which liberates Yi mole of iodine
to be titrated with 1 mole of sodium thiosulfate;
it is apparent from this relationship that the gram
equivalent weight of benzethonium chloride is 3
times its molecular weight. Each ml. of 0.1 M
potassium ferricyanide represents 13.98 mg. of
C27H42CIXO2.H2O. U.S.P.

Uses. — Benzethonium chloride was the most
active of a series of related quaternary ammonium
antiseptics studied by Rawlins et al. {loc. cit.).
Joslyn et al. (/. A. Ph., 1943, 32, 49; tested it by
the F.D.A. method on 8 different species of bac-
teria; these were killed, in 5 minutes, by strengths
ranging from 1 in 12,000 to 1 in 80,000, at 20°.
It was also strongly fungicidal, a 1 in 1000 solu-
tion killing actinomyces, trichophyton, monilia
and other fungi. Benzethonium chloride has come
into rather wide usage as a general germicide and
antiseptic; the most popular application forms
are a 1:1000 aqueous solution and a 1:500 tinc-
ture (alcohol-acetone solution).

Benzethonium chloride, in common with other
quaternary ammonium antiseptics, has the disad-
vantage that its activity is greatly lessened by
soap and a variety of organic substances, includ-
ing pus. Miller et al. (Proc. S. Exp. Biol. Med.,
1943, 54, 174) observed that this type of anti-
septic forms a thin, relatively tough, film on skin;
the film may be sterile on the outside but under-
neath it the skin may hold viable bacteria. An
advantage of benzethonium chloride is that its
germicidal activity increases with increase in pH;
at pH 10 it is several times as active against E.
typhosa and S. aureus as at pH 4. It has a low
order of acute or chronic toxicity against animals.
Herrell and Heilman {Am. J. Med. Sc, 1943,
206, 221) tested the toxicity to human leuko-
cytes of benzethonium chloride and benzalkonium
chloride; both were less injurious than mercurial
antiseptics.

In a preliminary study of the efficacy of quater-
nary ammonium compounds as molluscacides,
Vallejo-Freire et al. {Science, 1954, 119, 470)
found that a concentration of 10 parts per mil-
lion of Hyamine 1622 killed all Australorbis spe-
cies snails; since snails serve as the intermediate
host of Schistosoma the potential importance of
this property of quaternary ammonium com-
pounds is apparent.

A 1:1000 aqueous solution (uncolored), sup-
plied under the name Phemerol Chloride Solution,
is recommended as an antiseptic in preoperative
and postoperative care of wounds and infected
areas, also for application to accessible mucous
membranes of the gastrointestinal and genitour-
inary tracts. Phemerol Chloride Tincture is of
1:500 concentration, and contains alcohol and
acetone; it is recommended principally for prep-
aration of skin preoperatively (it is colored red)
and for antepartum preparation of obstetrical
patients. A 1:5000 ophthalmic solution, contain-
ing also 2 per cent of boric acid, is supplied for

use in ocular conditions where an antiseptic is
indicated.

The germicidal and detergent properties of
benzethonium chloride have found many sanita-
tion uses; for this purpose it is available in crys-
talline form, under the name Hyamine 1622. It is
recommended for sanitizing eating and cooking
utensils in restaurants, for similar use in dairies,
for control of obnoxious odors in public rest
rooms, for disinfectant use in laundering opera-
tions, for various veterinary germicidal uses, and
for control of growth of algae in swimming pools.
It is essential, of course, that it be used in proper
concentration for each of these purposes.

Methylbenzethonium Chloride, N.N.R. — A
derivative of benzethonium chloride in which a
methyl substituent is introduced in the benzene
ring of the phenoxy group, thereby forming a
cresoxy group, has found wide use, under the
name Diaparene chloride (Homemakers' Prod-
ucts), for bacteriostasis of urea-splitting organisms
which may be involved in diaper dermatitis.
Diaparene chloride is supplied in tablets contain-
ing 90 mg. of active ingredient; solution of 1 tab-
let in about 200 ml. of water produces a 1:25,000
solution for rinsing diapers.

Storage. — Preserve "in tight, light-resistant
containers." U.S. P.

BENZETHONIUM CHLORIDE
SOLUTION. U.S.P.

"Benzethonium Chloride Solution contains not
less than 93 per cent and not more than 107 per
cent of the labeled amount of C27H42CINO2.H2O."
U.S.P.

Description. — "Benzethonium Chloride Solu-
tion is a clear, colorless liquid. It is odorless and
has a bitter taste. It is slightlv alkaline to litmus."
U.S.P.

See the preceding article for concentration and
uses of this solution.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

BENZOIC ACID. U.S.P, B.P, LP.

[Acidum Benzoicum]

CeHs.COOH

"Benzoic Acid, dried over sulfuric acid for 3
hours, contains not less than 99.3 per cent of
C7H6O2." US. P. Both the B.P. and the LP. re-
quire not less than 99.5 per cent of C7H6O2;
preliminary' drying is not specified.

Phenylcarboxylic Acid; Phenylformic Acid; Flowers of
Benzoin; Flowers of Benjamin. Fr. Acide benrolque. Ger.
Benzoesauxe. It. Acido benzoico. Sp. Acido Benzoico.

Benzoic acid occurs both free and as esters in
various plants, especially balsams and resins, in
coal tar, and as hippuric acid (benzoylglycine) in
the urine of nearly all vertebrates. Formerly it
was obtained from benzoin, and from the hippuric
acid of horse urine; today it is probably entirely
prepared by synthesis. One commercial process
utilizes benzotrichloride, C6H5CCI3, as the start-
ing compound; this is hydrolyzed with lime, using
iron as a catalyst, and yields benzoic acid upon
acidification. Another commercial method in-

Part I

Benzoic and Salicylic Acid Ointment 155

volves decarboxylation of phthalic acid, CeBU-
(COOH)2, at a temperature of 2 75 to 300° C. in
the presence of a catalyst. Benzoic acid may also
be prepared by many other reactions, such as
oxidation of toluene with manganese dioxide and
sulfuric acid, oxidation of benzaldehyde or benzyl
alcohol, hydrolysis of benzonitrile, etc.

For methods of purifying benzoic acid so as to
obtain a product containing as much as 99.999
mole per cent of the acid, see Schwab and Wichers
(/. Research Natl. Bur. Standards, 1940, 25, 747).

Description. — "Benzoic Acid occurs as white
crystals, usually as scales or needles. It is odor-
less, or it may have a slight odor of benzaldehyde
or of benzoin. It is somewhat volatile at moder-
ately warm temperatures, and is freely volatile
in steam. One Gm. of Benzoic Acid dissolves in
275 ml. of water, in 3 ml. of alcohol, in 5 ml. of
chloroform, and in about 3 ml. of ether. One Gm.
of the Acid dissolves in 20 ml. of boiling water,
and in 1.5 ml. of boiling alcohol. It is soluble in
fixed and in volatile oils and is sparingly soluble
in petroleum benzin. Benzoic Acid melts between
121° and 123°." U.S.P.

Standards and Tests. — Identification. — Ben-
zoic acid responds to tests for benzoate. Residue
on ignition. — Not over 0.05 per cent. Chlorinated
compounds. — 500 mg. of benzoic acid is ignited in
the presence of calcium carbonate, the residue dis-
solved in nitric acid and silver nitrate solution
added: the turbidity is no greater than that pro-
duced by 0.6 ml. of 0.02 N hydrochloric acid in a
control test. Heavy metals. — The limit is 20 parts
per million. Readily carbonizable substances. — A
solution of 500 mg. of benzoic acid in 5 ml. of
sulfuric acid has no more color than matching
fluid Q. Readily oxidizable substances. — A hot,
acid solution containing 1 Gm. of benzoic acid
requires not more than 0.5 ml. of 0.1 iV potassium
permanganate to produce a pink color persisting
for 15 seconds. U.S. P. The B.P. and I.P. both
specify an arsenic limit of 2 parts per million and
a lead limit of 5 parts per million.

Assay. — A sample of about 500 mg. of benzoic
acid, previously dried over sulfuric acid for 3
hours, is dissolved in diluted alcohol which has
been neutralized to phenolphthalein indicator and
the solution titrated with 0.1 N sodium hydroxide.
One-fifth of the volume of 0.02 N hydrochloric
acid used in the test for chlorinated compounds
is subtracted from the volume of 0.1 N alkali
consumed. Each ml. of 0.1 N sodium hydroxide
represents 12.21 mg. of C7HGO2. U.S.P.

In the B.P. and I.P. assays a sample of 2.5
grams is titrated with 0.5 N sodium hydroxide
using phenol red as indicator. No correction is
made for the presence of chlorinated compounds.

Uses. — When benzoate ion is ingested it com-
bines with aminoacetic acid and appears in the
urine chiefly as hippuric acid. This conversion
takes place in the liver. Therapeutic doses of
benzoic acid have practically no effect on the
elimination of either urea or uric acid, although
both Denis (/. Pharmacol., 1915, 7, 601) and Ter-
roine (Arch, internat. pharm., 1939, 63, 300) had
reported that the output of uric acid is increased
after large doses. Benzoic acid is so irritant that

it cannot be administered internally without severe
gastric irritation, although the neutral benzoates
are tolerated well in doses of 6 Gm. or more (see
Sodium Benzoate). It was a popular ingredient
in many of the supposedly antiseptic mouth
washes. For a discussion of the use of benzoic acid
as a food preservative see Sodium Benzoate.

Benzoic acid is actively germicidal. Goshorn
and Degering (Ind. Eng. Chem., 1938, 30, 646)
found that at a pH of 3.5, a 1 in 800 solution will
kill in an hour both the colon bacillus and the
staphylococcus; at a pH of 5, however, it is not
a certain bactericide in strengths of even 1 in 20;
at the latter pH it will, however, inhibit bacterial
growth in 1 in 3000 solution. Rahn and Conn
(Ind. Eng. Chem., 1944, 36, 185) concluded that
the antiseptic activity of benzoic acid resides
chiefly, if not exclusively, in the non-ionized por-
tion because it is difficult for ions to permeate
living cell membranes.

A combination of benzoic and salicylic acids,
as in Whitfield's ointment, possesses fungistatic
and fungicidal properties. Exfoliation of the
upper layers of the skin is produced by kerato-
lytic action; hyperemia is also induced. In super-
ficial dermatomycoses the fungi are cast off with
the stratum corneum and the hyperemia aids in
the destruction of the parasite (Wise and Wolf,
J. A.M. A., 1936, 107, 1126). Goodman (Arch.
Dermat. Syph., 1944, 49, 16) emphasized the
relative lack of importance of the benzoic acid in
this combination; the appropriate keratolytic or
keratoplastic action is secured by selection of
the proper concentration of salicylic acid. Bern-
heim and Mulinos (/. Pharmacol., 1932, 44, 81)
reported that the benzoates act like the salicylates
in lessening the inflammatory reaction to the local
application of oil of mustard. E

If given by mouth, the dose is 0.6 to 2.0 Gm.
(approximately 10 to 30 grains).

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep. — Acacia Mucilage; Starch Glycer-
ite, U.S.P.; Camphorated Opium Tincture,
U.S. P., B.P.; Aminoacetic Acid Elixir; Benzoic
and Salicylic Acid Ointment; Tragacanth Muci-
lage, N.F.

BENZOIC AND SALICYLIC ACID

OINTMENT. U.S.P.

Whitfield's Ointment, [Unguentum Acidi
Benzoici et Salicylici]

Compound Ointment of Benzoic Acid.

Finely powder 60 Gm. of benzoic acid and 30
Gm. of salicylic acid, and incorporate these with
a portion of polyethylene glycol ointment until a
smooth, homogeneous mixture is obtained, after
which sufficient of the same ointment base is
added to make the product weigh 1000 Gm.
U.S.P.

It is to be noted that this new formula con-
tains half the concentration of benzoic acid and
salicylic acid represented in the formerly official
formula; also, the base has been changed from a
mixture of wool fat and white petrolatum to

156 Benzoic and Salicylic Acid Ointment

Part I

polyethylene glycol ointment, which is water-
soluble.

Uses. — Whitfield's ointment is a useful and
popular local application for treatment of super-
ficial fungous infections of the skin; the new half-
strength ointment is the one which was most fre-
quently used for at least the initial therapy of the
common type of ringworm. In chronic, hyper-
keratotic stages of the disease the stronger oint-
ment (representing 12 per cent of benzoic acid
and 6 per cent of salicylic acid) may be beneficial.
Whitfield's ointment is not indicated in the acute,
weeping or vesicular stage of dermatophytosis.

Storage. — Preserve "in tight containers, and
avoid prolonged exposure to temperatures above
30°." U.S.P.

BENZOIN. U.S.P., B.P.

Benzoinum

"Benzoin is the balsamic resin obtained from
Styrax Benzoin Dryander or Styrax parallelo-
neurus Perkins, known in commerce as Sumatra
Benzoin, or from Styrax tonkinensis (Pierre)
Craib ex Hartwich, or other species of the Section
Anthostyrax of the genus Styrax, known in com-
merce as Siam Benzoin (Fam. Styracece). Suma-
tra Benzoin yields not less than 75 per cent of
alcohol-soluble extractive. Siam Benzoin yields
not less than 90 per cent of alcohol-soluble ex-
tractive." U.S.P.

The B.P. limits the source of benzoin to Styrax
benzoin Dryand. and Styrax paralleloneurum
Perkins, known in commerce as Sumatra benzoin.

Gum Benjamin; Benzoe; Resina Benzoe; Asa Odorata;
Asa Dulcis. Fr. Benzoin du Laos, dit de Siam. Ger.
Benzoe; Benzoeharz; Siam-benzoe. It. Benzoino; Bel-
gioino. Sp. Benjui.

Styrax Benzoin, or Benjamin tree, is a tall tree
of quick growth, sending off many strong round
branches, covered with a whitish downy bark. Its
leaves are alternate, entire, oblong, pointed,
smooth above and stellate-tomentose beneath.
The flowers are in compound, axillary clusters,
nearly as long as the leaves, and usually hang, all
on the same side, upon short slender pedicels.
The tree is a native of Sumatra, Java, Borneo,
and other islands in the vicinity. Strueff described
the morphology of trees of Styrax Benzoin,
growing in Siam, Sumatra and Java, in Arch.
Pharm., 1911, 249, 10. Reinitzer reported on the
collection of Sumatra benzoin at Palembang (see
Arch. Pharm., 1926, 264, 368). The exudation is
purely the result of pathological processes, the
plant containing no resin receptacles. The trees,
which are either wild or cultivated, are wounded
at about six years, when the trunks are usually
about seven or eight inches in diameter. Once a
year the bark is wounded near the origin of the
lower branches; the sap which exudes hardens
on exposure to the air. The yield on each occasion
from one tree never exceeds three pounds. The
juice which flows first is the purest, and provides
the whitest and most fragrant benzoin.

Styrax paralleloneurus (not paralleloneurum)
Perkins is a shrub or tree, native to Sumatra,
with branches bearing petiolate, oblong or lance-
olate-oblong leaves up to 12 cm. in length and

3.5 cm. in width having round-cuneate base,
acuminate to acute apex and coriaceous texture,
prominently 7- to 8-pinnately nerved and reticu-
lately veined on the lower surface, which is brown-
ish tomentose. The inflorescence is racemose or
paniculate, up to 11 cm. in length, bearing small
flowers with pedicels 5 to 6 mm. long, each with
a broadly campanulate calyx, undulate or irregu-
larly denticulate along its margin and densely
fuscous-tomentose outside, a 5-partite corolla
whose tube is 3 mm. in length, its lobes recurved.
10 stamens, and a pistil with an obovoid, tomen-
tose ovary and smooth styles.

The tree or trees yielding Siam benzoin have
long been a source of controversy. According to
E. M. Holmes, one of them possesses leaves
thinner and less distinctly venated than those of
Styrax benzoin. Hartwich believed it to be a
new species, Styrax benzoides Craib (see Kew
Bulletin, 1912, p. 391). Holmes {Pharm. J., 1916,
804) attributed it, however, to the S. tonkinensis.
Rordorf {Pharm. J., 1917, 99, 111) received some
fruits which were sent him from Bangkok as
specimens supposedly derived from the benzoin
tree; these did not agree with any species previ-
ously described and he proposed a new species,
S. siamensis Rordorf. It seems probable that one
or more members of the section Anthostyrax
Pierre of the genus Styrax including S. tonkinensis
(Pierre) Craib ex Hartwich yield the Siam vari-
ety. The territory from which the balsam is
derived is a quite limited district in the Siamese
Province of Luang Probang along the River
Mekong.

Siam benzoin appears in commerce as two sub-
varieties, either in the form of separate tears
(Tear Siam benzoin) or in masses composed of
tears cemented together by a rich amber-colored
translucent resin, these masses usually being in
cubical blocks which take their form from the
wooden boxes in which the soft resin has been
packed (Block Siam benzoin). The tears are
small, mostly less than 2 or 3 cm. in length,
opaque, brittle and milky white on the interior,
but on keeping gradually oxidize into the reddish-
brown, transparent or translucent resin. The
finest variety is composed almost entirely of these
tears, loosely agglutinated together. Sumatra
benzoin is sent into commerce chiefly from Palem-
bang in Sumatra. It differs from the Siam vari-
eties in having a much grayer color; the resin
is grayish-brown, the tears are usually fewer than
in the finer variety, and the bits of wood, etc.,
more abundant. The odor differs from, and is less
agreeable than, that of Siam benzoin. "Palembang
benzoin" is an inferior variety of Sumatra ben-
zoin, of lighter weight and having an irregular,
porous fracture. It is the poorest of four grades
of benzoin produced at Palembang, Sumatra. It
consists of a reddish-brown resinous substance
with only a few tears imbedded in it. It is
claimed to yield a larger percentage of benzoic
acid and is used as a source of that product. It
is also asserted that it can be distinguished by
its tincture, when dropped into water, not pro-
ducing milkiness, but a flocculent deposit. Penang
benzoin also resembles Sumatra benzoin, but has
an odor which is more like that of storax, and

Part I

Benzoin

157

it is probably yielded by the Styrax Benzoin; pos-
sibly it is the product of one of the Sumatran
species, S. subdenticulata Mig. For an account
of the cultivation and collection of benzoin in
Sumatra see Reinitzer {Arch. Pharm., 1926, 264,
368).

A variety of benzoin known as Estoraque or
Benjui is produced in Bolivia from Styrax Pearcei
Perk. var. bolivianus. This has been shown by
Wichmann (Schweiz. Wchnschr. Pharm., 1912,
p. 237) to be of similar composition to the
Asiatic resin. According to this author resins
are also collected from a number of other species
of Styrax in South America.

Description. — "Unground Sumatra Benzoin
occurs in blocks or lumps of varying size, made
up of tears, compacted together with a reddish
brown, reddish gray, or grayish brown resinous
mass. The tears are externally yellowish or rusty
brown, milky white on fresh fracture; hard and
brittle at ordinary temperatures, but softened by
heat and becoming gritty on chewing. Its odor is
aromatic and balsamic. When heated it does not
emit a pinaceous odor. When Sumatra Benzoin is
digested with boiling water, the odor suggests
cinnamates or storax. It has an aromatic and
slightly acrid taste.

"Unground Siam Benzoin occurs in pebble-like
tears of variable size and shape, compressed,
yellowish brown to rusty brown externally, milky
white on fracture, separate or very slightly ag-
glutinated, hard and brittle at ordinary tempera-
tures but softened by heat and becoming plastic
on chewing. It has an agreeable, balsamic, vanilla-
like odor. Its taste is aromatic and slightly acrid."
U.S.P.

Standards and Tests. — Identification. — (1)
A solution of benzoin in alcohol is acid to litmus
paper and becomes milky on adding water. (2)
On heating in a test tube Sumatra benzoin evolves
a sublimate consisting of plates and small, rod-
like crystals that strongly polarize light; Siam
benzoin forms a sublimate directly above the
melted mass consisting of numerous long, rod-
shaped crystals which do not strongly polarize
light. (3) Sumatra benzoin produces a deep red-
dish brown, and Siam benzoin a deep purplish
red, coloration when 2 or 3 drops of sulfuric acid
are added to 1 ml. of the supernatant ether layer
from 250 mg. of benzoin which has been shaken
with 5 ml. of ether. (4) On heating 500 mg. of
benzoin with 10 ml. of potassium permanganate
T.S., in a test tube, only the Sumatra variety
develops a strong odor of benzaldehyde. Benzoic
acid. — 1 Gm. of benzoin, treated with 15 ml. of
warm carbon disulfide, yields in the case of the
Sumatra variety not less than 6 per cent and with
Siam benzoin not less than 12 per cent of residue
responding to the identification test for benzoic
acid. Acid-insoluble ash. — Not over 1 per cent
from Sumatra benzoin; not over 0.5 per cent from
Siam benzoin. Foreign organic matter. — Not over
1 per cent in Siam benzoin. U.S.P.

The B.P. limits matter insoluble in 90 per cent
alcohol to 20.0 per cent, ash to 2.0 per cent, and
loss on drying to 10.0 per cent.

Assay. — A sample of 2 Gm. of benzoin is ex-
tracted with alcohol for 5 hours in a Soxhlet or

other extraction apparatus; the extractive is pre-
vented from volatilizing from the alcohol solution
by the presence of 100 mg. of sodium hydroxide
in the receiving flask. The insoluble residue is
dried at 105° for 2 hours and weighed. The dif-
ference between the weight of the moisture-free
benzoin (calculated from a determination of
moisture by the official toluene method) and the
weight of the insoluble residue represents the
alcohol-soluble extractive. U.S.P.

Constituents. — Our knowledge of the consti-
tution of Siam benzoin has been greatly advanced
by the investigations of Reinitzer (Arch. Pharm.,
1926, 264, 131). He has shown that the fresh
exudate is composed chiefly of: crystalline coni-
feryl benzoate {lubanyl benzoate), about 78 per
cent, with a little less than 12 per cent of benzoic
acid, and 6 per cent of a triterpene acid siare-
sinolic (also called siaresinol), C30H48O4; these
bodies, all of which are solids, are liquefied by
the presence of a little more than 2 per cent of
cinnamyl benzoate and traces of vanillin. As the
resin hardens there is an evaporation of most of
the cinnamyl benzoate and a change in a portion
of the coniferyl benzoate from a crystalline to an
amorphous condition. The proportion of free
benzoic acid is difficult to determine accurately
because of the ease with which coniferyl ben-
zoate is saponified by alkalies.

The composition of Sumatra benzoin is not
so well understood, but apparently cinnamic acid
replaces much of the benzoic acid present in the
Siam variety, and sumaresinolic acid (suma-
resinol) replaces the siaresinol. In it are also
traces of stryacin (cinnamyl cinnamate), styrene
(phenyl ethylene), benzaldehyde, and vanillin (see
Brans, Pharm. Weekbl., 1936, 73, 374).

Adulterants. — Sumatra benzoin is sometimes
heavily adulterated with stony debris, sand and
bark. Schneider reports finding as much as 75
per cent of bark in a commercial article.

Uses. — Benzoin is an irritating expectorant
and was formerly extensively employed in pec-
toral afflictions. The compound tincture, and also
the simple tincture of benzoin, are still used
occasionally for their expectorant effect by oral
administration or, more frequently, by inhalation
of the vapors from boiling water to which a small
quantity of one of the tinctures has been added.
This practice, however, has been criticized as be-
ing more irritating than beneficial, steam alone
being preferred (J.A.M.A., 1941, 117, 675). The
most important and frequent use of benzoin
today is as an external antiseptic and protective.
It is usually employed in the form of compound
benzoin tincture, under which title the uses are
discussed. In the East Indies, benzoin is burnt by
the Hindus as a perfume in their temples of
worship.

Benzoin retards rancidification of fats and is
used for this purpose in the official benzoinated
lard; Husa and Riley (J. A. Ph. A., 1934, 23, 544)
demonstrated that in the case of Siam benzoin, at
least, the preservative action is due to coniferyl
benzoate. [v]

Dose, from 0.6 to 2 Gm. (approximately 10 to
30 grains).

Labeling. — "Label Benzoin to indicate

158

Benzoin

Part I

whether it is Sumatra Benzoin or Siam Benzoin."
US.P.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep. — Compound Benzoin Tincture,
U.S. P., B.P.; Benzoin Tincture, U.S.P.; Benzoin-
ated Lard, N.F.

BENZOIN TINCTURE. U.S.P.

[Tinctura Benzoini]

Tinctura Benzoinis; Tinctura Benzoes. Fr. Teinture de
benjoin. Ger. Benzoetinktur. It. Tintura di benzoino.
Sp. Tintura de benjui.

Prepare the tincture, by Process M (see under
Tinctures), from 200 Gm. of benzoin, in mod-
erately coarse powder, using as the menstruum
sufficient alcohol to make 1000 ml. US.P.

Alcohol Content. — From 75 to 83 per cent,
by volume, of C2H5OH. U.S.P.

Benzoin ticture possesses the therapeutic prop-
erties of benzoin. It is employed as a local
astringent and protective application and is some-
times used with steam as an inhalant.

Benzoin tincture has been administered in doses
of 1 to 2 ml. (approximately 15 to 30 minims).

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." US.P.

Off. Prep. — Compound Tar Ointment, N.F.

COMPOUND BENZOIN TINCTURE.
U.S.P., (B.P.)

[Tinctura Benzoini Composita]

B.P. Compound Tincture of Benzoin. Friar's Balsam;
Turlington's Balsam. Tinctura Balsamica; Tinctura Ben-
zoes Composita. Fr. Teinture balsamique; Baume du com-
mandeur de pernes. Ger. Zusammengesetzte Benzoetinktur;
Wundbalasm. It. Tintura di benzoino composto. Sp. Tintura
de Benjui Compuesta.

Prepare the tincture, by Process M (see under
Tinctures), from 100 Gm. of benzoin and 20 Gm.
of aloe, both in moderately coarse powder, 80
Gm. of storax, and 40 Gm. of tolu balsam, using
as the solvent sufficient alcohol to make 1000 ml.
US.P. The B.P. tincture is only slightly different.

Alcohol Content. — From 74 to 80 per cent,
by volume, of C2H5OH. U.S.P.

Uses. — Compound benzoin tincture is em-
ployed chiefly for its antiseptic and protective
effect as a local application to small fissures,
cracked nipples, and indolent ulcers. A common
use is for painting the skin prior to application of
adhesive tape for supportive dressings. Occasion-
ally a contact dermatitis may be encountered,
which Steiner (/. Invest. Dermat., 1949, 13, 351)
believes to be due to volatile oils and resins, and
which may be mistaken for adhesive tape sensi-
tivity. He recommended avoidance of the tincture
in individuals with allergic skin diseases, although
the incidence of reaction in other persons is re-
mote. Pearlman (Arch. Dermat. Syph., 1950, 61,
121) found compound benzoin tincture helpful
when applied to painful vesiculobullous lesions of
the oral mucosa in erythema multiforme; he em-
ployed it also in herpes simplex of the lips,
aphthous stomatitis, and Vincent's infection, with
benefit. Downing (ibid., 1946, 54, 714) recom-
mended the incorporation of compound benzoin
tincture in ointment form for application to

broken skin, as undiluted tincture tends to irritate
because of its high alcoholic content. The follow-
ing formula was suggested: compound benzoin
tincture, 30 ml.; zinc oxide ointment, 30 Gm.
The tincture is evaporated on a water bath to the
consistency of a soft extract, and incorporated,
while hot, in the ointment. This preparation is of
special value in dry, fissured dermatitis of the
fingers of industrial workers.

Compound benzoin tincture is the balsamum
traumaticum of the older pharmacopeias, and
may be considered as a simplified form of certain
complex compositions, such as baume du com-
mandeur, Wade's balsam, Balsam de Maltha,
Friar's balsam, Jesuit's drops, Turlington's bal-
sam, Vervain's balsam, St. Victor's balsam,
Persian balsam, Swedish balsam, Jerusalem bal-
sam, etc., which were formerly in great repute
as pectorals and vulneraries.

The tincture is occasionally employed internally
as a stimulating expectorant in chronic bronchitis.
More frequently it is used as an inhalant by
adding a teaspoonful of the tincture to a pint of
hot water and breathing the vapors; this mode
of treatment may be useful in the early stages of
acute bronchitis. It has also been recommended
in chronic dysentery with the idea that it would
exercise its local action upon the ulcerated surface
of the colon, but is of doubtful utility.

The dose is from 1 to 4 ml. (approximately
15 to 60 minims).

Storage. — Preserve "in tight light-resistant
containers and avoid exposure to direct sunlight
and to excessive heat." U.S.P.

BENZYL ALCOHOL. N.F, B.P.

Phenylcarbinol, [Alcohol Benzylicum]
C6H5.CH2OH

The B.P. requires Benzyl Alcohol to contain
not less than 97.0 per cent w/w of C7H8O.

Phenylmethanol. Phenylmethylol.

Benzyl alcohol occurs naturally as an ester in
several balsams, notably Peruvian and tolu, but
the commercial supply is made by synthesis, as by
the hydrolysis of benzyl chloride with alkali or
by the action of an alkali on benzaldehyde.

Description. — "Benzyl Alcohol is a colorless
liquid with a faint, aromatic odor and a sharp
burning taste. Benzyl Alcohol boils without de-
composition at about 206° and is neutral to litmus
paper. One Gm. of Benzyl Alcohol dissolves in
about 30 ml. of water. One volume of Benzyl
Alcohol dissolves in 1.5 volumes of 50 per cent
alcohol. It is miscible with alcohol, with ether
and with chloroform. The specific gravity of
Benzyl Alcohol is not less than 1.040 and not more
than 1.050." NJ.

Standards and Tests. — Distillation range. —
Not less than 94 per cent, by volume, distils be-
tween 202.5° and 206.5°. Refractive index. — Not
less than 1.5385 and not more than 1.5405, at 20°.
Identification. — Benzaldehyde, recognizable by its
odor, is produced on adding 2 or 3 drops of
benzyl alcohol to 5 ml. of a 1 in 20 aqueous
solution of potassium permanganate, then acidi-
fying with diluted sulfuric acid. Residue on

Part I

Benzyl Benzoate 159

ignition. — The weight of residue from 10 ml. is
negligible. Chlorinated compounds. — Benzyl al-
cohol complies with the requirements of this test
under Benzaldehyde. Aldehyde. — No yellow color
appears in the aqueous layer when 5 ml. of ben-
zyl alcohol is shaken with 5 ml. of sodium
hydroxide T.S. and the mixture allowed to stand
for 1 hour. N.F.

Assay. — About 1.5 Gm. of benzyl alcohol is
heated on a water bath for 30 minutes with 25 ml.
of a mixture of 1 volume of acetic anhydride and
7 volumes of pyridine to acetylate the alcohol
group. After adding 25 ml. of water the excess
acetic anhydride and by-product acetic acid is
titrated with 1 N sodium hydroxide, using phe-
nolphthalein as indicator. The operation is re-
peated without the benzyl alcohol. Each ml. of
the difference between the two titrations repre-
sents 108.1 mg. of CtHsO. B.P.

Uses. — Benzyl alcohol is employed for its
local anesthetic and bacteriostatic effects. In 1 to
4 per cent solution in water for injection or in
isotonic sodium chloride solution it is sometimes
employed as an analgesic by subcutaneous injec-
tion. Only the most concentrated of these solutions
are irritating and sometimes produce subcutaneous
edema on injection (see Sollmann, /. Pharmacol.,
1919, 13, 355; also Gruber, ibid., 1924, 23, 149).
The solutions are relatively non-toxic, benzyl
alcohol being converted in the body to hippuric
acid.

Benzyl alcohol has been found to possess anti-
bacterial activity. Macht et al. (J. Urol, 1920, 4,
355) referred to its having rapid bactericidal
action against several organisms in concentrations
of 1 to 3 per cent. Gershenfeld (Am. J. Pharm.,
1952, 124, 399) found that concentrations of 1
per cent or higher were bacteriostatic against
24-hour-old broth cultures of Staphylococcus
aureus, Escherichia coli communis, Bacillus sub-
tilis, Bacillus mesentericus, and Bacillus mega-
therium and against 16-month old spore cultures
of the last three organisms.

The combination of local anesthetic and bac-
teriostatic effects of benzyl alcohol is rather
widely utilized in the preparation of solutions for
intramuscular or subcutaneous administration;
the usual concentration range is 1 to 3 per cent
of the alcohol.

Topical application of solutions of benzyl al-
cohol is uncertain in its effects. It is effective as
an antipruritic when applied as a 10 per cent oint-
ment, or as a lotion containing equal volumes
of benzyl alcohol, ethyl alcohol, and water. Appli-
cation of a few drops of benzyl alcohol to an
exposed nerve or cavity is reported to be an
efficient anodyne for toothache.

Storage. — Preserve "in tight containers, re-
mote from fire." N.F.

BENZYL BENZOATE. U.S.P., B.P., LP.

[Benzylis Benzoas]
C6H5.CO.O.CH2.C6H5

"Benzyl Benzoate contains not less than 99 per
cent of C14H12O2." U.S.P. The B.P. requires not
less than 99.0 per cent, the LP. not less than 98.0
per cent, of C14H12O2.

Benzyli Benzoas. Ger. Benzoesaurebenzylester. Sp. Ben-
zoato de bencilo; Ester bencil-benzoico.

Benzyl benzoate occurs naturally in some of
the balsamic resins and is reported to be a con-
stituent of the perfumes of hyacinth, gardenia,
jasmin, and orange blossom. It may be prepared
synthetically by esterifying benzyl alcohol and
benzoic acid in the presence of a catalyst, by
the reaction of benzyl alcohol and benzoyl chlo-
ride, by heating benzyl chloride with potassium
benzoate in the presence of triethylamine, or by
the interaction of two molecules of benzaldehyde
in the presence of sodium benzoyloxide.

Description. — "Benzyl Benzoate is a clear,
colorless, oily liquid having a slight aromatic odor
and a sharp, burning taste. Benzyl Benzoate is
insoluble in water and in glycerin. It is miscible
with alcohol, with ether and with chloroform.
The specific gravity of Benzyl Benzoate is not
less than 1.116 and not more than 1.120." U.S. P.
The boiling point is about 323°. B.P., I. P.

Standards and Tests. — Congealing tempera-
ture.— Not below 18.0°. Identification. — (1)
Benzaldehyde, recognizable by its odor, is pro-
duced on warming 1 ml. of benzyl benzoate with
2 ml. of potassium permanganate T.S. (2) A
salmon-colored precipitate is formed on adding
ferric chloride T.S. to a portion of the solution
remaining from the assay from which alcohol has
been evaporated and diluted hydrochloric acid
added to acidify it. A white precipitate of ben-
zoic acid is produced on adding an excess of di-
luted hydrochloric acid to a second portion of
the solution remaining from the assay and from
which alcohol has been evaporated. Acidity. — Not
more than 0.3 ml. of 0.1 N sodium hydroxide is
required for neutralization of 5 ml. of benzyl ben-
zoate dissolved in neutral alcohol, phenolphthalein
T.S. being used as the indicator. U.S.P.

Assay. — About 2 Gm. of benzyl benzoate is
saponified by heating with 50 ml. of 0.5 N alco-
holic potassium hydroxide, the excess alkali being
titrated with 0.5 N hydrochloric acid, using phe-
nolphthalein T.S. as indicator. A residual titra-
tion blank is performed in the same manner on
the alkali solution. Each ml. of 0.5 N potassium
hydroxide represents 106.1 mg. of C14H12O2.
U.S.P.

Uses. — The introduction of benzyl benzoate
into medicine was due to physiological studies
performed by Macht (/. Pharmacol., 1918, 11,
419), who concluded from his experiments and
clinical trials that benzyl derivatives relaxed non-
striated muscles — such as the intestines, ureter,
arteries, etc. — and were therapeutically useful in
various spasmodic conditions such as asthma,
dysmenorrhea, renal or biliary colic, and also
to combat high blood pressure. For a brief period
the drug enjoyed a great popularity in the treat-
ment of these conditions, but it has all but ceased
to be used for these purposes (for literature see
Gruber, J. Lab. Clin. Med., 1925, 10, and Macht,
/. Pharmacol., 1929, 25, 281).

In more recent years it has been widely used as
a treatment for scabies. All methods of treatment
with benzyl benzoate have been uniformly effec-
tive, whether in lotion or emulsion form, and
whether single or several applications have been

160 Benzyl Benzoate

Part I

made. King (Brit. M. J., 1940, 2, 626) applied a
lotion consisting of equal parts of benzyl benzoate,
denatured alcohol, and soft soap. It was applied
vigorously for 5 minutes with a shaving brush
after a thorough scrubbing of the entire body with
soft soap and a 10-minute period of soaking in a
bath at 100° F. After the first application dried,
another one was applied, the clothes worn before
the treatment resumed, and 24 hours later a bath
taken and clean clothes put on. Slepyan (J. A.M. A.,
1944, 124, 1127) reported on the use of another
formula at the U. S. Naval Training Station at
Great Lakes. The lotion used there was prepared
by pouring 250 Gm. of benzyl benzoate on 20
Gm. of Duponol C, to this adding 2.5 per cent
bentonite magma to make 1000 ml., and shaking
well until the wetting agent dissolved. The routine
for treatment consisted in having the patient take
a shower, using soap freely and scrubbing the in-
volved areas, applying the lotion to the entire
body with a paint brush, repeating the treatment
5 minutes after the first application had dried,
retiring to bed 4 hours, showering again and, after
thorough drying, putting on clean clothes which
had been sterilized. Calamine ointment was ap-
plied to any irritated areas. This treatment proved
100 per cent effective for scabies and pediculosis
pubis.

The most satisfactory preparation appears to
be that recommended by Eddy (Bureau of Ento-
mology, U. S. Department of Agriculture) and
known as Benzyl Benzoate Chlor op heno thane
Lotion or NBIN Emulsion. It contains 10 per cent
of benzyl benzoate, 1 per cent of chloropheno-
thane, 2 per cent of ethyl aminobenzoate, and 2.5
per cent of polysorbate 80 in water. The benzyl
benzoate is active against mites, the ethyl amino-
benzoate is an ovicide, and the chlorophenothane
acts on larvae; the combined actions result in an
effective preparation and one which has a low
incidence of irritancy. Carpenter et al. (J. Invest.
Dermat., 1946, 7, 93) found it highly useful in
the treatment of scabies and pediculosis. The
emulsion is rapidly effective even when it is ap-
plied once at night and again the following morn-
ing. The only drawback of the NBIN formula is
the marked allergic dermatitis that may follow
its use in the exceptional patient having a hyper-
sensitivity to ethyl aminobenzoate. Shane (Can.
Med. Assoc. J., 1946, 54, 39) and Daugherty
(J.A.M.A., 1945, 127, 88) called attention to
sensitization that may occur from use of benzyl
benzoate. Such cases may be treated appropri-
ately with baths and soothing lotions. A transitory
sensation of slight burning may follow application
of benzyl benzoate ; the substance should never be
permitted to come in contact with the eyes.

During World War II benzyl benzoate was
used, in the form of a 5 per cent emulsion, to
impregnate clothing worn by soldiers as a pro-
tective measure against mites. Smith and Cole
(/. Nat. Malar. Soc, 1951, 10, 206) found that
the most effective repellent, applied to clothing
for several weeks storage, against A'edes cegypti
and A. quadrimaculatus was a mixture of N-butyl-
acetanilid and benzyl benzoate; the mixture was

also an outstanding repellent for ticks, fleas and
chiggers.

Beilby (Brit. M. J., 1946, 2, 77) relieved the
pruritus of varicella with a benzyl benzoate lotion.

Benzyl benzoate has a number of important
technical uses — as a solvent for cellulose ethers
and many natural and synthetic resins, as a cellu-
lose ester plasticizer, as an ingredient in and fixa-
tive for perfumes, and as a flavor in confectionery
and chewing gum. [v]

The oral dose formerly recommended was from
0.2 to 0.4 ml. (approximately 3 to 6 minims).

Storage. — Preserve "in tight containers and
avoid exposure to excessive heat." U.S. P.

BENZYL BENZOATE LOTION.
U.S.P. (B.P.)

[Lotio Benzylis Benzoatis]

"Benzyl Benzoate Lotion contains not less than
26 per cent and not more than 30 per cent of
C14H12O2." U.S.P. The B.P. Application of Benzyl
Benzoate is required to contain not less than 25.0
per cent w/v of C14H12O2 (limits, 22.3 to 27.5).

B.P. Application of Benzyl Benzoate. Sp. Locion de
Benzoato de Bencilo.

Mix 5 Gm. of triethanolamine with 20 Gm. of
oleic acid, add 250 ml. of benzyl benzoate, and
mix well. Transfer the mixture to a container of
about 2000-ml. capacity, add 250 ml. of water,
and shake thoroughly. Finally add 500 ml. more
of water, and shake thoroughly. U.S.P.

The B.P. product is made by mixing 250 Gm.
of benzyl benzoate with 20 Gm. of melted emul-
sifying wax, then pouring the mixture into suffi-
cient warm distilled water to make 1000 ml., the
whole being stirred thoroughly.

This formula is one of the several which have
been successfully employed in the treatment of
scabies (see under Benzyl Benzoate). The lotion is
applied locally over the entire body except the
face; the adult requires 120 to 180 ml. (approxi-
mately 4 to 6 fluidounces) ; a child needs 60 to
90 ml. (approximately 2 to 3 fluidounces).

Storage. — Preserve "in tight containers."
U.S.P.

SAPONATED BENZYL BENZOATE.

N.F.

[Benzylis Benzoas Saponatus]

"Saponated Benzyl Benzoate contains, in each
100 ml., not less than 93 Gm. and not more than
107 Gm. of C14H12O2." N.F.

Sp. Bensoato de Bencilo, Saponificado.

Mix 20 Gm. of triethanolamine with 80 Gm. of
oleic acid, add sufficient benzyl benzoate to make
1000 ml. and mix well. N.F.

This is a concentrated form of benzyl benzoate
lotion (see preceding article) ; to prepare it for
use as an external application of the same strength
as benzyl benzoate lotion, 275 ml. of saponated
benzyl benzoate is mixed with 725 ml. of water
and shaken thoroughly.

Storage. — Preserve "in tight containers." N.F.

Part I

Betanaphthol 161

BERGAMOT OIL.

Oleum Bergamottae

N.F.

''Bergamot Oil is a volatile oil obtained by ex-
pression from the rind of the fresh fruit of Citrus
Bergamia Risso et Poiteau (Fam. Rutacece).
Bergamot Oil yields not less than 36 per cent of
esters, calculated as linalyl acetate, C12H20O2."
N.F.

Oleum Bergamotae ^Ethereum. Essentia Bergamothae.
Fr. Essence de bergarnote. Ger. Bergamottol. It. Essenza
di bergamotto. Sp. Esencia de bergamota.

The bergamot plant is a small tree with oblong-
ovate, dentate, acute, or obtuse leaves, somewhat
paler on the under than on the upper surface, and
with long winged petioles. The flowers are small,
white and fragrant; the fruit is a pyriform or
globular, thin-skinned, hesperidium, about three
inches in diameter. The pulp of the fruit is sour,
somewhat aromatic, and not disagreeable. The
rind is shining, of a pale-yellow color when mature,
and abounds in volatile oil. This may be obtained
by expression or distillation. In the former case
it preserves the agreeable flavor of the rind, but
is somewhat turbid; in the latter it is limpid but
less sweet. The mode of procuring it by expression
is exactly the same as that used for lemon oil
(q.v.). The bergamot tree is extensively cultivated
in southern Calabria, where the production and
sale of the oil are under the control of the Italian
government. This oil, which is used in the prep-
aration of Eau de Cologne and various perfumes,
is brought from Italy, the south of France, Switz-
erland. Netherlands, and the United Kingdom.

Description. — "Bergamot Oil is a yellowish
brown to green liquid, having a characteristic,
fragrant odor, and an aromatic, bitter taste. It is
affected by light. Bergamot Oil dissolves in alco-
hol and in glacial acetic acid. Bergamot Oil dis-
solves in 2 volumes of 90 per cent alcohol. The
specific gravity is not less than 0.875 and not more
than 0.880." N.F.

Standards and Tests. — Optical rotation. —
Not less than +8° and not more than +24°, in a
100-mm. tube, at 25°. Refractive index.— Not less
than 1.4650 and not more than 1.4675, at 20°.
Heavy metals. — The oil meets the requirements of
the test for heavy metals in volatile oil. Fixed-
oil. — Not over 6 per cent of a soft greenish resi-
due remains on evaporating about 2 Gm. of the
oil, on a water bath, until the odor has completely
disappeared. N.F.

Assay. — The esters in 2 Gm. of oil are hy-
drolyzed by heating with 20 ml. of 0.5 N alcoholic
potassium hydroxide, under a reflux condenser, for
30 minutes. The excess of alkali is titrated with
0.5 N sulfuric acid, using phenolphthalein T.S. as
indicator. A residual blank titration is performed.
Each ml. of 0.5 N alcoholic potassium hydroxide
represents 98.14 mg. of esters calculated as linalyl
acetate. N.F.

Constituents. — Bergamot oil contains up to
45 per cent of linalyl acetate, about 6 per cent of
linalool, a solid compound called bergaptene or
bergamot camphor, also limonene, dipentene,
pinene, camphene, bornylene, bisabolene, dihydro-
cumic alcohol, nerol, and terpineol. Bergaptene,

C12H8O4, is the lactone or inner anhydride of
bergaptenic acid, C12H10O5

Uses. — Though possessed of the stimulant
properties of the volatile oils in general, bergamot
oil is employed chiefly as a perfume. According
to Galewsky (Pharm. Ztg., 1915, 60, 55), the oil
is an extraordinarily active insecticide and useful
to protect the body against lice and other vermin.
Lane and Strauss (J.A.M.A., 1930, 95, 717) re-
ported a number of cases of dermatitis from the
use of toilet-waters containing bergamot oil.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

BETANAPHTHOL.

[Betanaphthol]

N.F.

Naphthol; Naphtol; )3-naphthol; Betahydroxynaphthalene;
Isonaphthol. Naphtholum; j3-Naphtolum. Fr. Naphtol /3 ;
Naphtylol 0. Ger. /3-Naphthol. It. /S-Naftolo; Isonaftolo.
Sp. Naftol-/3; Betanaftol.

Beta- or 2-naphthol is found in coal tar, but it
is produced commercially by fusing sodium naph-
thalene beta-sulfonate with alkali and then acidi-
fying the product to liberate the naphthol. Sodium
naphthalene beta-sulfonate is obtained by reacting
naphthalene with sulfuric acid at 165°; at lower
temperatures naphthalene alpha-sulfonic acid pre-
ponderates but this is converted to the beta-
isomer at the higher temperature. The naphthols
bear the same relationship to naphthalene as
phenol does to benzene.

Description. — "Betanaphthol occurs as white
to pale buff-colored, shining, crystalline leaflets,
or as a white or yellowish white, crystalline pow-
der. It has a faint, phenol-like odor, and is stable
in air, but darkens on exposure to sunlight. Beta-
naphthol sublimes readily when heated, and vola-
tilizes with the vapors of alcohol and of water.
One Gm. of Betanaphthol dissolves in about 1000
ml. of water, in 1 ml. of alcohol, in about 17 ml.
of chloroform, in 1.5 ml. of ether, and in about
80 ml. of boiling water. It is soluble in glycerin
and in olive oil and is readily dissolved by solu-
tions of alkali hydroxides. Betanaphthol melts be-
tween 120°andl23°."iV.F.

Standards and Tests. — Identification. — (1)
A faint, bluish fluorescence develops on adding
ammonia T.S. to a cold, saturated solution of
betanaphthol. (2) A blue color, changing to green
and then to brown, develops in the aqueous phase
of a mixture of 100 mg. betanaphthol, 5 ml. of 1
in 4 potassium hydroxide solution and 1 ml. of
chloroform on warming. (3) A greenish color is
formed on adding ferric chloride T.S. to a cold,
saturated solution of betanaphthol; after a time
whitish flakes separate, these turn brown on heat-
ing. Residue on ignition. — Not over 0.1 per cent.
Acidity. — The filtrate from a 1 in 100 aqueous
mixture of betanaphthol, shaken for 15 minutes
before filtering, is neutral to litmus paper. Naph-
thalene or other organic impurities. — 500 mg. of
betanaphthol dissolves completely in 30 ml. of

162 Betanaphthol

Part I

ammonia T.S. and the color of the solution is not
deeper than pale yellow. N.F.

Amy (/. A. Ph. A., 1931, 20, 1153) observed
that betanaphthol rapidly turns brown when ex-
posed to light, but that in the dark no change-
takes place.

Uses. — Betanaphthol has been largely replaced
by more effective and less toxic antiseptic and
parasiticidal drugs. It is locally irritant to mucous
membranes, but on account of its slight solubility
cannot exercise a caustic effect in aqueous solu-
tions. Bechold (Ztschr. Hyg. Infektionskr., 64,
113) found that it kills Staphylococcus in 1 in
4000 and E. coli in 1 in 8000 concentration after
24 hours. E'we (/. A. Ph. A., 1918, 41, 166) re-
ported its phenol coefficient as 11.3 by the U. S.
Hygienic Laboratory method. As a surgical disin-
fectant it is not commonly used but has been
widely employed in skin diseases, such as favus,
scabies, ringworm, etc., for its parasiticidal effect.
For this purpose it may be applied in the form of
an ointment in strengths of from 0.5 to 5 per cent.
A 10 per cent ointment has been used, alone or
with sulfur, for psoriasis.

Betanaphthol was for a time used as an intes-
tinal antiseptic in the treatment of enteritis, in-
testinal fermentation and similar conditions.
More effective and less toxic drugs are now avail-
able. It was formerly also employed as a vermi-
fuge, especially in the treatment of uncinariasis,
but in the doses required it is more dangerous
than some other anthelmintics and it has been
largely replaced by other drugs. Betanaphthol is
rapidly absorbed. Its use is contraindicated in the
presence of liver or kidney disease.

Betanaphthol was formerly used as a food pre-
servative, but such use has been forbidden by
law. S

Toxicology. — While betanaphthol is much
less poisonous than phenol, in overdose it may
give rise to serious and even fatal poisoning. Both
Kliige (Munch, med. Wchnschr., 1918) and
Gumpel (Med. Klin., 1925) reported deaths from
external application of betanaphthol ointments.
The symptoms of poisoning, where the drug has
been taken orally, are nausea, vomiting, and often
diarrhea with abdominal pain accompanied with
albuminuria and suppression of urine; the urine
is usually brownish-red from presence of beta-
naphthoquinone. In some cases convulsions, fol-
lowed by paralysis, have been reported. In 79 pa-
tients administered betanaphthol as a vermifuge
severe destruction of red blood cells was obsenred
in four (Smillie, J. A.M. A., 1920, 74, 1503); this
is, however, a very rare effect. Blood pressure is
lowered by depression of the heart and vasomotor
center. Other than removing betanaphthol from
the stomach by lavage with olive or cottonseed
oil the treatment of poisoning is symptomatic.
Infusions of glucose in saline solution, or even
blood transfusions, may be required.

Dose, as an intestinal antiseptic, from 120 to
300 mg. (approximately 2 to 5 grains) two to
four times daily; as a vermifuge doses as large
as 2 Gm., repeated once, have been employed.

Storage. — Preserve "in well-closed, light-re-
sistant containers." NJ?.

BETHANECHOL CHLORIDE. U.S.P.

Carbamylmethylcholine Chloride

CH3CH— CHjjN (CH3)3
O-CO-NHj,

Urecholine Chloride (Merck).

Bethanechol chloride is the urethane of P-
methylcholine chloride. Its preparation involves
heating of propylene chlorohydrin with phosgene
and then with ammonia in ether solution; the
resulting chloropropyl urethane is treated with
triethylamine. For further information concern-
ing its synthesis see U. S. Patent 2,322,375 (1943).

Description. — "Bethanechol Chloride occurs
as colorless, white crystals or as a white crystal-
line powder, usually having a slight amine-like
odor. It is stable in air. Its 1 per cent solution
has a pH between 5.5 and 6.5. One Gm. of Be-
thanechol Chloride dissolves in 1 ml. of water,
and in 10 ml. of alcohol; it is less soluble in
dehydrated alcohol. It is insoluble in chloroform
and in ether. Bethanechol chloride melts between
217° and 221°." U.S.P.

Standards and Tests. — Identification. — (1)
An emerald-green color, almost entirely fading in
5 to 10 minutes, is produced when 0.1 ml. of 1 in
100 solution of cobalt chloride and 0.1 ml. of
potassium ferrocyanide T.S. are added to a solu-
tion of 50 mg. of bethanechol chloride in 2 ml.
of water (choline chloride gives the same reaction
but the color does not fade). (2) A brown precipi-
tate, rapidly changing in color to dark olive-
green, is produced when 0.1 ml. of an aqueous
solution containing 10 mg. of iodine and 20 mg.
of potassium iodide is added to 1 ml. of a 1 in 100
solution of bethanechol chloride. (3) Bethanechol
chloride responds to tests for chloride. Loss on
drying. — Not over 1 per cent, when dried at 105°
for 2 hours. Residue on ignition. — Not over 0.1
per cent. Nitrogen. — Not less than 14.0 per cent
and not more than 14.6 per cent, when deter-
mined by the Kjeldahl method. Chloride. — Not
less than 17.7 per cent and not more than 18.3
per cent, when determined by the Volhard method,
the excess of 0.1 N silver nitrate being titrated
with 0.1 N ammonium thiocyanate after addition
of nitrobenzene and using ferric ammonium sul-
fate as indicated. U.S.P.

Action. — This parasympathomimetic agent
(see under this title in Part II) is not destroyed
by cholinesterase ; it is stable in the blood stream
and in tissues and is active whether given orally
or subcutaneously. In this respect it resembles
carbachol and differs from methacholine. It has
very little nicotinic action, resembling in this
property methacholine rather than carbachol
(Molitor, /. Pharmacol., 1936, 58, 337). Admin-
istered subcutaneously, it has about one-tenth the
parasympathomimetic activity of carbachol and
about one-thirtieth the toxicity of the latter.

In normal humans, Starr and Ferguson (Am. J.
Med. Sc, 1940, 200, 372) found therapeutic
doses, when given orally, sublingually or subcu-
taneously, to have little or no effect on heart rate,
blood pressure, peripheral circulation, salivation

Part I

Bishydroxycoumarin 163

or sweating, but increased peristalsis and a desire
to void were present. Increase in tone of the
hypotonic urinary bladder was reported by Boone
(South. M. J., 1950, 43, 1073). Violent symptoms
of cholinergic stimulation, including hypotension,
abdominal cramp, diarrhea and shock, follow in-
travenous or intramuscular administration of as
little as 5 mg. The action of the drug is abolished
by atropine. Subcutaneous administration of as
much as 10 mg. may cause abdominal cramp,
flushing and sweating.

Uses. — Urecholine chloride has been used for
relief of postoperative abdominal distention (Staf-
ford et al, Surg. Gynec. Obst., 1949, 89, 570)
and gastric retention following vagotomy for pep-
tic ulcer (Machella and Lorber, Gastroenterology,
1948, 11, 426; Grimson et al, J. A.M. A., 1947,
134, 925). A marked rise of pressure in the
common bile duct following use of the drug was
observed by Curreri and Gale (Ann. Surg., 1950,
132, 348). Carson (/. Pediatr., 1949, 35, 570)
used 5 to 20 mg. three times daily by mouth ef-
fectively in children 4 to 6 years of age afflicted
with Hirschsprung's disease. Lee (/. Urol., 1949,
62, 300; 1950, 64, 408) as well as Starr and
Ferguson (loc. cit.) used it for postoperative uri-
nary retention. Fleming (Am. J. Obst. Gyn., 1952,
64, 134) demonstrated its efficacy in the treat-
ment of postpartum urinary retention. It causes
contraction of the normally innervated bladder
and the cord bladder and is useful in adynamic
ileus (Stein and Meyer, J.A.M.A., 1949, 140,
522). Urecholine chloride has been employed suc-
cessfully to relieve constipation, paralytic ileus
and urinary retention which occurred in the
course of treatment of hypertension with hexa-
methonium (Freis et al., Circulation, 1952, 5, 20;
Schroeder, Arch. Int. Med., 1952, 89, 523).

Contraindications. — Urecholine has been in-
effective in essential hypertension and in paroxys-
mal auricular tachycardia. It should not be used
after a gastrointestinal anastamosis until healing
has taken place, or in the presence of peritonitis,
mechanical intestinal or vesical neck obstruction,
in asthmatic or hyperthyroid individuals, during
pregnancy, or in cases of coronary artery disease.
It should not be given intravenously or intramus-
cularly, and a hypodermic of 0.6 mg. of atropine
sulfate should be ready for immediate use when-
ever it is injected subcutaneously.

Dose. — The usual dose is 10 mg. (about %
grain) orally 3 times daily, with a range of 5 to
30 mg. The maximum safe oral dose is usually
30 mg., and the total dose in 24 hours seldom ex-
ceeds 120 mg. Subcutaneously the usual dose is
2.5 mg. (approximately Vzi grain), with a range
of 2.5 to 5 mg. The maximum safe subcutaneous
dose is usually 10 mg., and the total dose in 24
hours seldom exceeds 40 mg. Sublingually the
range of dose is 10 to 20 mg

Storage. — Preserve "in well-closed containers."
U.S.P.

BETHANECHOL CHLORIDE
INJECTION. U.S.P.

"Bethanechol Chloride Injection is a sterile
solution of bethanechol chloride in water for in-

jection. It contains not less than 95 per cent and
not more than 105 per cent of the labeled amount
of C7H17CIN2O2." U.S.P.

The pH of the injection is required to be be-
tween 5.5 and 7.

Assay. — The bethanechol component is pre-
cipitated as a reineckate, which is subsequently
dissolved in acetone and the intensity of the red
color of the solution is determined at 525 mn. A
known quantity of Choline Chloride Reference
Standard is similarly treated, and from the meas-
ured intensity of color of the two solutions the
content of bethanechol chloride in the injection is
calculated. U.S.P.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." U.S.P.

Usual Size. — 5 mg. in 1 ml.

BETHANECHOL CHLORIDE
TABLETS. U.S.P.

"Bethanechol Chloride Tablets contain not less
than 90 per cent and not more than 110 per cent
of the labeled amount of C7H17CIN2O2." U.S.P.

Usual Size. — 5 mg. (approximately M2 grain).

BISHYDROXYCOUMARIN

U.S.P. (LP.)

3,3'-Methylenebis(4-hydroxycoumarin)

"Bishydroxycoumarin, dried at 105° for 3
hours, contains not less than 98 per cent of
C19H12O6." U.S.P. The LP. recognizes the com-
pound by the name Dicoumarol, and defines it as
3:3'-methylene-bis-4-hydroxycoumarin; no purity
rubric is specified.

I. P. Dicoumarol; Dicoumarolum. Dicoumarin; Meli-
toxin; Dicumarol (Abbott, Merrell, Schieffelin).

It has been known for a long time that cattle
feeding on spoiled sweet clover hay (see Meli-
lotus) developed hemorrhagic disease due to a
deficiency of prothrombin in the blood of the
animals. From such spoiled clover Link and his
associates (/. Biol. Chem., 1941, 138, 529; 1942,
142, 941) isolated the substance now called
bishydroxycoumarin and identified it as the
agent responsible for the hemorrhagic diathesis.

Bishydroxycoumarin may be sythesized by the
process of Stahmann, Huebner and Link (/. Biol.
Chem., 1941, 138, 513; U. S. Patent 2,345,635,
April 4, 1944) starting with salicylic acid; the
acid is successively esterified to methyl salicylate,
acetylated to methyl acetylsalicylate, heated with
sodium to produce 4-hydroxycoumarin, and
finally reacted with formaldehyde in boiling
ethanol solution to produce bishydroxycoumarin.

Description. — "Bishydroxycoumarin occurs
as a white or creamy white, crystalline powder.
It has a faint, pleasant odor and a slightly bitter
taste. Bishydroxycoumarin is practically insoluble
in water, in alcohol, and in ether. It is slightly
soluble in chloroform, and is readily soluble in

164 Bishydroxycoumarin

Part I

solutions of fixed alkali hydroxides. Bishydroxy-
coumarin melts between 287° and 293°." U.S.P.
The LP. gives the melting range is 285° to 293°.

Standards and Tests. — Identification. — (1)
Salicylic acid is obtained on fusing bishydroxy-
coumarin with an equal quantity of potassium
hydroxide, extracting the cooled melt with water,
and acidifying the filtered extract with hydro-
chloric acid. (2) The diacetate of bishydroxy-
coumarin, prepared by heating the substance with
acetic anhydride, melts between 249° and 252°.
Acidity. — Not more than 0.5 ml. of 0.02 N sodium
hydroxide is required to neutralize the filtrate
separated from 500 mg. of bishydroxycoumarin
which has been shaken with 10 ml. of water for
1 minute; the indicator is methyl red T.S. Loss
on drying. — Not over 0.5 per cent, when dried
at 105° for 2 hours. Residue on ignition. — The
residue from 200 mg. is negligible. U.S.P.

Assay. — A sample of 300 mg. of bishydroxy-
coumarin, dried at 105° for 2 hours, is dissolved
in water with the, aid of sodium hydroxide T.S.,
the solution filtered and acidified with hydro-
chloric acid, and the precipitated bishydroxycou-
marin filtered into a tared filtering crucible,
washed with ice-cold water, dried at 105° for
3 hours and weighed. U.S.P.

Uses. — Bishydroxycoumarin, more commonly
referred to by its trade-marked name Dicumarol,
is one of a group of drugs used extensively for
its systemic effect in delaying coagulation of
blood in the prophylaxis and treatment of throm-
boembolic disease. Of the orally administered
anticoagulants it is the compound which has
provided the medical profession with the largest
number of recorded observations (for discussion
of newer related substances see Ethyl Biscou-
macetate).

Use of bishydroxycoumarin is the outcome of
observations that cattle eating improperly cured
sweet clover hay (see Melilotus) develop a
hemorrhagic tendency (Schofield, Can. Vet. Rec,
1922, 3, 74; Roderick, J. A. Vet. M. A., 1929. 74,
314). Roderick (N. Dakota Agri. Exp. Sta. Bull..
1931, 250, 56) demonstrated that the defect
arose from the presence of insufficient prothrom-
bin; this finding was confirmed by Quick (Am.
J. Physiol., 1937, 118, 260). The isolation from
spoiled sweet clover of the substance, now known
as bishydroxycoumarin, responsible for the
hemorrhagic diathesis has been referred to above.

Meyer and associates (Am. J. Med. Sc, 1942,
204, il) and Butt et al. (Proc. Mayo, 1941, 16
388) investigated its use in human subjects as a
means of delaying the intravascular clotting of
blood. Both groups demonstrated that bishydroxy-
coumarin diminishes the prothrombin content
of blood, lengthening the prothrombin time.
Since the drug fails to affect the prothrombin
time when added to blood in vitro, it is assumed
that some change occurs after its ingestion to
make it effective, this action occurring in the
fiver.

Action. — Coleman (Ann. Int. Med., 1949, 30,
895) described the role of bishydroxycoumarin in
the mechanism of blood clotting essentially as
follows: In the first stage of blood clotting there
is conversion of prothrombin to thrombin in the
presence of calcium and thromboplastin. In the

second stage thrombin unites with fibrinogen to
form fibrin. The latter acts as a supporting
framework for platelets and other cellular com-
ponents of the blood in the clot. Prothrombin is
formed in the liver in the presence of vitamin K ;
thromboplastin is present in the platelets and
tissue juices, especially in the brain and lung.
Both calcium and fibrinogen are present in blood
plasma. Despite the presence normally of these
substances in the circulating blood, clotting does
not take place within the vessels in health be-
cause of movement of the circulation, the absence
of free thromboplastin and the presence of small
amounts of antithrombin and heparin in the
plasma. Bishydroxycoumarin inhibits formation
of prothrombin in the liver. Although this begins
almost immediately after ingestion, the pro-
thrombin already present in the plasma must
be exhausted. Since this requires 24 to 48 hours,
the action of an initial dose of bishydroxycou-
marin is not evident clinically until after that
period of time. Clotting time is proportional to
the amount of thrombin in the presence of ade-
quate amounts of calcium, thromboplastin and
fibrinogen; under normal conditions this is in
turn proportional to the amount of prothrombin.
Approximately three-fourths of the clotting time
is taken up by conversion of prothrombin to
thrombin, the remaining one- fourth in the forma-
tion of fibrin from thrombin and fibrinogen.

The fate of bishydroxycoumarin has been
studied by Lee et al. (Proc. S. Exp. Biol. Med.,
1950, 74, 151), who administered Dicumarol
labeled with carbon-14 in the methylene bridge,
intravenously to mice and rabbits. Activity disap-
peared rapidly from the blood and was recovered
in the fiver, bile, intestinal contents, and later
in the urine in the form of metabolic products.
Approximately 10 per cent of the activity was
fixed in the liver. Use of the isotope dilution tech-
nique demonstrated that this activity was due to
unchanged Dicumarol.

Numerous methods for the determination of
prothrombin time have been devised and there
is marked variation in results according to the
method. This factor must be taken into account
in any valid comparison of effective prothrombin
levels reported by different authors. Coleman
(loc. cit.) classified the methods into those per-
formed on plasma, i.e., the method of Quick and
all its modifications (Stewart and Pohle, Magath,
Fullerton, and Link), and those performed on
whole blood, as in the Smith bedside technique
and the micro-method of Kato and Poncher. It
is recommended, therefore, that in any hospital
only one method should be used and the staff
must know which it is in order that they may
interpret their therapy in light of published
reports. Futher, there is a technical error of
10 per cent even when tests are done by the same
technician using a single method. Tests are re-
ported in terms of the number of seconds of
prothrombin activity for a given blood sample
and for a normal control, as well as in per cent
of normal (the control sample).

Numerous reports indicate that the action of
bishydroxycoumarin is enhanced by the presence
of vitamin C deficiency, the presence of liver
disease, jaundice, biliary fistula, kidney disease,

Part I

Bishydroxycoumarin 165

and by the administration of such drugs as the
salicylates, quinine, ACTH and cortisone. Its ef-
fect is diminished by concomitant administration
of the xanthine derivatives, as caffeine, theo-
bromine, theophylline, and possibily digitalis. It is
known that if heparin is used initially in com-
bined therapy, it interferes with prothrombin
determinations and that these should never be
made within three hours of any given dose of
heparin. Coleman further called attention to the
rapid deterioration of the prothrombin content
of stored bank blood, there ordinarily being a
loss of 50 per cent activity in a week's time.

Wellman and Allen (Proc. Mayo, 1951, 26,
257), in studies on consecutive records of 100
patients given Dicumarol in constant dosage,
found that prothrombin values varied widely;
thus there is no constantly correct dosage for a
given level. Others have pointed out that even
in the same individual there may be sudden and
totally unexpected changes in prothrombin levels
in response to a given dose of the drug, empha-
sizing that constant and extremely careful control
must be exercised in the administration of this
potent substance. Recent experimental studies by
Losner and Volk (Am. J. Clin. Path., 1953, 23,
866) suggest that their citrate clotting time may
be correlated with prothrombin time determina-
tions by the photoelectric modification of the
one-stage method of Quick, and may in the future
provide clinicians with a simple and rapid method
for control of therapy. Their results indicate that
there is also correlation with the Lee-White
coagulation time, which is of importance in
heparin therapy.

Therapeutic Uses. — Many uses for anticoagu-
lant therapy have appeared in the literature. It
is essential to remember that in no case is it be-
lieved that the anticoagulant drugs affect an
intravascular clot which has already formed. They
do, however, tend to prevent the propagation of
a thrombus already formed. They are of definite
value in prophylaxis of thromboembolic phe-
nomena, pulmonary embolism in particular; they
diminish the likelihood of embolic episodes from
mural thrombi formed in transmural myocardial
infarction and tend to inhibit the formation of
intracardiac thromboses in cardiac infarction and
congestive heart failure or the arrhythmias,
auricular fibrillation in particular. Specific indi-
cations thus include: acute arterial occlusion
whether thrombotic or embolic, including pulmo-
nary embolism and peripheral phenomena, se-
lected instances of myocardial infarction, selected
cases of heart failure, prophylaxis of post-
operative and post-partum thromboembolism, and
frostbite with its attendant thrombotic lesions.

Surgery. — Administration both in prophylaxis
and treatment of postoperative thromb embolism
was recommended in earlier reports by Reich
et al. (Surgery, 1945, 18, 238), Parsons (Surg.
Gynec. Obst., 1945, 81, 79), and Allen (J. A.M. A.,
1947, 134, 323). De Takats (J.A.M.A., 1950,
142, 527) called attention to the other factors
involved in the prevention of thrombosis in re-
lation to surgery, namely, the need for early
ambulation, early movement in bed, and better
post-operative care, including attention to fluid,
electrolyte and nitrogen balance. These measures,

as well as the exhibition of the anticoagulants,
have favorably influenced mortality and reduced
vascular accidents incident to surgical procedures
in recent years. In his discussion of this paper
Kvale cited his experience at the Mayo Clinic,
stating that if the prothrombin level is main-
tained below 30 per cent there is little chance
of further thromboses and that if the value is
above 10 per cent there is minimal risk of bleed-
ing. In their series of 2000 surgical patients there
were only two deaths from hemorrhage, neither
of which could be attributed solely to bishydroxy-
coumarin. Other writers claim that such low levels
of prothrombin are too hazardous in most in-
stances.

In Smith's series (Surg. Gynec. Obst., 1950,
90, 439) bishydroxycoumarin was given to 3078
women undergoing surgery, chiefly pelvic and
vaginal plastic procedures. The dose adminis-
tered was 200 mg. in patients weighing more
than 60 Kg., 100 mg. when the weight was lower.
In 50 per cent of the patients the drug was
administered on the first or second postoperative
day and again five days later; in the other 50
per cent the dose was given the night before
operation and in most instances was repeated four
or five days later. There were no deaths, few
thromboembolic complications, few and only
minor hemorrhages, and no control in the labora-
tory was needed. In a series of surgical patients
given bishydroxycoumarin prophylactically in
daily dosage of 100 to 300 mg. until complete
recovery, Rehn and Halse (Deutsche med.
Wchnschr., 1949, 74, 1552) recorded lethal
embolism in only five and thrombophlebitis in 36
of 4411 patients, while in 28,118 untreated pa-
tients undergoing operations the incidence was
100 and 413, respectively. There was lethal
hemorrhage in two and slight bleeding in 67 of
the treated group. Smith and Mulligan (Surg.
Gynec. Obst., 1948, 86, 461) claimed a con-
siderable reduction in incidence of thrombo-
embolic phenomena in 2353 selected patients
given the drug because of surgical operation.
Urdan and Wagner (Am. J. Obst. Gyn., 1951,
61, 982) treated with bishydroxycoumarin 450
patients undergoing major gynecologic surgery
until the patients were ambulatory three days;
there was phlebothrombosis in only one. In 450
untreated patients, there were seven such in-
stances and in addition 11 had thrombophlebitis,
13 had pulmonary embolism, of which 4 were
fatal. Allen (Surgery, 1949, 26, 1) found good
results in reduction of thromboses in 905 surgical
patients, but noted some increased bleeding tend-
ency at intestinal suture lines and from large
denuded areas. Schumacker et al. (ibid., 1947,
22, 910) and others urged combined therapy
with Dicumarol and heparin after surgical repair
of peripheral vessels, as in aneurysms and arterio-
venous fistulas.

Obstetrics. — The prevention of post-partum
thromboembolic lesions is another use for bishy-
droxycoumarin. Brambel et al. (Bull. Sch. Med.
Univ. Maryland, 1950, 35, 91) gave 200 mg.
orally within 12 to 24 hours after delivery to
3284 women; the total dose during the five to
seven days in the hospital averaged 600 mg.
Incidence of thrombophlebitis was lowered from

166 Bishydroxycoumarin

Part I

an expected 0.48 per cent to 0.06 per cent. They
kept the prothrombin time between 40 and 50
per cent (Quick one-stage method). There were
no deaths in the treated group. Adamson et al.
(Am. J. Obst. Gyn., 1950, 59, 498) recom-
mended administration of a 300-mg. dose of the
drug at the onset of labor, with continued use
for at least ten days post-partum in any gesta-
tional patient with either present thrombo-
phlebitis or similar preceding history or in those
with venous disease. Their results in 15 such
patients were described as dramatic. Brambel
and Hunter (ibid., 1950, 59, 1153) found the
prothrombin activity of the nursing infants un-
affected by administration of therapeutic doses
to 125 nursing mothers. Experimental observa-
tions in rabbits by Kraus (J.A.M.A., 1949, 139,
758) demonstrated, however, that in these ani-
mals bishydroxycoumarin passes the placental
barrier and that the newborn rabbits showed
extreme depression of prothrombin activity and
hemorrhagic tendencies. Their observations indi-
cated that there may be irreversible damage in
the fetus if the mother's prothrombin level is
kept below 10 per cent for two days' time.

Myocardial Infarction. — A historic report on
the use of anticoagulants in coronary thrombosis
with myocardial infarction was published by
Wright, Marple and Beck (J. AM. A., 1948, 138,
1074), in which records compiled by a committee
of internists interested in cardiovascular disease
were reviewed, the entire project being under the
supervision of the American Heart Association.
Of the 800 cases included in the report 432 un-
selected patients received anticoagulant therapy
in addition to conventional therapy, while 368
patients did not and constituted the control
group. Of those given anticoagulants 81 per cent
received Dicumarol only; 14 per cent were given
heparin in addition at the outset. Of the control
group 24 per cent died; in the treated group
deaths constituted 14.9 per cent. Thrombo-
embolic complications developed in 25 per cent
of the controls and in only 11 per cent of the
treated patients. Analysis of the death rates by
weeks led to the recommendation that if anti-
coagulant therapy has not been begun earlier, it
should be instituted even as late as the second
or third week after infarction, or even later if
complications develop. To give maximal protec-
tion treatment should be continued for at least
four weeks after the last thromboembolic episode.
It was recommended on the basis of these findings
that anticoagulant therapy should be used in all
cases of coronary thrombosis with myocardial
infarction unless a definite contraindication exists.
The need for careful clinical and laboratory con-
trol was emphasized.

More recently a large number of reports re-
garding the administration of anticoagulants in
myocardial infarction have appeared, and there
is criticism of the routine use of these drugs in
this disease. Russek et al. (Circulation, 1952, 5,
707) in an analysis of 1047 cases of acute infarc-
tion treated conservatively could find no justifi-
cation for routine anticoagulant therapy. Their
death rate in 489 "good risk" cases was only 3.1
per cent and incidence of thromboembolism was
only 0.8 per cent. According to them mortality

preventable through use of anticoagulants in this
group would have been only 1 per cent at best.
They concluded that the risk of complications
induced by bishydroxycoumarin outweighs its
benefits in routine use and that it should be re-
served for the more serious instances in which
there is greater risk of thromboembolism. This
opinion is contrasted with that of Schilling
(J.A.M.A., 1950, 143, 785) who, in a series of
60 treated patients compared with an equal num-
ber of untreated controls, found the fatality rate
diminished from 40 per cent to 16.7 per cent. He
called attention to the state of hypercoagulability
existing in all patients at the time of myocardial
infarction and urged that heparin be given at
once, followed by bishydroxycoumarin, to obtain
immediate anticoagulant action in all such pa-
tients in whom there is no definite contraindi-
cation. His findings are supported by Richter
(N. Y. State J. Med., 1952, 52, 1301).

Favorable reports in prevention of coronary
thrombosis in patients with acute myocardial in-
sufficiency with prodromal symptoms of impend-
ing infarction have been presented by Nichol
(South. M. J., 1950, 43, 565) and by Smith and
Papp (Brit. Heart J., 1951, 13, 467). The latter
authors explain failure of preventive treatment
when it occurs by the presence of widespread
coronary narrowing but with only minimal ab-
normalities evident in the electrocardiogram,
representing subendocardial ischemia.

Congestive Heart Failure. — Griffith et al. (Ann.
Int. Med., 1952, 37, 867) described a statisti-
cally significant reduction in thromboembolism
in 390 patients, in congestive heart failure, main-
tained at prothrombin levels below 60 per cent,
although for adequate prophylaxis 45 per cent
is needed. Their total series of patients, including
controls, numbered 627 cases. Among the controls
there were 2.8 per cent with hemorrhagic phe-
nomena; among those treated there were 2.9
per cent. They stated that for active treatment
of intravascular clotting a prothrombin level of
10 to 20 per cent is needed. Levinson and Griffith
(Circulation, 1951, 4, 416) and Wishart and
Chapman (New Eng. J. Med., 1948, 239, 701)
found comparable results. Askey and Cherry
(J.A.M.A., 1950, 144, 97) stated that a patient
with rheumatic heart disease, congestive failure
and auricular fibrillation has a 45 per cent chance
of having an intracardiac clot, and that there is
a 20 per cent chance that his death will be at-
tributable to thromboembolism.

Auricular Fibrillation. — Among 20 patients
with auricular fibrillation treated with bishydroxy-
coumarin during periods of 4 to 28 months, the
incidence of thromboembolism appeared to have
decreased from that which would be expected
on a statistical basis and in fight of earlier expe-
rience with the same persons; complications were
insignificant. Cosgriff (I.A.M.A., 1950, 143, 870)
stated that auricular fibrillation occurs in 25
per cent of patients with rheumatic heart dis-
ease. He treated, for periods as long as two years,
selected patients who in the past had had one or
more embolic episodes and found that bishydroxy-
coumarin produced favorable results.

Long term bishydroxycoumarin therapy has
been reported by a number of clinicians. Cosgriff

Part I

Bishydroxycoumarin 167

(Ann. Int. Med., 1953, 38, 278) in 35 patient-
courses in 28 ambulatory patients with heart
disease noted only 13 embolic episodes during
625 patient-months of therapy as compared with
103 episodes during 275 patient-months prior to
treatment. Only one major hemorrhage occurred
in a total of 625 patient-months. Of 17 patients
who discontinued treatment three-fourths sus-
tained another embolic episode. Favorable reports
have been published by others, including Nichol
and Borg (Circulation, 1950, 1, 1097), Johnson
(Illinois M. I., 1952, 101, 83) and Rice et al.
(Ann. Int. Med., 1950, 32, 735). Although Shapiro
and Weiner (Am. Heart I., 1951, 41, 749) advo-
cate intermittent administration of relatively large
doses in long-term therapy, most clinicians prefer
to use frequent maintenance dosage. Studies by
Foley and Wright (N.Y. Med., 1950, 6, 16)
pointed out that long-term administration of the
drug has in some instances led to bleeding which
revealed the presence of other lesions, as cancer,
ulcers, renal calculi, etc.

Retinopathy. — Occlusive vascular disease of
the retina is another indication for therapy with
anticoagulants. In the experience of Duff et al.
(Arch. Ophth., 1951, 46, 601) there was im-
provement in 54 of 93 patients treated. They
found that in such patients short-term therapy
with heparin was as effective as long-term dicu-
marol administration and entailed less risk of
hemorrhage. MacLean and Brambel (Am. J.
Ophth., 1947, 30, 1093) used bishydroxycoumarin
alone or with rutin in 19 patients with various
vascular retinopathies, with improved visual
acuity in every instance.

Contraindications. — Among the contraindi-
cations to the use of bishydroxycoumarin, Allen
(I.A.M.A., 1947, 134, 323) included hepatic dis-
ease, vitamin C or K deficiency (where it is un-
necessary), renal insufficiency (because of the
prolonged effect), blood dyscrasias with bleeding
tendency, recent operations involving the central
nervous system, and the presence of any ulcera-
tive lesions where bleeding occurs. Sachs and
Henderson (J.A.M.A., 1952, 148, 839) adminis-
tered the drug to nine patients with chronic renal
disease and impaired renal function in ordinary
dosage, with no unusual effects on prothrombin
time. They concluded that this does not provide
a contraindication to therapy, provided there is
no gross urinary bleeding. The danger of produc-
ing massive retroperitoneal hemorrhage from
lumbar sympathetic block during anticoagulant
therapy has been emphasized by Hohf (J. A.M. A.,
1953, 152, 399) and others.

Toxicology. — The great danger from the
administration of bishydroxycoumarin is that of
hemorrhage. Dalgaard (Nordisk Medicin, 1953,
49, 121) tabulated a total of 80 reported deaths
from its use. In most serious cases the hemor-
rhage is localized to regions with pathological
changes. Wright and Rothman (Arch. Surg., 1951,
62, 23) in a summary of 36 reported deaths
from the drug noted that most of them occurred
during the course of treatment of subacute bac-
terial endocarditis with cerebral hemorrhage, in
the presence of malignancy, from wounds post-
operatively, and in treatment of venous accidents
and heart disease. Most fatalities were caused by

gross overdosage, but in their four cases the
prothrombin level was 33 to 40 per cent, indicat-
ing that other factors were involved. Hemorrhage
may occur in the urinary, gastrointestinal, or
respiratory tract, from the uterus, under the skin
or into the integument as petechiae, in the retro-
peritoneal tissues, and Axelrod and Kleifeld
(N.Y. State J. Med., 1951, 51, 2789) observed
two instances of hemorrhage into the rectus ab-
dominus muscle. Two proven instances of hemo-
pericardium were seen during a course of treat-
ment by Goldstein and Wolff (I.A.M.A., 1951,
146, 616). Capillary dilatation and increased
capillary fragility are known to occur during
treatment.

Management of Poisoning. — Treatment for
hypoprothrombinemia induced by bishydroxy-
coumarin is the prompt administration of vita-
min K. Blood transfusion or plasma infusion
were formerly resorted to, but present knowledge
indicates that they are needed only to replace
blood volume lost as the result of gross hemor-
rhage. The advent of an emulsion of vitamin Ki
that can be administered intravenously with
safety has greatly simplified treatment of bleed-
ing from this cause. Rehbein et al. (Ann. Surg.,
1952, 135, 454) found a dose of 50 mg. to be
as prompt and effective as higher dosage, without
subsequent resistance to exhibition of bishy-
droxycoumarin. This amount by vein returns the
prothrombin level to normal within six hours,
regardless of the degree of hypoprothrombinemia
or the amount of recently administered drug. A
dose of only 0.5 to 2.5 mg. given intravenously
will return the level to therapeutic range within
three to six hours. The availability of this prepa-
ration thus provides a safeguard in case there is
sudden need to operate upon a patient whose
plasma prothrombin is depressed therapeutically.
Stragnell (Am. Heart J., 1952, 44, 124) also
found vitamin Ki and the Ki oxide to be highly
effective in doses of 100 mg. by vein. He claims,
however, that there is a period of hypercoagula-
bility during a phase of resistance of the action
of bishydroxycoumarin after its use. If such
occurs heparin can be given if needed. He claims
further that the water-soluble synthetic prepara-
tions are of little avail in this connection. On the
contrary, Overman, Sorenson and Wright
(I.A.M.A., 1951, 145, 393) stated that the
amount of 2-methyl-l,4-naphthoquinone present
in a water-soluble vitamin K preparation varies
with the salt used, and thus one must compare
the amount of this active ingredient in any
evaluation of relative efficacy of the water-soluble
and oil-soluble preparations. It is their finding
that results are proportional to the amount of
the active ingredient administered. Dalgaard (loc.
cit.) found that a single oral dose of 500 mg. of
vitamin Ki is almost as rapid and as effective
as intravenous administration, except if there be
vomiting, biliary fistula or drainage. In his expe-
rience the clinician who wishes to raise a low
prothrombin level to obtain therapeutic activity
instead of returning the level to normal should
administer one of the synthetic vitamin K prepa-
rations instead of vitamin Ki.

Dose. — There is no standard dose of bishy-
droxycoumarin; therapy must be individualized.

168 Bishydroxycoumarin

Part I

It is essential to control treatment with pro-
thrombin time determinations; these are to be
performed daily at the outset of treatment, and
the level for the day must be known before the
dosage for that day is prescribed. The usual
initial dose is 200 to 300 mg. for an adult. It
must be remembered that there is a lag of 24
to 12 hours before the full effect of the dose is
manifest. Ordinarily if a prothrombin level of
more than 25 per cent is reported on the second
day, dosage is 100 to 200 mg. Thereafter dosage
varies according to the prothrombin time deter-
minations and the general clinical condition of
the patient, the amount given usually ranging
from 50 to 100 mg. If the prothrombin level by
Quick's method is below 20 per cent no drug is
administered. The drug is given orally, there
being no parenteral preparations that are stable.
Administration in a rectal suppository is feasible
and has been shown to be effective.

When it is desired to obtain anticoagulant ef-
fects rapidly, simultaneous administration of
heparin and bishydroxycoumarin is resorted to,
the heparin being withdrawn after the approxi-
mately 48-hour latent period of bishydroxycou-
marin.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

BISHYDROXYCOUMARIN

CAPSULES. N.F.

"Bishydroxycoumarin Capsules contain not
less than 90 per cent and not more than 110
per cent of the labeled amount of C19H12O6."
N.F.

Usual Size. — 50 mg. (approximately J4
grain).

BISHYDROXYCOUMARIN
TABLETS. U.S.P. (LP.)

"Bishydroxycoumarin Tablets contain not less
than 93 per cent and not more than 107 per cent of
the labeled amount of C19H12O6." U.S.P. The
corresponding LP. limits are the same.

I.P. Tablets of Dicoumarol; Compressi Dicoumaroli.

Usual Size. — 25, 50, and 100 mg. (approxi-
mately H, %, and 1>2 grains).

BISMUTH

Bi (209.00)

Fr. Bismuth. Ger. Wisraut. It. Bismuto. Sp. Bisrauto.

Bismuth, under the name wismut, was described
by Basil Valentine in 1450, and by Agricola in
1546. It is generally found in the metallic state,
occasionally as a sulfide (bismuthinite) or a
telluride. and rarely as an oxide. It has been
found, mainly as telluride of bismuth, in Colo-
rado, along with gold and silver ores. Small
quantities have been found in Utah and Wyo-
ming. Bismuth is mined in substantial quantities
in Bolivia and Australia. The bismuth ore from
South America is said to be naturally free from
arsenic, and to be therefore preferable for me-
dicinal purposes. In the United States increasing

amounts of bismuth are recovered as a by-
product in refining certain metals, lead in par-
ticular.

Bismuth is a brittle, pulverizable, brilliant
metal, of a crystalline texture, and of a white
color with a slight reddish tint; its crystals are
rhombohedral. It undergoes but a slight tarnish
in the air. Its density is about 9.8, melting point
2 71°. The most notable property of bismuth is
the ease with which it forms easily fusible alloys,
such as are used as valves in fire sprinkler sys-
tems, for wood cuts, etc. Wood's metal consists
of cadmium, tin, lead and bismuth and melts at
60.5°. Rose's metal consists of lead, tin and bis-
muth and melts at 94°. At a high temperature,
in closed vessels, bismuth volatilizes, and may be
distilled. When heated in air to a full red heat,
it ignites, and burns with a faint blue flame,
forming an oxide of a yellow color. This is the
trioxide, or bismuthous oxide, Bi203. Through
oxidation this oxide may be converted to bismuth
tetroxide or peroxide, having the formula Bi20-i.
A still higher oxidation state is represented by
bismuthic oxide, Bi20s. Bismuth is acted on
slightly by hydrochloric acid, but vigorously by
nitric acid, which dissolves it with copious libera-
tion of red fumes. Sulfuric acid, when cold, has
no action on it, but at elevated temperatures dis-
solves it with liberation of sulfur dioxide.

Uses. — The insoluble salts of bismuth are used
as protectives in various inflammations of the
skin or mucous membranes (see under Bismuth
Sub carbonate). Bismuth oxy chloride, under the
name pearl white, has found some use as an in-
gredient of cosmetics.

Antiluetic Therapy. — In 1921 Sazerac and
Levaditi (Compt. rend. acad. sc, 1921, 173, 338
and 1201) introduced bismuth in the treatment
of syphilis. Although it has a more decided cura-
tive action and is less toxic than mercury, bismuth
is less effective than the arsphenamine group, or
penicillin, in bringing about rapid healing of in-
fectious syphilitic lesions. With bismuth therapy
alone the serological reaction returns very slowly
to normal and in a small percentage of cases
serological and even infectious relapse occurs
despite continued bismuth therapy. Bismuth re-
placed mercury as the drug to be used in con-
junction with the arsenicals. In syphilitic aortitis,
however, bismuth alone or with iodides was the
accepted form of therapy because of the danger
of serious and often fatal exacerbations of the
luetic vascular lesion from the more rapidly-
acting arsenicals: the same therapeutic hazard
exists in the treatment of cardiovascular syphilis
with penicillin. Bismuth was also preferred in
cases of hepatic gumma or syphilitic hepatitis
and for patients in whom arsenical drugs cause
serious toxic reactions.

The mechanism of the action of bismuth in
syphilis is a controversial subject. Based on
experimental studies with rabbits, it has been
reported to be only treponemostatic; other
workers, however, found it to be treponemocidal.
Some clinical observers have held the opinion
that bismuth functions as a "resistance builder"
which increases the immunity of human tissue to
syphilitic infection (see Moore, The Modern
Treatment of Syphilis, 1941). Eagle (Bull. Johns

Part I

Bismuth

169

Hopkins Hosp., 1938, 63, 305; Am. J. Syph.
Gonor. Ven. Dis., 1939, 23, 310; /. Pharmacol,

1939, 66, 10 and 436) found in vitro that con-
centrations of bismuth of 1 in 50,000 to 1 in
225,000, comparable to the amounts present in
tissue under therapeutic conditions, were tre-
ponemocidal and that bismuth was about one-
fourth to one twenty-fifth as active as arsenoxide
in this respect; he suggested that bismuth, as
well as arsphenamine, arsenoxide and mercury,
acted by combining with the sulfhydryl groups
of the protoplasm of the Treponema pallidum.
Kolmer et al. {Am. J. Syph. Gonor. Ven. Dis.,

1940, 24, 439) confirmed Eagle's observations.
Antimalarial Therapy. — It was reported by

Cole et al. (J.A.M.A., 1940, 115, 422) that bis-
muth has distinct antimalarial powers and is
useful in controlling the malarial therapy of
neurosyphilis.

Absorption. — The absorption of bismuth
from the intestines is so slow that it must be
given by injection in order to obtain a systemic
action. The many bismuth compounds that have
been used, or continue to be used, therapeuti-
cally may be classified on the basis of solubility,
as follows: water-soluble, oil-soluble, and in-
soluble (in oil or water, or both). Bismuth
potassium tartrate and bismuth sodium tartrate
are examples of salts used in aqueous solution; a
number of non-official complex organic salts of
bismuth (see in Part II) are used in oil solution;
precipitated bismuth and bismuth oxychloride
are examples of insoluble compounds used in
aqueous suspension, while bismuth subsalicylate
and bismuth potassium tartrate are examples of
compounds, insoluble in oil, administered in oil
suspension.

The rate and degree of absorption of injected
bismuth depend on the solubility of the com-
pound used, being greatest with water-soluble
compounds. Suspensions of insoluble compounds
in oil are absorbed slowly over many weeks and
often become encapsulated in the tissues and
remain for years. The rate of absorption of oil-
soluble compounds or suspensions of water-
soluble compounds in oil is intermediate. Practi-
cally all compounds, including water-soluble
ones, are precipitated in the tissues.

Distribution. — Following injection, bismuth
is distributed throughout all the tissues of the
body. High concentrations in the kidneys and
liver have been found on analysis of human tis-
sues at autopsy (Am. J. Syph. Gonor. Ven. Dis.,
1939, 23, 143). Bismuth readily passes the pla-
centa to the fetus (Am. J. Syph. Gonor. Ven.
Dis., 1940, 24, 223). Hanzlik and his associates
(Am. J. Syph. Gonor. Ven. Dis., 1932, 16, 335
and 350; Arch. Dermat. Syph., 1938, 37, 1003)
claimed better penetration of the central nervous
system with sodium iodobismuthite than with
other compounds but Levaditi and his associates
(Bull. soc. franc, dermat. syph., 1933, 40, 738)
did not confirm this and Johnson and Barnett
(Am. J. Syph. Gonor. Ven. Dis., 1936, 20, 651)
found no evidence for clinical superiority of this
compound. The many available compounds are
therapeutically effective if given in adequate
doses at appropriate intervals (Clausen et al.,
J. Pharmacol, 1942, 76, 338). In the treatment

of early syphilis in connection with arseno-
therapy, the more continuous action of the in-
soluble compounds has been preferred. In late
syphilis with visceral involvement, more frequent
injections of water- or oil-soluble compounds
might be indicated provided the Jarisch-Herx-
heimer reaction is not to be feared.

Excretion. — Excretion of bismuth is achieved
largely by the kidneys although some is excreted
into the colon. Urinary excretion depends upon
the concentration of bismuth in blood, with
water-soluble compounds reaching their peak
within a few hours; with insoluble compounds,
a lower peak is reached about 5 days after
injection and remains at a low level for weeks.
During antiluetic therapy with insoluble com-
pounds, the urine eliminates 2 to 4 mg. of bis-
muth daily (Am. J. Syph. Gonor. Ven. Dis.,
1939, 23, 143). Hanzlik (J.A.M.A., 1929, 92,
413) found that the metal increases the secretion
of urine and is clinically useful as a diuretic.
Injection of bismuth or one of its many salts
has been employed in the treatment of many
conditions besides syphilis, including: cellulitis,
fusospirochetosis (Vincent's), therapeutic ma-
laria, pertussis, pharyngitis and tonsillitis, polio-
myelitis, rat bite fever, relapsing fever, rheu-
matoid arthritis, tularemia, typhoid fever, warts,
yaws, etc. (see the various bismuth compounds
in both Parts I and II).

Toxicology. — (See also under Bismuth Sub-
nitrate) — Bismuth rarely causes serious or fatal
poisoning (see Beerman, Arch. Dermat. Syph.,
1932, 26, 797) unless it is inadvertently injected
into a blood vessel, in which case acute bismuth
poisoning occurs and, if a preparation in oil has
been injected, oil embolism with shock is pro-
duced. Most patients tolerate from 50 to 100
intramuscular injections and many have received
a total dose of as much as 20 Gm. in this way
over a period of 2 to 3 years. The most common
local reaction is pain, which may be minimized
by proper technic of injection (see Bismuth
Subsalicylate Injection). The type of oil employed
as the vehicle may be an irritant factor. Simulta-
neous use of a local anesthetic is of little avail
because the discomfort is usually delayed until
after the anesthetic has ceased to be effective.
Sterile abscess formation or myositis is rarely
observed. Accidental injection into a small
artery causes severe pain and induration with
mottling of the skin, which is often followed by
necrosis of the area.

Systemic manifestations of bismuth poisoning
include stomatitis, nephrosis, hepatitis, colitis
and muscular pains. After about 6 injections, a
black stippled line appears on the margins of the
gums. Later pigmentation appears on the buccal
mucosa and the soft palate. This pigmentation
persists for years. Ulcerative stomatitis occurs
less frequently and may be minimized by careful
oral hygiene. Although bismuth is deposited in
the cells of the renal tubules and results in
calcification of these cells, clinically significant
renal damage is rare. However, the urine should
be examined for albumin and casts during bis-
muth therapy because in the presence of pre-
existing renal disease serious or fatal depression
of kidney function may develop (Heyman, Am.

170

Bismuth

Part I

J. Syph. Conor. Ven. Dis., 1944, 28, 721).
Instances of anuria and uremia have occurred
after a single injection (see Urol. Cutan. Rev.,
1(M2, 46, 7 70 and 780). The perplexing problem
of jaundice during the course of antiluetic
therapy has been clarified somewhat through
studies of infectious hepatitis, homologous serum
jaundice, etc. (Neefe, Stokes and Gellis, Am. J.
Med. Sc, 1945, 210, 561). Nomland et al. (J.A.
M.A., 1938, 111, 19) reported a number of
cases of jaundice with bismuth therapy but
found that this untoward effect appeared only
about one-half as often as after neoarsphenamine.
Kulchar and Reynolds (J.A.M.A., 1942, 120, 34)
reported instances of bismuth hepatitis. Beattie
and Marshal (Brit. M. J., 1944, 1, 547) divided
119 cases of postarsphenamine jaundice into an
early mild type which occurred within 2 weeks of
the first injection and a later type which was
observed after 12 to 17 weeks of treatment; the
latter form was thought to be infectious hepa-
titis transmitted by inadequately sterilized
syringes and needles. Forbes (Brit. M. J., 1944,
2, 852) found that it was safe and desirable to
continue injections of bismuth during the pres-
ence of jaundice arising during the arsenotherapy
of syphilis. Gastroenteritis or peripheral neuritis
or dermatitis of papular or exfoliative type are
very infrequent untoward effects of intramuscular
injections of bismuth. Occasionally a syndrome of
weight loss, fever and muscular and joint pains
is encountered. The Jarisch-Herxheimer reaction
is rare with bismuth therapy and usually of a
cutaneous type. Curtis (J.A.M.A., 1930, 95,
1588) reported a case of sudden death following
intravenous administration of 15 mg. of bismuth
in the form of the tartrate. Masson (/. Pharma-
col., 1926, 30, 39 and 101) found that the lethal
dose of bismuth and sodium tartrate intrave-
nously for cats was equivalent to 4.5 mg. of the
metal per Kg. of body weight although rabbits
withstood almost 5 times this amount. Contra-
indications to the therapeutic use of bismuth
injections are severe hepatic or renal disease or
the development of ulcerative stomatitis or der-
matitis during the course of therapy.

In the treatment of bismuth intoxication Leff
(Military Surgeon, 1932, 70, 456) recommended
immobilization of bismuth in the body by the
use of calcium salts and a milk diet, with bella-
donna to control intestinal spasms. After the
subsidence of acute symptoms ammonium chlo-
ride in doses of 2 to 3 Gm. daily by mcuth
increased the rate of urinary excretion (Arch.
Dermat. Syph., 1940, 42, 868). Dimercaprol is
also useful.

PRECIPITATED BISMUTH. B.P.

Bismuthum Praecipitatum

Under this title the B.P. recognizes a finely
subdivided form of metallic bismuth which may
be prepared by reduction of a hydrochloric acid
solution of bismuth trichloride by means of
hypophosphorous acid. It contains not less than
98.5 per cent of metallic bismuth.

Description. — Precipitated bismuth is a dull
gray powder, easily dispersible in water, in which
it shows no particles having a diameter of more

than 15 microns. The B.P. prescribes tests for
limit of copper, of silver, and of chloride; the
arsenic limit is 8 parts per million.

The assay is based upon the precipitation of
bismuth phosphate from a nitric acid solution by
means of ammonium phosphate. The precipitate
is filtered through a Gooch crucible, washed with
hot water, and ignited. Each gram of bismuth
phosphate corresponds to 0.6875 Gm. of bismuth.

There are on the market under various trade
names preparations of metallic bismuth in a
more or less finely divided condition. Bismoid
(Lilly) and Bismuthoidol (Fougera) are products
of this type.

Uses. — This preparation is intended for the
treatment of syphilis (Willcox, Pract., 1948, 2,
203). When injected intramuscularly the bismuth
is slowly changed into some soluble compound,
probably a protein combination which is absorb-
able. Mehrtens and Hanzlik (J. A.M. A., 1928, 91,
223) found that metallic bismuth is absorbed very
slowly, less than 2.5 per cent of the injected dose
of colloidal metal appearing in the urine within
four days after its intramuscular injection. In this
country metallic bismuth is not as popular as
are some of its saits. The colloidal bismuth prepa-
rations are usually injected in aqueous dispersion
while the pulverized ones are used as oily sus-
pensions.

The B.P. gives the dose as from 100 to 200 mg.
(approximately 1^ to 3 grains).

Off. Prep.— Injection of Bismuth, B.P.

INJECTION OF BISMUTH. B.P.

Injectio Bismuthi

This is a 20 per cent suspension of finely pre-
cipitated bismuth in a 5 per cent solution of dex-
trose in water for injection, and preserved with
0.1 per cent of chlorocresol. It is sterilized by
heating in an autoclave. The assay process de-
scribed under Precipitated Bismuth is applied to
this preparation.

Dose, by intramuscular injection, 0.5 to 1 ml.
(approximately 8 to 15 minims).

BISMUTH MAGMA. N.F.

Milk of Bismuth, Bismuth Cream, [Magma Bismuthi]

"Bismuth Magma contains bismuth hydroxide
and bismuth subcarbonate in suspension in water,
and yields not less than 5.2 per cent and not
more than 5.8 per cent of Bi203." N.F.

Mix 80 Gm. of bismuth subnitrate with 60 ml.
of purified water and 60 ml. of nitric acid in a
suitable container; agitate the mixture and warm
gently until solution is effected. Pour the solu-
tion, stirring constantly, into 5 liters of purified
water containing 60 ml. of nitric acid. Dilute
480 ml. of diluted ammonia solution with 4 liters
of purified water in a glazed or glass vessel of
at least 12 liters capacity. In this solution dis-
solve 10 Gm. of ammonium carbonate and then
pour into it, quickly and with constant stirring,
the bismuth solution. If the mixture is not dis-
tinctly alkaline, add enough diluted ammonia solu-
tion to make it so, then allow the mixture to
stand until the precipitate has subsided. Remove
the supernatant liquid, wash the precipitate twice
with purified water by decantation, then transfer

Part I

Bismuth Potassium Tartrate

171

the magma to a strainer of close texture and
provide for continuous washing with purified
water until the washings cease to produce color
with phenolphthalein T.S. Do not allow the
magma to become dry during the washing oper-
ation. Finally drain the moist magma, transfer
it to a graduated vessel, add enough purified
water to make the product measure 1000 ml.;
mix it thoroughly. Note. — The method of prep-
aration may be varied, provided the product
meets the official requirements. N.F.

Description. — "Bismuth Magma is a thick,
white, opaque, suspension which separates upon
standing. It is odorless and almost tasteless. Bis-
muth Magma is miscible with water and with
alcohol." N.F.

Standards and Tests. — Identification. — (1)
Bismuth Magma responds to tests for bismuth,
and for carbonate. (2) A white precipitate is
produced when a clear solution of 1 ml. of bis-
muth magma and 1 ml. of diluted hydrochloric
acid is poured into 10 volumes of distilled water.
Water-soluble substances. — Not over 5 mg. of
ignited residue is obtained from 50 ml. of filtrate
from a mixture of 10 ml. of the magma which has
been boiled with enough water to make 100 ml.
when cold. Alkalies and alkaline earths. — After
precipitating with hydrogen sulfide the bismuth
from a solution of 2 ml. of magma, 5 ml. of hydro-
chloric acid and enough distilled water to make 100
ml., one-half of the clear filtrate, on evaporation
with 5 drops of sulfuric acid, yields not more than
3 mg. of residue. Arsenic. — 2 ml. of the magma
meets the requirements of the test for arsenic.
Lead. — 5 ml. of magma is dissolved with nitric
acid, then diluted with distilled water to precipi-
tate the bismuth as subnitrate. After filtering, the
liquid is evaporated and again filtered to remove
any bismuth subnitrate which may have remained
in solution and to this filtrate an equal volume
of diluted sulfuric acid is added. No precipitate
(of lead sulfate) should be obtained. N.F.

Assay. — A weighed quantity of bismuth magma
is evaporated to dryness and the residue ignited
to constant weight, as Bi203. N.F.

Uses. — Bismuth magma is a convenient form
for the administration of bismuth hydroxide and
bismuth subcarbonate. It is used especially in the
symptomatic treatment of diarrhea, [vj

The dose for an adult is from 4 to 15 ml.
(approximately 1 to 4 fluidrachms) ; for children,
in proportion to age.

Storage. — Preserve "in tight containers and
protect it from freezing." N.F.

BISMUTH OXYCHLORIDE.

Bismuthi Oxychloridum

B.P.

This is a basic salt of varying composition re-
sulting from the interaction of bismuth nitrate
and sodium chloride or hydrochloric acid. It con-
tains not less than 79.0 per cent and not more
than 81.0 per cent of Bi, and not less than 12.5
per cent of CI.

Basic Bismuth Chloride; Bismuthyl Chloride; Flake
White; Pearl White. Fr. Chlorure basique de bismuth;
Oxychlorure de bismuth; Blanc d'Espagne; Blanc de Fard;
Blanc perle. Ger. Wismutoxychlorid ; Basisches Wismut-
chlorid; Perlweisz. It. Cloruro basico di bismuto. Sp. Cloruro
de bismuto, basico.

Bismuth oxychloride, approximating in compo-
sition to the formula BiOCl, is described in the
B.P. as a white or nearly white, amorphous or
finely crystalline powder, stable in air, and with-
out odor or taste. It is insoluble in water, but
dissolves in dilute hydrochloric acid.

Standards and Tests. — Besides conforming
to tests characteristic of bismuth and of chloride,
bismuth oxychloride is required to comply with
tests for limit of lead, copper, and sulfates, as
described for bismuth carbonate, and also with
a test for limit of nitrates based upon persistence
of the blue color of indigo carmine solution in
an aqueous mixture of the salt and nitrogen-free
sulfuric acid. Silver must be absent. The arsenic
limit is 2 parts per million. The assay for bismuth
is the same as for precipitated bismuth, and that
for chlorine is a Volhard titration using silver
nitrate and ammonium thiocyanate solutions.
Bismuth oxychloride should be protected from
light.

Uses. — In medicine bismuth oxychloride may
be used for the same purposes as bismuth sub-
nitrate; it is employed as an antisyphilitic by
intramuscular injection, particularly in the form
of the B.P. Injection of Bismuth Oxychloride. It
has been used also as a roentgen contrast medium
in the gastrointestinal tract, for this purpose
being suspended in mucilage of acacia. It is used
in certain cosmetic preparations, and occasion-
ally finds industrial use as a pigment.

Dose, orally, from 0.6 to 2 Gm. (approxi-
mately 10 to 30 grains) ; intramuscularly, 100
to 200 mg. (approximately 1^ to 3 grains).

INJECTION OF BISMUTH
OXYCHLORIDE. B.P.

Injectio Bismuthi Oxychloridi

This is a suspension of 10 per cent w/v
bismuth oxychloride in an aqueous solution con-
taining 0.9 per cent sodium chloride and 0.1
per cent chlorocresol. It is sterilized by heating
in an autoclave. It is required to contain bis-
muth oxychloride equivalent to from 7.5 to 8.5
per cent w/v of Bi; the assay is similar to that
for precipitated bismuth. It is intended for in-
tramuscular injection in the treatment of syphilis.
The dose is from 1 to 2 ml. (approximately 15
to 30 minims).

BISMUTH POTASSIUM TARTRATE.

N.F. (LP.)

Potassium Bismuth Tartrate, Potassium Bismuthyl
Tartrate, [Bismuthi Potassii Tartras]

"Bismuth Potassium Tartrate contains the
equivalent of not less than 60 per cent and not
more than 64 per cent of Bi." N.F. The LP.
purity rubric is the same.

LP. Potassium Bismuthyltartrate ; Bismuthi et Kalii
Tartras. Sp. Tartrato Potdsico-Bismutico.

A considerable variety of complex bismuth
and alkali metal tartrates have been prepared
for use in the treatment of syphilis. Theoretically,
tartaric acid is capable of forming many com-
pounds with bismuth and an alkali metal such
as potassium or sodium, or both, and in practice
it is found that several compounds can be pre-
pared. There is evidence that in many of these

172

Bismuth Potassium Tartrate

Part I

salts bismuth, as bismuthyl radical (BiO), sub-
stitutes for the hydroxyl hydrogen of one or
both of the secondary alcohol groups of tartaric
acid, as well as replacing one or both of the
hydrogen atoms in the carboxy groups. Com-
pounds in which the bismuthyl group is present
in the secondary alcohol groups are referred to
as salts of bismuthyl- or bismuthotartaric acid.

The salts may be prepared by dissolving bis-
muth tartrate in a solution of potassium hydrox-
ide, if bismuth and potassium tartrate is desired,
or in sodium hydroxide solution if bismuth and
sodium tartrate is desired, then adding tartaric
acid and finally evaporating the solution. The
bismuth tartrate may be prepared by the inter-
action of bismuth subnitrate and tartaric acid
in the presence of water. In the B.P. it is stated
that the official bismuth and sodium tartrate may
be prepared by reacting bismuth hydroxide and
sodium acid tartrate.

Warren {JAMA., 1925, 84, 1066) analyzed a
number of complex bismuth tartrates and found
that the bismuth content varied from 31 to 73
per cent. He emphasized the necessity for clini-
cians to inquire into the composition of the
bismuth products they use, particularly with
reference to the bismuth content, before evalu-
ating the effectiveness of such preparations.

Description. — 'Bismuth Potassium Tartrate
is a granular, white, odorless powder, having a
sweetish taste. It darkens on exposure to light.
One Gm. of Bismuth Potassium Tartrate dissolves
in about 2 ml. of water. It is insoluble in alcohol,
in ether, and in chloroform. It is decomposed by
dilute mineral acids." N.F. The LP. specifies
that a solution in water shall be neutral to
litmus T.S.

Standards and Tests. — Identification. — (1)
A brownish black precipitate is produced on
adding ammonium sulfide T.S. to a 1 in 10
solution of bismuth potassium tartrate. (2) A
violet color is imparted to a non-luminous flame
by bismuth potassium tartrate. (3) A white pre-
cipitate is produced on adding a few drops of
silver nitrate T.S. to 5 ml. of a 1 in 10 solution
of bismuth potassium tartrate; on boiling, the
mixture blackens and a silver mirror forms.
Alcohol-soluble extractive. — 1 Gm. of bismuth
potassium tartrate, when boiled with 20 ml. of
alcohol for 15 minutes, yields not more than 0.5
per cent of soluble extractive. Arsenic. — The limit
is 10 parts per million. Lead. — A diluted nitric
acid solution of the residue from ignition of
bismuth potassium tartrate, representing in 5 ml.
about 500 mg. of the original salt, shows no
turbidity on adding diluted sulfuric acid. N.F.
The LP. limits arsenic to 5 parts per million.

Assay. — About 400 mg. of bismuth potassium
tartrate is dissolved in water and the bismuth
precipitated, in the presence of a slight excess
of nitric acid, as phosphate, BiP04. The precipi-
tate is collected in a Gooch crucible after washing
by decantation with a dilute solution of ammo-
nium nitrate, and finally ignited at a dull red
heat. The weight of bismuth phosphate, multi-
plied by 0.6875, represents the weight of ele-
mental bismuth in the sample taken for assay.
N.F.

For optimum stability of solutions of potassium
tribismuth tartrate for parenteral administration,
Jurist and Christensen (/. A. Ph. A., 1931, 20,
349) recommended that they contain 25 per cent
of sucrose and be adjusted, if necessary, to a
pH of 11.0 to 11.2 with potassium or sodium
acid tartrate (but see the limitation of pH range
under Bismuth Potassium Tartrate Injection).
Solutions of bismuth are local irritants and they
did not believe it possible to avoid this effect by
any modification of the solution.

Uses. — Bismuth potassium tartrate is used
for treating syphilis (see Bismuth). It may be
given either in aqueous solution or suspended
in sweet almond, olive or peanut oil. and injected
deep into the gluteal muscle. Monteiro and
Silcox (Arch. Otolaryng., 1941, 34, 719) advo-
cated intramuscular injections of this compound
in aqueous solution in the treatment of tonsillitis
due to streptococcal infections; for infants they
employed a dose of 1 to 5 mg. The salt has been
employed also in the treatment of Vincent's
angina.

The dose is from 100 to 200 mg. (approxi-
mately 13^2 to 3 grains), suspended in oil, every
7 days up to a total dose of 3 Gm. (approxi-
mately 45 grains) ; or 50 mg. (approximately
•)4 grain) in aqueous solution three times weekly
up to a total of 18 doses.

Storage. — Preserve "in well-closed, light-
resistant containers." N.F.

BISMUTH POTASSIUM TARTRATE
INJECTION. N.F.

[Injectio Bismuthi Potassii Tartratis]

"Bismuth Potassium Tartrate Injection is a
sterile solution of bismuth potassium tartrate in
water for injection or a sterile suspension of
bismuth potassium tartrate in oil. It contains an
amount of bismuth (Bij equivalent to not less
than 57 per cent and not more than 66 per cent
of the labeled amount of bismuth potassium tar-
trate. Bismuth Potassium Tartrate Injection
meets the requirements under Injections." N.F.

Sp. Inyeccion de Tartrate Potdsico-Bismutico.

The N.F. recognizes two different forms of
injection under the same title; it would see to
have been better to have given them separate
names, as their effects, while similar, are not
identical. The pH of the aqueous injection is re-
quired to be between 6.0 and 9.0.

Uses. — Both the aqueous and the oily prep-
arations are to be given intramuscularly (for uses
see discussion under Bismuth Potassium Tar-
trate). They are never given intravenously be-
cause of the proximity of the therapeutic dose
to the toxic. The aqueous solution is rapidly
absorbed and, if administered two or three times
weekly, a high concentration of bismuth may be
maintained in the blood stream. Slower absorp-
tion and lower concentration of bismuth follow
injection of the oil suspension but the effects are
of greater duration and necessitate injection only
once a week.

Labeling. — 'Label Bismuth Potassium Tar-
trate Injection to indicate whether the Injection

Part I

Bismuth Sodium Tartrate

173

is a water solution or an oil suspension." N.F.

Storage. — "Preserve Bismuth Potassium Tar-
trate Injection (water solution), in single-dose
containers, preferably of Type I glass. Preserve
Bismuth Potassium Tartrate Injection (oil sus-
pension) in single-dose or multiple-dose contain-
ers, preferably of Type I glass. Protect the Injec-
tion from light." N.F.

Usual Sizes. — 2 ml. containing 30 or 50 mg.
(approximately Y or Y\ grain) in water; 2 ml.
containing 100 or 200 mg. (approximately lY
or 3 grains) in oil.

BISMUTH SODIUM TARTRATE. B.P.

Sodium Bismuthyltartrate, Bismuthi et Sodii Tartras

Bismuth Sodium Tartrate is required to con-
tain not less than 35.0 per cent and not more
than 42.0 per cent of Bi. B.P.

Sodium Bismuth Tartrate. Fr. Tartrate de bismuth et de
sodium. Ger. Wismut-Natriumtartrat. It. Tartrato di bismuto
e di sodio. Sp. Tartrato de bismuto y de sodio.

Bismuth sodium tartrate may be prepared,
according to the B.P., by the interaction of bis-
muth hydroxide and sodium acid tartrate. As
with bismuth potassium tartrate, the number of
compounds which may be thus named is large,
and there may be considerable variation in the
composition of the salts. Thus, N.N.R. 1952
recognized as Bismuth Sodium Tartrate a basic
salt containing 72.7 to 73.9 per cent of bismuth,
which represents approximately twice the content
of bismuth in the B.P. salt. It is apparent that
a great deal of caution should be exercised in
prescribing and dispensing the bismuth alkali
tartrates, to be certain that a salt of the intended
content of bismuth is supplied.

Description and Tests. — Bismuth sodium
tartrate of the B.P. occurs as a white powder
or as slightly yellow scales, soluble in less than
1 part of water. In addition to tests for identity
for bismuth, sodium and tartrate, the salt must
also comply with limit tests for lead and copper;
the limit of arsenic is 2 parts per million. The
salt is assayed by precipitation as bismuth phos-
phate, which is weighed.

The salt formerly included in N.N.R. was
described as a finely divided, white, odorless and
tasteless powder, permanent in air. All but 0.1
per cent of the product dissolves in about 3 parts
of water to give an alkaline solution.

Uses.— Hudgins (Clin. Med., 1944, 51, 277)
reported his experiences with a series of 1200
intravenous injections of 1- to 2-ml. doses of
bismuth sodium tartrate (N.N.R. specification),
in 3 per cent aqueous solution, in 100 luetic
patients over a period of 7 years. There were
no serious toxic effects; occasional instances of
nausea, vomiting, and aching of teeth were ob-
served. He gave injections at intervals of 3 to 7
days, claiming the advantage of less discomfort
by this route than when intramuscularly adminis-
tered. As with arsenicals, intravenous injection
of bismuth is contraindicated in cardiovascular
syphilis. Hudgins used this treatment also in
Vincent's infections, tonsillitis and pharyngitis,
and for warts (see Bismuth Subsalicylate). Bis-
muth sodium tartrate has been widely used for

treatment of yaws, also for treatment of relaps-
ing fever caused by the spirochete Borrelia
recurrentis, and other strains (East African M. J.,
1943, 20, 55).

Although intravenous administration of bis-
muth has not been generally found acceptable
or advisable, because the effective and toxic
doses by this route are thought to be very close
(/. Pharmacol., 1942, 76, 339), Jackson reported
excellent results in treating tularemia, in which
disease Foshay specific antiserum, sulfonamide
drugs, and penicillin have failed (Am. J. Med.
Sc, 1945, 209, 513). He treated 61 cases by
injecting a 3 per cent solution (of N.N.R.-
specification salt) intravenously, starting with
1 ml., and following this by 1 ml. per 100 pounds
of body weight in adults and 1 ml. per 50 pounds
in children daily until the temperature fell to
99° F., then every other day for 4 doses, and
finally twice weekly for 4 doses. Recovery was
prompt (an average of 7 doses being required
until patients were afebrile) and no toxic effects
were produced other than slight nausea. In chronic
brucellosis, Wissman and Carpenter (/. Indiana
M. A., 1949, 42, 424) obtained marked sympto-
matic improvement in 12 out of 16 cases. In peptic
ulcer, Duffy (/. Oklahoma M. A., 1951, 44, 12)
reported benefit. Marked diuretic action has been
reported with bismuth sodium tartrate.

In rheumatoid arthritis Hall (Lancet, 1944, 1,
264; 1945, 2, 385) reported obtaining better
results from intramuscular injection of bismuth
sodium tartrate, in aqueous solution, than with
gold salt therapy; he employed 32-mg. doses at
intervals of 4 weeks to 3 months, according to
recurrence of symptoms, cautioning against
larger and more frequent doses. If gold therapy
has been used, bismuth treatment should be
postponed for several months to permit excre-
tion of gold.

Toxicology. — Inadvertent intravenous injec-
tion of 650 mg. (presumably of the B.P. bismuth
sodium tartrate) in three Africans was reported
by Goodman (Brit. M. J., 1948, 1, 978); two
collapsed and died within 2 minutes, while the
third suffered vascular collapse in 6 minutes,
showed a blue line on the gums on the third day,
developed oliguria on the fifth day, and showed
albumin, red blood corpuscles and casts in all
urine passed, with a rapid rise of blood urea.
This patient' died on the tenth day; autopsy
revealed an enlarged liver, hemorrhagic colitis,
acute nephritis, and blue gingivitis.

The dose of the N.N.R. -strength salt, when
used as an antisyphilitic by intramuscular injec-
tion, is 30 mg. (approximately z/2 grain) three
times weekly for a maximum of 6 to 10 weeks;
the initial dose should be 15 mg. (approximately
% grain). For intravenous dosage see above. The
weaker B.P. compound may be given in doses
of 60 to 200 mg. (approximately 1 to 3 grains),
according to the B.P.

In the 1952 edition, the N.N.R. described
Solution Bismuth Sodium Tartrate containing,
in aqueous solution, either 15 or 30 mg. of bis-
muth sodium tartrate, 20 mg. of benzyl alcohol,
and 250 mg. of sucrose in each ml.; the solution
is supplied in 60-ml. vials.

174 Bismuth Sodium Tartrate, Injection of

Part I

INJECTION OF BISMUTH
SODIUM TARTRATE. B.P.

Injection of Sodium Bismuthyltartrate, Injectio Bismuthi
et Sodii Tartratis

This injection is described as a sterile solution
of bismuth sodium tartrate (B.P.) in water for
injection, adjusted to a pH of 5.5 by addition
of tartaric acid; the solution is sterilized by
heating in an autoclave or by filtration through
a bacteria-proof filter. The content of Bi is not
less than 33.3 per cent and not more than 44.1
per cent of the content of bismuth sodium tar-
trate stated on the label.

BISMUTH SUBCARBONATE.
U.S.P. (B.P.), I.P.

Basic Bismuth Carbonate, [Bismuthi Subcarbonas]

''Bismuth Subcarbonate is a basic salt which,
dried at 105° for 3 hours, yields on ignition not
less than 90 per cent of BisOa." US.P. The B.P.
recognizes this substance as a basic salt of varying
composition that may be obtained by the inter-
action of bismuth nitrate and a soluble carbonate.
No rubric is stated by the B.P. but a determina-
tion of the residue on ignition must yield not less
than 90.0 per cent and not more than 92.0 per
cent of such residue. The I.P. requires bismuth
subcarbonate to contain not less than 89.0 per
cent and not more than 92.0 per cent of Bi203.

B.P. Bismuth Carbonate; Bismuthi Carbonas. Bismuth
Oxycarbonate; Bismuthyl Carbonate. Bismutura Subcar-
bonicum; Bismutum Carbonicum; Carbonas Bismuthicus
Basicus. Fr. Carbonate de bismuth; Sous-carbonate de
bismuth. Ger. Basisches Wismutkarbonat ; Wismutsub-
carbonat. It. Carbonato di bismuto. Sp. Subcarbonato de
bismuto.

Bismuth subcarbonate is prepared by the re-
action of solutions of bismuth nitrate and a
soluble carbonate, the chemical composition of
the salt depending upon the conditions of pre-
cipitation. For this reason its chemical formula
cannot be definitely stated but it is approximately
(Bi202C03)2.H20.

Description. — '"Bismuth Subcarbonate is a
white or pale yellowish white powder without odor
and taste. It is stable in air, but is slowly affected
by light. Bismuth Subcarbonate is insoluble in
water and in alcohol." U.S.P.

Standards and Tests. — Identification. — Bis-
muth subcarbonate dissolves completely, with
effervescence, in nitric or hydrochloric acid; the
solution in nitric acid responds to tests for bis-
muth. Loss on drying. — Not over 2 per cent, when
dried at 105° for 3 hours. Alkalies and earths. —
Not over 5 mg. of a sulfated residue of alkalies
and earths is obtained from 2 Gm. of bismuth
subcarbonate. Chloride. — The limit is 700 parts
per million. Nitrate. — The limit is 0.75 per cent.
Sulfate. — A dilute nitric acid extract of bismuth
subcarbonate shows no precipitate with barium
nitrate T.S. Copper. — No bluish tint is produced
on adding a slight excess of ammonia T.S. to a
dilute nitric acid extract of bismuth subcarbonate.
Lead. — No cloudiness develops on adding diluted
sulfuric acid to a dilute nitric acid extract of
bismuth subcarbonate. Silver. — No precipitate, in-
soluble in an excess of hydrochloric acid but
soluble in ammonia T.S., is formed on adding

hydrochloric acid to a dilute nitric acid extract of
bismuth subcarbonate. Arsenic. — The limit is 10
parts per million. U.S.P. The B.P. permits not
more than 2 parts per million of arsenic; upon
ignition, the salt leaves not less than 90.0 per cent
and not more than 92.0 per cent of residue.

Assay. — A sample of 1 Gm. of bismuth sub-
carbonate, dried at 105° for 3 hours, is ignited
to constant weight. The weight of the residue of
Bi203 is not less than 90 per cent of the weight
of the sample. U.S.P. The I.P. assay is similar,
except that the bismuth subcarbonate is not dried
prior to the ignition.

Uses. — Bismuth subcarbonate has been widely
employed for symptoms of gastrointestinal irrita-
tion on the basis of the perhaps oversimplified
concept that this heavy, insoluble salt of bismuth
coated and protected inflamed mucous membranes.
The salt obviously has this property but experi-
ence indicates that this does not occur with any
degree of effectiveness in vivo. Nevertheless it
continues to be prescribed, for the lack of more
specific agents, for nausea and pyrosis or, in other
words, for indigestion, dysphagia and diarrhea due
to infectious, chemical or neurogenic causes. In
diarrhea it is usually innocuous, unless it delays
the use of specific measures; the common practice
of administering camphorated opium tincture with
bismuth subcarbonate illustrates the ineffective-
ness of bismuth salts in diarrhea. In cases of
gastritis, and especially in gastric ulcer, the fact
that it acts as a mild alkali, as has been re-empha-
sized by Alstead (Lancet, 1941, 2, 420), gives the
subcarbonate preference over the subnitrate.
which is acid in reaction. Bismuth subcarbonate
has been claimed to be valuable for the expulsion
of seat-worms (Loeper, J.A.M.A., 1920, 75, 903).

The lower toxicity of bismuth subcarbonate,
as compared with the subnitrate, is an advantage
of the former substance when large doses are to
be taken, as in roentgenography, where 30 to 60
Gm. of an insoluble bismuth salt has been given.
This quantity of the subcarbonate produces no
disturbance either of the alimentary canal or the
general system: of course, barium sulfate has
come into almost exclusive use for this purpose.

Bismuth subcarbonate has been included in
various powders and pastes for topical application
to the skin or to mucous membranes to allay irri-
tation; it is usually also an ingredient of the rectal
suppositories which are generally available for use
in effecting symptomatic relief of anal discomfort.

The usual dose is 1 Gm. (approximately 15
grains), with a range of 1 to 4 Gm.; the maxi-
mum single dose is usually 4 Gm. and not more
than 30 Gm. is generally given during 24 hours.

Storage. — Preserve "in well-closed, fight-
resistant containers." UJS.P.

BISMUTH SUBCARBONATE
TABLETS. N.F.

[Tabellae Bismuthi Subcarbonatis]

"Bismuth Subcarbonate Tablets yield an amount
of Bi203, not less than S3 per cent and not more
than 97 per cent of the labeled amount of bismuth
subcarbonate." N.F.

Assay. — A representative sample of powdered

Part I

Bismuth Subnitrate

175

tablets, equivalent to 600 mg. of bismuth sub-
carbonate, is digested with a mixture of sulfuric
and nitric acids, diluted to 200 ml. with water,
filtered, and 100 ml. of the filtrate employed for
precipitation of bismuth as the phosphate, BiP04.
The precipitate is filtered off, washed, dried and
ignited to constant weight. Each Gm. of BiP04
represents 766.5 mg. of Bi20"3. N.F.

Usual Size. — 5 and 10 grains (approximately
300 and 600 mg.).

BISMUTH SUBGALLATE. N.F., B.P.

Bismuth Gallate, Dermatol, [Bismuthi Subgallas]

"Bismuth Subgallate is a basic salt which, dried
at 105° for 3 hours, yields not less than 52 per
cent and not more than 57 per cent of Bi203."
N.F. The B.P. specifies no purity rubric.

Bismuth Oxygallate; Bismuthyl Gallate; Bismuth Mono-
gallate. Bismutum Subgallicum; Bismuthi Gallas Basicus;
Subgallas Bismuthicus. Fr. Gallate de bismuth ; Sous-
gallate de bismuth; Acide bismuthogallique. Ger. Basisches
Wismutgallat. It. Gallato basico di bismuto; Sottogallato
di bismuto. Sp. Galato de bismuto, basico ; Subgalato de
bismuto.

Bismuth subgallate may be prepared by the
action of gallic acid on freshly precipitated bis-
muth hydroxide. It was introduced to the medical
profession under the proprietary name of Derma-
tol. Although several structural formulas have
been proposed for it, that suggested by Tahagi
and Nagasi (/. Pharm. Soc. Japan, 1936, 56, 31)
as a dibasic complex acid of the composition

I 1

(HO.Bi03.C6H4.COO)H2.H20

best explains its properties.

Description. — "Bismuth Subgallate occurs as
an amorphous, bright yellow powder. It is odor-
less and tasteless. It is stable in the air, but is
affected by light. Bismuth Subgallate dissolves
readily with decomposition in warm, moderately
dilute hydrochloric, nitric, or sulfuric acid; it is
readily dissolved by solutions of alkali hydroxides,
forming a clear, yellow liquid, which rapidly as-
sumes a deep red color. Bismuth Subgallate is
nearly insoluble in water, in alcohol, and in ether.
It is insoluble in very dilute mineral acids." N.F.

Standards and Tests. — Identification. — (1)
A yellow residue, responding to tests for bismuth,
is produced on heating bismuth subgallate to red-
ness. (2) A purplish blue mixture is produced on
adding 1 drop of ferric chloride T.S. to the filtrate,
freed from dissolved gas, from 100 mg. of bismuth
subgallate mixed with an excess of hydrogen sul-
fide T.S. Nitrate. — No brownish red color appears
at the zone of contact of the filtrate from a sus-
pension of 100 mg. of bismuth subgallate in 5 ml.
of diluted sulfuric acid and 5 ml. of ferrous sul-
fate T.S. when it is superimposed on 5 ml. of
sulfuric acid. Alkalies and earths. — Not over 5 mg.
of a sulfated residue of alkalies and earths is ob-
tained from 1 Gm. of bismuth sulbgallate. Arsenic.
— 200 mg. of bismuth subgallate meets the re-
quirements of the test for arsenic. Copper, lead,
or silver. — 3 Gm. of bismuth subgallate is ignited
and a diluted nitric acid extract of the residue is
prepared. Portions of this extract must not re-
spond to tests for copper, lead, or silver as de-

scribed under bismuth subnitrate. Free gallic acid.
— 1 Gm. of bismuth subgallate yields not more
than 5 mg. of material soluble in 20 ml. of alco-
hol. N.F.

The B.P. tests are essentially the same as those
of the N.F. A residue on ignition of not less than
52.0 per cent and not more than 57.0 per cent,
calculated with reference to the substance dried
at 105°, is specified; this is similar to the N.F.
assay.

Assay. — A sample of 1 Gm. of bismuth sub-
gallate, dried for 3 hours at 105°, is ignited, then
dissolved in nitric acid, the solution evaporated
to dryness and the resulting residue carefully
ignited to constant weight as Bi203. The weight of
the residue is not less than 52 per cent and not
more than 57 per cent of the weight of the dried
sample. N.F.

Uses. — Bismuth subgallate is chiefly employed
as a dusting powder in the treatment of eczema
and other skin diseases and occasionally of
wounds. Its value probably depends on its ab-
sorbent and protective action although it may
exert some slight inhibition of bacterial growth.
It is occasionally employed like the other insol-
uble salts of bismuth in the treatment of enteritis
on the supposition that it exerts an astringent as
well as a protective effect (see Gallic Acid, Part
II). A suspension of 5 per cent of finely ground
bismuth subgallate in olive oil or cod liver oil
has been employed by rectal injection in treating
amebic and chronic bacillary dysentery (Turner,
Trans. Roy. Soc. Trop. Med. Hyg., 1940, 34,
112); the dose varied from 4 to 10 fluidounces
daily. 0

Dose, 0.5 to 2 Gm. (approximately 7^2 to 30
grains).

Storage. — Preserve "in tight, light-resistant
containers." N.F.

BISMUTH SUBNITRATE. N.F., LP.

Basic Bismuth Nitrate, [Bismuthi Subnitras]

"Bismuth Subnitrate is a basic salt which, dried
at 105° for 2 hours, yields upon ignition not less
than 79 per cent of Bi203." N.F.

The LP. defines Bismuth Subnitrate as a basic
salt, the composition of which varies with the
conditions of preparation, usually approximated
by the formula 6Bi2O3.5N2O5.8H2O; not less than
79.0 per cent and not more than 82.0 per cent of
Bi203 is required, the assay sample not being
dried.

Bismuth Oxynitrate; Bismuthyl Nitrate; White Bis-
muth; Magistery of Bismuth. Bismutum Subnitricum;
Bismuthum Album; Bismuthi Nitras Basicus. Fr. Azotate
basique de bismuth lourd; Sous-azotate de bismuth; Sous-
nitrate de bismuth; Magistere de bismuth. Ger. Basisches
Wismutnitrat; Wismutsubnitrat; Wismut-weisz. It. Nitrato
basico de bismuto ; Sottonitrato di bismuto. Sp. Nitrato de
bismuto, basico ; Subnitrato de bismuto.

Bismuth subnitrate may be prepared by adding
a solution of the normal nitrate, Bi(N03)3, to
boiling water, whereupon the basic product is pro-
duced by hydrolysis. The normal nitrate is ob-
tained by dissolving pure metallic bismuth in
nitric acid.

Bismuth trinitrate forms colorless crystals of
the formula, Bi(N03)3.5H.20; it is soluble in

176

Bismuth Subnitrate

Part I

glycerin and acids but is changed by water to the
insoluble subnitrate. This salt was at one time
used for medicinal purposes but is no longer thus
employed.

Description. — "Bismuth Subnitrate occurs as
a white, slightly hygroscopic powder. When
brought in contact with moistened blue litmus
paper it shows an acid reaction. Bismuth Sub-
nitrate is practically insoluble in water, and in
alcohol, but is readily dissolved by hydrochloric
or nitric acid." X.F.

Standards and Tests. — Identification. — Bis-
muth subnitrate responds to tests for bismuth and
for nitrate. Loss on drying. — Not over 3 per cent,
when dried at 105° for 2 hours. Carbonate. — No
effervescence occurs on dissolving 3 Gm. of bis-
muth subnitrate in 3 ml. of warm nitric acid; the
resulting solution is used in tests for sulfate,
copper, lead and silver. Chloride. — The limit is
350 parts per million. Ammonium salts. — Moist-
ened red litmus paper is not turned blue by the
vapor produced on boiling 100 mg. of bismuth
subnitrate with 5 ml. of sodium hydroxide T.S.
Alkalies and earths. — Not over 5 mg. of a sulfated
residue of alkalies and earths is obtained from
1 Gm. of bismuth subnitrate. Arsenic. — 200 mg.
of bismuth subnitrate meets the requirements of
the test for arsenic. Sulfate. — The solution from
the carbonate test is poured into water, filtered,
concentrated, and filtered again; a portion of the
filtrate shows no precipitate on adding barium
nitrate T.S. Copper. — Another portion of the
filtrate used in the preceding test shows no bluish
tint on adding a slight excess of ammonia T.S.
Lead. — A third portion of the filtrate used in the
test for sulfate shows no cloudiness on adding
diluted sulfuric acid. Silver. — A fourth portion of
the filtrate used in the test for sulfate produces
no precipitate, insoluble in a slight excess of
hydrochloric acid but soluble in ammonia T.S.,
on adding hydrochloric acid. N.F.

Assay. — A sample of about 1 Gm. of bismuth
subnitrate, dried at 105° for 2 hours, is ignited
to constant weight. The weight of the residue,
BiaOa, is not less than 79 per cent of the weight
of the sample. N.F.

Incompatibilities. — Bismuth subnitrate is in-
compatible with potassium iodide (slowly forming
a brick-red bismuth iodide) and with alkaline bi-
carbonates. The acidity of bismuth subnitrate
resulting from hydrolysis of aqueous suspensions
of the substance sometimes leads to the develop-
ment of explosive mixtures in prescriptions con-
taining sodium bicarbonate. In common with
other bismuth salts it is reduced by sunlight in the
presence of bromides, or of organic matter.

Uses. — The fact that bismuth subnitrate is
practically insoluble in water led to the belief that
it was incapable of being absorbed from the
gastrointestinal tract, but it is now known that
absorption of some bismuth and especially of
nitrite ion resulting from reduction of the nitrate
component may occur under certain conditions in
the intestines. Traces of bismuth in the urine and
in various internal organs have been found after
oral administration of the salt. The use of large
quantities, such as 30 to 60 Gm. of bismuth sub-

nitrate as a radiopaque medium has resulted in a
number of serious cases of nitrite poisoning.

Bismuth subnitrate, like the other insoluble
bismuth salts, has been used for its protective
action in gastritis, enteritis, and similar inflamma-
tions. It is, however, inferior for this purpose to
the carbonate because of the possibility of nitrite
poisoning. Roe (J.A.M.A., 1933, 101, 352) re-
ferred to several such cases, of which 3 ended
fatally. Miller (Gastroenterology, 1945, 4, 430)
reported a case of methemoglobinemia due to
bismuth subnitrate in the presence of enteritis.
Wallace (J.A.M.A., 1947, 133, 1280) observed
the occurrence of acute methemoglobinemia in a
5-week-old infant given bismuth subnitrate for
diarrhea; recovery followed oral administration
of 50 mg. of methylene blue in 120 ml. of 5 per
cent dextrose. Steiglitz (/. Pharmacol., 1936, 56,
216) advocated bismuth subnitrate as a means of
obtaining slow, continuous action of the nitrites
in the treatment of high blood pressure. Ayman
(J.A.M.A., 1932, 98, 545), however, failed to
observe any benefit in this class of patients. Its
action evidently depends upon certain unknown
and variable conditions in the alimentary canal.

Bismuth subnitrate has some astringent and
mild antiseptic action when applied to raw sur-
faces and it was used as a dusting powder in vari-
ous wounds and ulcers prior to the antibiotic era.
Beck (J.A.M.A., 1908, 50, 868) obtained favor-
able results on injecting into the chronic fistulas
of bone tuberculosis a mixture of 30 per cent of
bismuth subnitrate aseptically incorporated into
a previously sterilized mixture representing 5 per
cent each of white wax and paraffin and 60 per
cent of white petrolatum. This mixture, known as
Beck's Bismuth Paste, was official in N.F. VIII.
In a number of cases the injection of the bismuth
paste into abscess cavities has led to bismuth
poisoning. Thorkildsen (Nord. Med., 1950. 44,
1786) reported clearing of open or closed tuber-
culous empyema following repeated injections of
10 per cent bismuth subnitrate in petrolatum
into the lesion. BIPP, an ointment of bismuth
subnitrate 220 Gm., iodoform 440 Gm. and petro-
latum 220 Gm. was much used in England as a
wound dressing. Wilson and Luikart (Arch.
Dermat. Syph., 1951, 64, 580) used a putty com-
posed of 86 per cent bismuth subnitrate and 16
per cent anhydrous wool fat to shield normal skin
during roentgen irradiation of tumors; this putty
was as effective as 1 mm. of lead as a shield.

Even when applied to raw surfaces bismuth
subnitrate undergoes some chemical change and
sufficient nitrite may be absorbed to cause serious
methemoglobinemia, which may terminate fatally.
The symptoms of bismuth poisoning which have
followed the surgical use of bismuth subnitrate
are as follows: There appears first a bluish fine
on the edges of the gum which spreads and be-
comes darker in color until the whole tongue and
pharynx are almost black. There also develops
ulcerative stomatitis with salivation, nephritis,
vomiting, and in some cases mental disturbances;
methemoglobinemia, as noted above, is also ob-
served. The mortality in this poisoning is high.

Part I

Bismuth Subsalicylate 177

Oxygen inhalation and blood transfusions are
indicated. E

Dose, from 0.3 to 2 Gm. (approximately 5 to
30 grains).

Storage. — Preserve "in well-closed contain-
ers." N.F.

Off. Prep.— Bismuth Magma; Bismuth Sub-
nitrate Tablets; Compound Resorcinol Ointment,
N.F.

BISMUTH SUBNITRATE TABLETS.
N.F.

[Tabellae Bismuthi Subnitratis]

"Bismuth Subnitrate Tablets yield an amount
of Bi203 not less than 73 per cent and not more
than 85 per cent of the labeled amount of bismuth
subnitrate." N.F.

Usual Sizes. — 5 and 10 grains (approximately
0.3 and 0.6 Gm.).

BISMUTH SUBSALICYLATE.
U.S.P. (B.P.) LP.

Basic Bismuth Salicylate, [Bismuthi Subsalicylas]

"Bismuth Subsalicylate is a basic salt which,
dried at 105° for 3 hours, yields upon ignition
not less than 62 per cent and not more than 66
per cent of Bi203." U.S.P. The B.P. defines Bis-
muth Salicylate as a basic salt of varying com-
position; on ignition it leaves not less than 63.0
per cent and not more than 67.0 per cent of resi-
due. The LP. requires Bismuth Subsalicylate to
contain not less than 62.0 per cent and not more
than 67.0 per cent of Bi203.

B.P. Bismuth Salicylate; Bismuthi Salicylas. Bismuth
Oxysalicylate; Bismuthyl Salicylate. Bismutum Subsal-
icylicum; Salicylas Bismuthicus Basicus. Fr. Salicylate
basique de bismuth; Salicylate de bismuth officinal. Ger.
Basisches Wismutsalizylat ; Wismutsubsalicylat. It. Sali-
cilato basico di bismuto. Sp. Salicilato de bismuto;
Subsaiicilato de Bismuto.

A number of methods for preparing this salt
have been reported in the literature. Wolff reacted
a glycerin solution of bismuthous nitrate with a
concentrated aqueous solution of sodium sali-
cylate. Fischer and Griitzner precipitated bismuth
hydroxide by adding ammonia to a solution of
bismuth trinitrate and then heated the precipitate
with salicylic acid in molecular proportion. Other
methods vary in the manner of preparing the
bismuth hydroxide with which salicylic acid is
reacted. Bracaloni (Boll, chitn. farm., 1938, 77,
605) pointed out the necessity of continued wash-
ing of freshly prepared bismuth subsalicylate in
order to obtain a residue of constant composition.
He also recommended that preparations of this
salt containing less than 60 per cent Bi203 should
not be used in preparing oil suspensions for thera-
peutic use since such samples give a hard, yellow-
ish white deposit adhering to the bottom of the
vial after sterilization at 100° for one hour. The
bismuth is combined not only with the hydrogen
of the carboxyl group but with the hydrogen of
the phenolic group as well, hence it is not a true
salt of bismuth and salicylic acid.

Description. — "Bismuth Subsalicylate is a
white or nearly white, amorphous, or microcrystal-

line, odorless powder. It is stable in air, but is
affected by light. Bismuth Subsalicylate is prac-
tically insoluble in cold water." U.S.P.

Standards and Tests. — Identification. — (1)
A yellow residue, responding to tests for bismuth
and blackened by hydrogen sulfide, is produced on
heating bismuth subsalicylate. (2) A deep violet
blue mixture results when 100 mg. of bismuth
subsalicylate is agitated with a solution of 5 drops
of ferric chloride T.S. in 10 ml. of water. Loss on
drying. — Not over 3 per cent, when dried at 105°
for 3 hours. Nitrate. — A mixture of 50 mg. of
bismuth subsalicylate, 100 mg. of sodium sali-
cylate and 5 ml. of water, superimposed on 5 ml.
of sulfuric acid, produces no pink or brownish
red color at the zone of contact. Other tests. —
3 Gm. of bismuth subsalicylate is ignited and
from the residue a dilute nitric acid extract is
prepared; portions of this solution meet the re-
quirements of the tests for sulfate, copper, lead,
and silver described under bismuth subcarbonate.
Free salicylic acid. — 1 Gm. of bismuth subsali-
cylate yields not more than 5 mg. of material
soluble in 20 ml. of chloroform. Alkalies and
earths. — Not over 5 mg. of a sulfated residue of
alkalies and earths is obtained from 2 Gm. of bis-
muth subsalicylate. Arsenic. — The limit is 10 parts
per million. U.S.P. The B.P. and LP. specify an
arsenic limit of 2 parts per million.

Assay. — About 1 Gm. of bismuth subsalicylate,
dried at 105° for 3 hours, is ignited, then dissolved
in nitric acid, the solution evaporated to dryness
and the resulting residue carefully ignited to con-
stant weight as Bi203. The weight of the residue
is not less than 62 per cent and not more than
66 per cent of the weight of the dried sample.
U.S.P.

Uses. — Bismuth subsalicylate was originally in-
troduced for the treatment of enteritis on the
theory that it would exert not only the protective
action of the insoluble bismuthyl salts but also
would be slowly changed in the intestines with
liberation of salicylic acid, which would exert an
antiseptic action. Any such action, however, is
likely to be very feeble in an alkaline medium
(see Salicylic Acid).

As an antisyphilitic the subsalicylate has been
the most frequently employed form of bismuth.
It forms the basis of a number of proprietary anti-
luetic mixtures. As stated elsewhere (see under
Bismuth) the antisyphilitic bismuth compounds
fall into two major groups — the soluble and the
insoluble — and there is a marked difference in the
effects produced. Following intramuscular injec-
tion of one of the insoluble compounds, usually
in suspension in a neutral vegetable oil, absorption
is slow but continuous, so that the system remains
constantly under the influence of a low concentra-
tion of bismuth. An oil suspension is official in the
U.S.P. (see following).

With repository penicillin assuming the im-
portant role in trie effective, short-term treatment
of all types of syphilis, the question of the com-
parative effectiveness of combined bismuth and
penicillin treatment is frequently raised. Levaditi
(Presse med., 1950, 58, 1397) found combined
treatment with long-acting penicillin and bismuth

178 Bismuth Subsalicylate

Part I

the most effective treatment of experimental
syphilis in rabbits. Johnwick (/. Ven. Dis Inform.,
1950, 31, 303) concluded that nothing was gained
by the addition of bismuth and arsenic in the
treatment of asymptomatic neurosyphilis with
penicillin. Jones (Ohio State M. J., 1951, 131)
observed that the addition to penicillin therapy of
eight weekly treatments with bismuth and an
arsenical proved somewhat more effective in the
treatment of primary syphilis than did penicillin
alone. Plotke et al. (Am. J. Syph. Gonor. Ven.
Dis., 1950, 34, 425) obtained, at the Chicago
Intensive Treatment Center, the most satisfactory
outcome in early syphilis using a combination of
penicillin, bismuth and an arsenical, with a lower
percentage of treatment failures; with the com-
bined schedule, however, the incidence of treat-
ment reactions increased. Sulzberger (Year Book
Dermat. Syph., 1952, 322) observed that, from a
public health point of view, the results achieved
with penicillin alone in early syphilis appear to be
as satisfactory as with the combined treatment,
and early clinical and serologic response has been
highly satisfactory.

Saunders (Am. J. Trop. Med., 1937, 17, 335)
found 6 injections of bismuth subsalicylate, at
weekly intervals, to be effective in yaws; the in-
cidence of relapse, however, was greater than with
arsenical therapy. Cox and Hodas (N. Y. State J.
Med., 1945, 45, 741) advocated weekly intra-
muscular injections in the treatment of Vincent's
angina (trench mouth). Of 150 patients with
Vincent's angina treated by Grosmann (Illinois
M. J., 1946, 89, 28), 90 per cent were cured with
2 intramuscular injections of 3 and 4 grains, re-
spectively, in oil. A third injection of 4 grains
was required for the others. Procaine penicillin
(q.v.) has replaced the heavy metals in the treat-
ment of all treponemal diseases.

Douthwaite (Brit. M. J., 1944, 2, 276) treated
12 cases of rheumatoid arthritis with weekly in-
jections for 10 weeks with good results in 4 and
temporary relief (for 8 weeks) in 4 cases; 11 of
these patients had failed to respond previously to
therapy with gold salts. On the theory that the
common wart is due to an infection with a filter-
able virus, Lurie (J.A.M.A., 1934, 103, 1399)
employed intramuscular injections of bismuth
subsalicylate with asserted success.

Seifter and McDonald (J.A.M.A., 1943, 123,
149) reported a case in which 9 ml. of an oil in-
jection (675 mg. of bismuth) was accidentally
administered in a single dose. Pigmentation of the
mucous membranes, ulcerative stomatitis and
pharyngitis, fever, leukocytosis and albuminuria
developed, but the patient recovered. During 24
days he excreted 37 per cent of the bismuth in
the urine; the injection area was incised and
drained but none of the bismuth was discharged
through the incision. The maximum urinary con-
centration was 16 mg. on the fifth day (for toxic
effects of bismuth compounds see Bismuth), [v]

The usual dose of bismuth subsalicylate, as an
antisyphilitic drug, is 100 mg. (approximately lJ/2
grains), injected intramuscularly, at weekly in-
tervals; the maximum safe dose is 200 mg. For
therapeutic programs with arsenicals see under
Oxophenarsine Hydrochloride. The dose as a gas-

trointestinal protective is 0.6 to 2 Gm. (approxi-
mately 10 to 30 grains), administered orally.

Storage. — Preserve "in well-closed, light-re-
sistant containers." US.P.

BISMUTH SUBSALICYLATE
INJECTION. U.S.P. (LP.)

[Injectio Bismuthi Subsalicylates]

"Bismuth Subsalicylate Injection is a sterile
suspension of bismuth subsalicylate in oil. It con-
tains an amount of bismuth (Bi) equivalent to
not less than 53 per cent and not more than 62 per
cent of the labeled amount of bismuth subsali-
cylate." U.S.P.

The LP. Injection of Bismuth Subsalicylate is
a sterile suspension of bismuth subsalicylate in
arachis oil containing 1.0 per cent w. v each of
camphor and phenol; the injection is prepared by
aseptic trituration of the bismuth compound with
previously sterilized oil, containing the camphor
and phenol. The content of Bi is not less than
53.0 per cent and not more than 62.0 per cent of
the labeled amount.

Ampuls of Bismuth Subsalicylate. Ampullae Bismuthi
Subsalicylates. Sp. Inyeccion de Subsalicilato de Bismuto.

Most of the preparations of this injection on
the market are made with peanut oil as a vehicle;
other oils, such as olive and cottonseed, may also
be employed. Chlorobutanol, in 3 per cent con-
centration, is commonly employed as a local anes-
thetic and antiseptic. In one preparation, Stabisol
(Squibb), a more fluid and less viscous suspension
is obtained by using 20 per cent of ethyl oleate in
the oil vehicle, together with about 0.015 per cent
of calcium oleate as an emulsifier.

Uses. — For the uses and dose of this injection
see the preceding article. It is always given intra-
muscularly and a brief discussion of the technique
of injection is here in order. The patient should
he prone and fully relaxed, with the heels rotated
outward and the toes inward to produce relaxation
of the gluteal muscles. The injection should be
given near the inner angle of the outer and upper
quadrant of the gluteal region where there are
fewer blood vessels and nerves and on which area
the patient does not sit. The site of injection
should be palpated carefully to avoid making the
injection into an area of induration. After thor-
ough shaking of the preparation to be injected.
1 ml. is aspirated into a sterile 2 -ml. syringe and a
sterile 20 or 22 gauge needle, \Yz to 2 inches long,
is attached. After applying an antiseptic the but-
tock is drawn downward with one hand and held
in the position until the needle has been inserted;
this permits closing of the needle track by the
tissues after the needle is withdrawn. The syringe
is held between the index and middle fingers and
the thumb of the free hand and, with a wrist
motion only, the needle is plunged boldly into the
muscle pointed upward and slightly medial at an
angle of about 70° with the skin; a slow pushing
movement should be avoided. Before making the
injection the plunger of the syringe should be
pulled back several times to make certain that a
blood vessel has not been penetrated. If the least
amount of blood appears in the syringe, or if the
patient complains of pain radiating into the thigh

Part I

Blood, Citrated Whole Human 179

or leg, the needle should be withdrawn and the
injection made into another location. The butt
of the needle is held with one hand to steady it
while the injection is made. Injection into a blood
vessel results in serious embolic manifestations;
disabling causalgia has resulted from careless in-
jection of bismuth subsalicylate into the sciatic
nerve sheath.

The usual dose of bismuth subsalicylate is 100
mg. (approximately 1J^ grains), injected intra-
muscularly, at weekly intervals; the maximum
safe dose and the total dose in 24 hours are
200 mg.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I, Type
III or Type IV glass. Protect the Injection from
light." U.S.P.

Usual Sizes. — 1 ml. containing 100 or 120 mg.
(approximately \Yz or 2 grains); also multiple
dose containers.

BITHIONOL. U.S.P.

2,2'-Thiobis(4,6-dichlorophenol)

OH OH

ci^<^\^s^^4. Ci

"Bithionol, dried at 105° for 4 hours, contains
not less than 97 per cent and not more than 103
per cent of C12H.6CI4O2S." U.S.P.

Actamer (Monsanto Chemical Co.)

Bithionol, a bacteriostatic agent active in the
presence of soap, was synthesized by Muth in
1933 by interaction of 2,4-dichlorophenol and
sulfur chloride (German Patent No. 583,055).
Structurally it is related to hexachlorophene, the
two compounds being used for the same purposes.

Description. — "Bithionol occurs as a white
or grayish white, crystalline powder. It is odor-
less or has a slight aromatic or phenolic odor.
Bithionol is insoluble in water. It is freely soluble
in acetone, in alcohol and in ether. It is soluble
in chloroform and in dilute solutions of fixed
alkali hydroxides. Bithionol melts between 186°
and 189°." U.S.P.

Standards and Tests. — Identification. — (1)
A transient purple color develops immediately on
adding a drop or two of ferric chloride T.S. to a
solution of 50 mg. of bithionol in 5 ml. of alcohol.
(2) On adding 2 or 3 drops of a 1 in 20 solution
of titanium trichloride to a solution of 100 mg.
of bithionol in 0.5 ml. of acetone, in a test tube,
and shaking, a yellow-orange oil separates in the
top layer (distinction from hexachlorophene,
which separates in the bottom layer). (3) Addi-
tion of lead acetate T.S. to a solution of a sodium
fusion of bithionol produces a black precipitate
(distinction from hexachlorophene, which gives
no precipitate). Loss on drying. — Not over 1 per
cent, when dried at 105° for 4 hours. Residue on
ignition. — Not over 0.1 per cent. U.S.P.

Assay. — About 1.4 Gm. of bithionol, previ-
ously dried at 105° for 4 hours, is dissolved in

acetone and the solution slowly titrated with 0.1
N sodium hydroxide, the end-point being deter-
mined potentiometrically. In the titration one of
the phenolic hydrogens is neutralized. A blank
titration is performed on acetone to neutralize any
acidity it may have. Each ml. of 0.1 N sodium
hydroxide represents 35.61 mg. of C12H6CI4O2S.
U.S.P.

Uses. — Bithionol is a bacteriostatic agent
which is compatible with and retains its activity in
the presence of soap; in these respects it resembles
hexachlorophene, to which it is related chemically.
The ready availability of bulk bithionol has re-
sulted in its being rather widely used in the for-
mulation of surgical soap compositions by hospital
pharmacists.

In a bar soap, a concentration of 2 per cent of
bithionol was observed to reduce the number of
resident bacteria on the skin by 97 per cent after
12 days of daily use; a 1.5 per cent concentration
effected a reduction of 94 per cent, and a 1 per
cent concentration a reduction of 92 per cent
(Hunter et al., Am. Perfumer, 1953, 61, 122). A
high degree of "substantivity" apparently brings
about a rapid and cumulative adherence of re-
sidual bithionol on the skin. It is particularly
effective against the Gram-positive cocci that
comprise a considerable proportion of the normal
flora of the skin and which are believed to cause
body odor and skin infections. The antimicrobial
activity of bithionol is inhibited by the presence
of body fluids.

Hopper et al. {Bull A.S.H.P., 1953, 10, 199)
prepared a solution of soap (made from coconut
oil fatty acids) containing 3 per cent of bithionol,
to be used as a surgical scrub in a hospital; it was
found to be highly effective in reducing the bac-
terial count on hands. When the concentration of
bithionol was reduced to 2 per cent the effective-
ness of the preparation was markedly reduced.

The acute and chronic toxicity of bithionol are
low. Patch tests disclosed no reactions other than
an occasional mild irritation attributable to the
soap vehicle employed for the bacteriostatic agent
(see Hunter et al., loc. cit.).

Bithionol is used in the formulation of liquid
and solid soap compositions for use in hospitals
as a surgical scrub or otherwise. While the solu-
bility of bithionol in water is very low, its solu-
bility increases with increasing pH through con-
version of a phenolic hydroxyl to a salt; thus soap
increases its solubility in water, especially if suf-
ficient alkali is provided to react with a phenolic
group of bithionol. It is to be noted that the bac-
teriostatic activity of bithionol is markedly re-
duced in the presence of Tween 80, according to
Erlandson and Lawrence {Science, 1953, 118,
274).

Storage. — Preserve "in tight, well-closed con-
tainers." U.S.P.

CITRATED WHOLE HUMAN
BLOOD. U.S.P., (B.P.)

Citrated Whole Blood (Human)

"Citrated Whole Human Blood is blood which
has been drawn under rigid aseptic precautions
and which is protected from coagulation by the

180

Blood, Citrated Whole Human

Part I

presence of a suitable volume of Anticoagulant
Acid Citrate Dextrose Solution. Only those per-
sons may serve as a source of Citrated Whole
Human Blood who are in physical condition to
give blood and are free of those diseases trans-
missible by transfusion of blood, as far as can be
determined from the donor's personal history and
from such physical examination and clinical tests
as appear necessary for each donor on the day
upon which the blood is drawn." U.S.P. The B.P.
definition is essentially similar.

B.P. Whole Human Blood.

This monograph describes certain properties
and uses of whole blood. Certain derivatives of it
are also official, and are described in separate
monographs under the titles Normal Human
Serum Albumin, Normal Human Plasma, Human
Serum, Thrombin, Concentrated Red Blood Cor-
puscles, Human Fibrin Foam, and Human Fibrin-
ogen.

Description.— "Citrated Whole Human Blood
is a deep red, opaque liquid from which the cor-
puscles readily settle upon standing for 24 to 48
hours, leaving a clear, yellowish or reddish super-
natant layer. If the blood has been drawn soon
after the donor has eaten, it may, on standing,
acquire a layer of fat-like material near its sur-
face." U.S.P. Citrated whole human blood com-
plies with the requirements of the National Insti-
tutes of Health of the United States Public
Health Service.

Uses. — Citrated whole human blood is used for
transfusion when it is desirable to administer the
cellular blood elements as well as to increase the
volume of the fluid portion of the blood of a
patient. It is indicated for acute and chronic
hemorrhage, secondary shock, blood dyscrasias,
acute and chronic infections and various other
pathologic states.

It is impossible to give detailed consideration
to all purposes for which transfusion of human
blood is employed. In general they may be
grouped into four categories: (1) to replenish
hemoglobin in various forms of anemia; (2) to
introduce various types of antibodies in cases of
infection; (3) to restore blood volume after
hemorrhage or in severe dehydration; (4) to
raise the protein content of blood in hypopro-
teinemia.

Methods of blood transfusion may be classified
as (1) direct, in which whole blood, unmodified,
is transferred directly from donor to recipient,
and (2) indirect, in which blood is collected while
it is simultaneously citrated, and then is even-
tually injected into the recipient. Because of the
difficulties involved in direct transfer of large
volumes of blood from donor to recipient in the
few minutes available between withdrawal and
coagulation of blood the indirect method is more
commonly employed.

The history of blood transfusion may go as far
back as 1492, when it is believed that transfusion
may have been attempted on Pope Innocent VIII.
Many men of many nations have, however,
claimed the distinction of having made the first
transfusion. Most early attempts involved trans-
fusion of animal blood to man; in some instances

the patient survived. James Blundell would ap-
pear to have actually been the first to transfuse
blood from man to man, in 1818. In the United
States Austin Flint may have been the first to
infuse blood, in 1860. Many physicians have con-
tributed to make transfusion successful {J. A.M. A.,
1941, 117 1627). The basic discoveries were (1)
that agglutination and destruction of red cells
occurred in the recipient animal when blood from
a different animal species was added (Bordet,
1895; Erhlich and Morganroth, 1900); (2) the
identification of three human blood types by
Landsteiner in 1901, and a fourth by De Costello
and Sturli in 1902; (3) the complete classification
of the four main blood types and a method for
determining them, worked out by J. Jansky in
Bohemia in 1907 and independently by W. L.
Moss in the United States in 1910; (4) the pre-
vention of coagulation by use of sodium citrate,
discovered independently by several investigators,
the first probably being A. Hustin of Belgium
(1914); (5) the development of aseptic technics
of handling blood; (6) the discovery in 1940 by
K. Landsteiner and A. S. Wiener {Proc. S. Exp.
Biol. Med., 1940, 43, 223) of the various Rh fac-
tors which occur in about 85 per cent of the
population in the United States. The ready avail-
ability of citrated whole human blood has made
transfusion a procedure of increasing frequency,
although direct transfusion with compatible
whole blood is less likely to cause untoward reac-
tions in the recipient.

Blood Grouping and Rh Typing Sera. — Safe
blood transfusion requires that the blood of the
recipient and donor be classified as to group and,
particularly in the case of pregnancy or multiple
transfusions, that the bloods be typed in relation
to the Rh factor.

For the determination of compatibility for
transfusion, human blood is divided into four
groups. Three classifications of blood grouping are
recognized as follows:

Blood Grouping Classifications

Landsteiner 's
or Inter-
national

Classification

Jansky's
Classifi-
cation

Moss's
Classifi-
cation

Incidence
in Man

O
A
B
AB

Group I
Group II
Group III
Group IV

Group IV
Group II
Group III
Group I

45%
39%
12%

The Landsteiner, or International Classifica-
tion (Landsteiner, The Newer Knowledge of Bac-
teriology and Immunology; Chicago, University
of Chicago Press, 1928, p. 893), is the system in
general use and the one used for designation of
human blood grouping sera as recognized by
U.S.P. and the National Institutes of Health.
Groups A and AB may be divided further into
subgroups Ai and A2 and into AiB and A2B re-
spectively (Wiener, Blood Groups and Transfu-
sions, 3rd ed., Springfield, Illinois, Charles C
Thomas, 1943, p. 198). These subgroups occur
because of the variation of the A agglutinogen.
Blood specimens giving the strongest reactions

Part I

Blood, Citrated Whole Human

181

contain Ai and are classified as Ai or AiB. Blood
specimens containing a weaker antigen are classi-
fied as subgroup A2 or A2B. Subgrouping of
group A and group AB individuals is done by
means of special anti-A serum known as Absorbed
Anti-A Serum (Anti-A). This serum will produce
clumping of erythrocytes which contain the Ai
antigen and give a negative reaction with blood
specimens of the A2 and A2B subgroups. The
chief applications of subgrouping are in forensic
medicine and in the study of transfusion reactions.
Applications of subgrouping in cases of disputed
paternity is limited by the difficulty of subgroup-
ing blood from newborn infants.

Grouping of blood is possible because of two
main antigenic substances (agglutinogens) in the
red cells and the two main antibodies (agglutin-
ins) in the plasma. The antigens in the red cells
are named A and B, and the antibodies in the
plasma are designated to correspond with the
group of red cells that they agglutinate — anti-A
and anti-B. Thus, use of only two test sera makes
it possible to classify any sample of blood into
one of the four groups. The test is performed by
mixing a sample of the subject's blood (red blood
cell suspension) with the test serum, either on a
microscope slide or in a small test tube. The re-
action, or agglutination, between the blood and
test sera is macroscopically apparent in 3 to 20
minutes, depending upon the technic used. The
four groups of blood react with sera according to
the following scheme:

Sera of Groups

Cells of Groups

0
A
B
AB

—

+
+

+
+
+

— — No agglutination + = Agglutination

If there is no agglutination of red blood cells
under test, with either anti-A or anti-B serum, the
blood group is O. If there is agglutination with
both anti-A and anti-B sera the blood group is
AB. If there is agglutination with anti-A serum
only, the blood group is A. If there is agglutina-
tion with only anti-B serum the blood group is B.
Using the two official anti-sera, blood tested reacts
in the following manner:

Test Sera

Cells Tested (Group)

Anti-A Serum
Anti-B Serum

—

+
+

"Anti-A Blood Grouping Serum is derived from
high-titered serums of humans, with or without
stimulation by the injection of group-specific red
cells or substances. It agglutinates human red
cells containing A-agglutinogens; i.e., blood
groups A and AB (including subgroups Ai, A2,
As, AiB, and A2B). It may contain a suitable anti-
bacterial preservative." U.S.P.

"Anti-B Blood Grouping Serum is derived from
high-titered serums of humans, with or without

stimulation by the injection of group-specific red
cells or substances. It agglutinates human red
cells containing B agglutinogens; i.e., blood
groups B and AB (including subgroups AiB and
A2B). It may contain a suitable antibacterial
preservative." U.S.P.

Blood grouping sera are obtained from profes-
sional donors (Weiner et al., J.A.M.A., 1953, 151,
1441) who, usually, have been immunized by the
injection of group specific red cells (A or B).
The blood is withdrawn by aseptic surgical pro-
cedure; the volume withdrawn is dependent upon
the donor's capacity to give. The collected blood
is allowed to clot and the serum removed imme-
diately on separation. The freshly drawn serum
is inactivated by heating in a water bath at 56° C.
for 10 minutes after which it is titrated for avidity
and isohemagglutinins in comparison with the
Standard Reference Serum of the National Insti-
tutes of Health of the United States Public
Health Service, with whose requirements the
serum must conform before distribution is per-
mitted. For further description and information
concerning tests applied see U.S.D., 1950 Edition,
p. 1992-4.

For the purpose of transfusion the donor and
recipient should be of the same blood group.
Theoretically, 0 group blood may be used uni-
versally (v.i.) since O group cells contain neither
A nor B agglutinogens. Following the determina-
tion of group, the safest procedure is properly to
match the bloods of donor and recipient by cross
agglutination. For this test samples of donor's
and recipient's blood are collected in tubes con-
taining dry oxalate sufficient to prevent clotting,
followed by centrifuging of a portion to collect
cells and plasma from each sample. A mixture of
the donor's whole blood and ihe recipient's ox-
alated plasma, and of the donor's oxalated plasma
and the recipient's whole blood is made on a glass
slide and observed about 5 minutes for agglutina-
tion. The test also may be made in test tubes
using a 2 per cent suspension of cells, instead of
whole blood, with oxalated plasma. If no agglu-
tination occurs, in either test, the donor's and
recipient's bloods are compatible. The omission
of any safety precaution with regard to transfu-
sion is rarely justified. Cross agglutination is
always desirable and the delay it causes may
usually be bridged by the administration of plasma
or dextrose solution.

The absence of group A and group B factors in
group O erythrocytes eliminates, theoretically, the
possibility of agglutination occurring between red
cells of the donor and the anti-A and anti-B ag-
glutinins of the patient's serum. However, the
use of group 0 blood is not always safe because
of the presence of high concentrations of anti-A
and anti-B isoagglutinins in the sera of certain
donors. To make group 0 blood universally ac-
ceptable it should be conditioned by the addition
of blood group specific substances A and B. These
purified group specific substances are polysac-
charide-amino acid complexes that are capable of
reducing the titer of the anti-A and anti-B iso-
agglutinins of group 0 blood. Group specific sub-
stance A is usually isolated from hog gastric
mucin and group specific substance B is usually

182 Blood, Citrated Whole Human

Part I

isolated from the glandular portion of horse gas-
tric mucosa. Blood group specific substances A
and B may be added to group 0 blood at the time
of collection, or, since the neutralization of iso-
agglutinins is immediate, at the time of adminis-
tration. Group 0 blood conditioned with blood
group specific substances A and B is rarely re-
sponsible for reactions due to the presence of
anti-A or anti-B isoagglutinins, particularly if the
absence of isoagglutinins has been demonstrated.

Grouping of blood into the various groups,
done by the use of anti-A and anti-B blood
grouping sera, may be confirmed by the use of
anti-A. B blood grouping serum (group 0 serum).
This serum contains both anti-A and anti-B ag-
glutinins. Bloods of groups Ai, A2, B, AiB and
A2B will react with this serum while only group 0
blood will fail to be agglutinated. This test serum
is also valuable in rapid screening for universal
donor blood.

Effect of Parents' Blood Groups. — Blood
groups are inherited as dominant characteristics
according to the Mendelian law: for every in-
herited characteristic, including blood group,
there is a pair of genes, one contributed by each
parent. The blood group that a child can inherit
is therefore dependent on the combinations re-
sulting from genes contributed by both parents.
Intermarriage of parents with different blood
groups results in a variety of combinations, but
if the parents' blood groups are known, those pos-
sible for the child can be predicted:

Parents'

Possible

Blood Groups

Blood Group of Child

OxO

Ox A

0,A

OxB

0,B

Ax A

0,A

AxB

0. A. B. AB

BxB

O.B

OxAB

A,B

AxAB

A, B,AB

BxAB

A. B.AB

AB x AB

A.B.AB

Blood groups are inherited and never change.
For this reason they may have legal importance
in identifying bloodstains or in determining par-
entage in a negative sense.

M and N Factors. — In 1927 Landsteiner and
Levine found that injection of rabbits with hu-
man red cells of group O resulted in the produc-
tion of two specific anti-sera which they called
anti-M or anti-N. Although M and N factors of
human blood are rarely antigenic in man, their
determination is useful in forensic medicine, an-
thropological investigations, and red cell survival
studies. Landsteiner and Levine showed that the
M and N factors are alleles of equal dominance
and are transmitted according to the Mendelian
laws of heredity. All individuals have M, N, or
MN in their blood. The possible reactions with
anti-M and anti-N sera are thus:

Anti-M

Sir a

Anti-N

Sera

Pheno-
type

Geno-
type

Incidence
(White, U. S.)

+
+

M
N
MN

30%
22%
48%

The simple mode of inheritance makes the M
and N factors especially useful in paternity test-
ing. The possible findings in various matings are
as follows:

Types of
Parents

Per Cent of children in

Parentage

Type
M

Type
X

Type
MN

excluded if
child is type

MxM
NxN

MxN
M x MX
X xMX
MX x MX

100
0
0

50
0

100

N or MN

M or MN

MorN

Xone

If M blood is given to an X recipient then
tests with anti-M and anti-X sera will show a
mixture of both clumped and freely suspended
cells. The proportion of agglutinated to free cells
is the same as the proportion of the volume of
donor's blood to the volume of recipient's blood.
Thus, if 500 ml. of M blood is transfused into a
type N recipient who has a blood volume of 4500
ml. then tests with anti-M and anti-N sera will
show 10 per cent of the cells clumped with the
anti-M serum (with 90 per cent free) and 90 per
cent of the cells clumped with the anti-N serum
(with 10 per cent free). Repeated tests will show
how much transfused donor's blood remains in
the recipient over given periods of time.

Anti-M and anti-N sera are prepared by the
hyperimmunization of rabbits with the appropri-
ate O group antigens. After collection the rabbit
serum is absorbed to remove species specific anti-
bodies.

Rh Factors. — Determination of the Rh type
of donor and recipient, for transfusion purposes,
is as important as the determination of blood
group. For this purpose there are available Anti-
Rh Typing Sera. While numerous sub-types are
recognized, the two sub-types most commonly
used in clinical tests of this nature are Anti-Rha'
and Anti-Rho".

Anti-Rho Typing Serum is specific for the Rho
factor. It agglutinates all human red cells contain-
ing Rho factor (types Rho, Rho', Rho". Rho'Rho");
it does not agglutinate cells containing only rh'
and rh", nor rh (Rh negative) cells.

"Anti-Rho' Typing Serum agglutinates all hu-
man red blood cells containing Rho and rh' fac-
tors (types Rho, Rho', Rho", Rho'Rho", rh' and
rh'rh"), but does not agglutinate cells containing
rh" factor alone, nor rh type cells." U.S.P.

"Anti-Rho" Typing Serum agglutinates all hu-
man red blood cells containing Rho and rh" fac-
tors (types Rho, Rho', Rho". Rho'Rho", rh" and
rh'rh"X but does not agglutinate cells containing
rh' factor alone, nor rh type cells." U.S.P.

Part I

Blood, Citrated Whole Human

183

Anti-Rh typing serums are clear, slightly yel-
lowish fluids which may develop slight turbidity
on aging. The dried serums are light yellow to
deep cream color.

Isoimmunization. — In 1939 Levine and Stetson
(J.A.M.A., 1939, 113, 126) offered an explanation
for the origin of an atypical agglutinin held to be
the cause of a severe reaction in a recently preg-
nant woman at the time of her first transfusion.
The serum of this group 0 patient, who had de-
livered a macerated fetus, agglutinated the cells
of about 80 per cent of group 0 individuals. It
was suggested that the fetus inherited a dominant
agglutinable factor from the father but which
was not present in the mother's blood. Isoim-
munization could then have resulted from the
transplacental passage of minute quantities of
fetal red blood cells into the mother's circulation.
This concept of placental isoimmunization paved
the way for the subsequent findings on the patho-
genesis of erythroblastosis. In 1940 Landsteiner
and Wiener (Proc. S. Exp. Biol. Med., 1940, 43,
223) were investigating a factor in the red blood
cells of rhesus monkeys related to, but not identi-
cal with, the human M factor. In the course of
their studies of the reactions of human blood with
an anti-rhesus serum produced in rabbits, another
factor was differentiated and was called Rh (using
the first two letters of the word rhesus). This
factor was subsequently found to be identical
with the human blood factor previously described
by Levine and Stetson.

The clinical significance of the Rh factor soon
became apparent as the antigenicity of this new
blood factor was demonstrated. Levine and his
co-workers (Am. J. Obst. Gyn., 1941, 42, 925)
investigated the blood of a number of patients
similar to the one described in the report with
Stetson. In each case there was a severe or fatal
reaction, occurring at the time of the first trans-
fusion, in a woman who had recently delivered a
child. The obstetrical histories of these women
were striking in that there was a high incidence
of fetal and neo-natal morbidity. It was suggested
that the phenomenon of isoimmunization with
fetal blood, responsible for intra-group transfu-
sion reactions, was directly correlated with the
fetal and neo-natal morbidity due to one or an-
other form of erythroblastosis fetalis. The intra-
uterine blood destruction was brought about by
the action of the maternal antibodies which
found their way into the fetal circulation to re-
act with and destroy the Rh positive blood of
the fetus. In the majority of cases of erythro-
blastosis fetalis the mother is Rh negative and the
father Rh positive. When there is a thinning of
the chorionic villus, during the latter third of
pregnancy, minute quantities of fetal red blood
cells, carrying the inherited Rh positive factor
from the father, find their way into the maternal
circulation. With this stimulus the mother pro-
duces Rh antibodies which readily pass into the
fetal circulation with subsequent destruction of
the fetal Rh positive red blood cells.

The Rh factor occurs with the following fre-
quency :

White (U. S.)

Negro

Chinese

Rh negative

15%
7%
1%

It is significant that among the Chinese erythro-
blastosis fetalis is a very rare disease.

A basic group of six related factors, commonly
referred to as the Rh-Hr system, has been de-
scribed by investigators in the United States and
England. These have been designated by Fisher
and Race as D-d, C-c, and E-e, while Wiener has
used the symbols Rho-Hr<>, rh'-hr', and rh"-hr".
Each factor has been discovered by means of its
specific antibody in the serum of individuals im-
munized by pregnancy or transfusion. The anti-
body formed most frequently is anti-Rho which
reacts with 85 per cent of the white U. S. popu-
lation and thus reveals Rho, the original Rh an-
tigen.

Considerable confusion has resulted from the
use of several nomenclatures. The two principal
nomenclatures for the Rh-Hr sera are as follows:

Sera Nomenclature

Incidence

Fisher-Race

Wiener

Positive

Negative

Anti-D

Anti-Rho

Anti-d

Anti-Hro

Anti-C

Anti-rh'

Anti-c

Anti-hr'

Anti-E

Anti-rh"

Anti-e

Anti-hr"

As shown, the original Rh factor is the most anti-
genic. The terms Rh positive and Rh negative as
used in clinical medicine have, therefore, come to
refer solely to the presence or absence of Rho
(D). Patients carrying rh' (C) or rh" (E) but
lacking Rho (D) are always listed as Rh negative,
but, for purposes of donating blood an individual
may be considered Rh negative only when he
lacks all three factors.

One or more transfusions, or injections, of Rh
positive blood may sensitize an Rh negative re-
cipient so that subsequent transfusions may cause
a serious reaction. If an Rh negative woman be-
comes pregnant and the fetus is Rh positive
(having inherited this factor from the father),
she may become sensitized to the Rh factor. It
may require several pregnancies for her to become
sufficiently sensitized to reach a dangerous level,
unless she has previously received a transfusion
of Rh positive blood. The Rh antibodies of the
mother may pass across the placenta into the
blood stream of the fetus and cause passive sensi-
tization of the fetus with destruction of its red
blood cells, causing severe anemia and the entire
symptom complex of erythroblastosis fetalis.
Such a fetus may die in utero, or if born alive
may require immediate or early transfusions of
Rh negative blood (v.i.). Considerable publicity
has been given to the Rh factor in the lay press,
resulting in usually unfounded fears in the preg-
nant woman. Rh incompatible matings occur in

184 Blood, Citrated Whole Human

Part I

only 13 per cent of all marriages. The majority of
Rh negative women do not produce anti-Rh anti-
bodies and those who do, as a result of pregnancy
with Rh positive children, will usually first have
at least two unaffected children. About SO per cent
of the Rh positive fathers in incompatible matings
will be heterozygous, so that half of the offspring
may be Rh negative. The incidence of erythro-
blastosis in all matings is 1 in 200 pregnancies
and in incompatible matings is 1 in 26 full term
pregnancies. With present-day knowledge and the
use of exchange transfusions the dangers to the
newborn have been greatly reduced.

Routine laboratory Rh typing and the trans-
fusion of only the proper Rh type blood has
markedly reduced intragroup transfusion reac-
tions. Mass blood typing programs have made
thousands of individuals familiar with their Rh
types and the Rh negative individual in a com-
munity is often called on for emergency trans-
fusion. Those individuals who form Rh antibodies
serve as donors for the needed Rh typing reagents.
Attempts to produce typing reagents for the Rh
factor from animals have been unsuccessful.

Blocking Antibody. — Anti-Rh serums of human
origin are of two general classes, depending upon
the response of the individual donor. In the one
instance Rh antibodies may be found in the serum
of sensitized individuals which will cause aggluti-
nation of Rh positive cells suspended in physio-
logic saline solution. This type of antibody is
designated by various workers as "complete,"
"heat-labile," "bivalent," etc. In other instances
and most frequently, Rh antibodies resulting from
sensitization to Rh positive cells will not agglu-
tinate, or only weakly agglutinate saline suspen-
sions of Rh positive cells but will agglutinate Rh
positive cells in the presence of a sufficient amount
of protein (serum or albumin). This type of anti-
body is designated as "blocking," "univalent,"
"heat-stabile," etc.

Coombs' Test. — The most specific and certain
test for blocking antibody is the indirect Coombs
test. The reagent is an antiglobulin prepared by
injecting human serum into rabbits. Antiglobulin
(human) precipitins develop in the rabbit and the
rabbit serum is assayed by the precipitin reaction
with normal human blood serum. The animal
serum is adsorbed with human erythrocytes of
many types to eliminate species specific agglu-
tinins; the antiglobulin (human) material re-
mains. For the indirect test, erythrocytes sus-
pended in isotonic saline solution are added to the
serum of the patient suspected of containing
partial antibodies against these cells and the mix-
ture is incubated at body temperature for 15 min-
utes. Then the cells are washed 3 times with fresh
saline solution and resuspended in a 2 per cent
suspension to which the antiglobulin reagent is
added and the mixture is then centrifuged at low
speed for a minute. On gentle shaking, the failure
of masses of erythrocytes to break up and resus-
pend evenly in the solution indicates that the cells
were coated with a globulin and the antiglobulin
reagent has caused precipitation of these globulin
particles on adjacent cells. These fragile masses
of erythrocytes represent a positive test and dem-
onstrate the presence of a blocking, univalent,

etc., antibody in the patient's serum for the sus-
pected cells. The direct Coombs test is usually
positive in erythroblastosis fetalis and in acquired
hemolytic anemia; for this test, the cells of the
patient, after washing with saline solution, are
added directly to the antiglobulin serum. A posi-
tive clumping of erythrocytes demonstrates the
presence of blocking antibody on the cells. The
utilization of this technic is essential in the selec-
tion of donors (cross-matching) for pregnant
women, erythroblastotic infants and instances of
acquired hemolytic anemia (v.i.).

Complete Rh typing is a complex technic and
should be done only by the fully experienced.
Because of the many variations in the typing sera
the specific recommendations of the manufacturer
should be followed explicitly.

"Anti-Rh Typing Serums comply with the ste-
rility, hemoglobin, potency and avidity tests and
other requirements of the National Institutes of
Health of the United States Public Health Service,
including the release of each lot individually
before their distribution." U.S.P.

"Anti-Rh Typing Serums should be stored at a
temperature between 2° and 10°, preferably at
the lower limit. Dispense them in the unopened
container in which they were placed by the manu-
facturer." U.S.P.

Blood Banks.— In 1936 Yudin (J.A.M.A., 106,
997) demonstrated that citrated blood could be
preserved by refrigeration and the reports of
Jeaneney (Progres med., No. 14, 1936) led to the
establishment of the so-called blood banks. The
corpuscles in whole blood undergo hemolysis in
a relatively short time even when properly refrig-
erated; the leukocytes and platelets begin to dis-
integrate in a few days and there is marked reduc-
tion in complement and antibodies (Am. J. Med.
Sc, 1939, 198, 631), but the red cells may remain
for two or three weeks. Many preservative solu-
tions, for addition to whole blood, have been pro-
posed; these commonly contain disodium or tri-
sodium citrate (citric acid being also added when
the latter is used) and dextrose. For a review of
the subject of blood preservation, see /. Parenteral
Therapy, 1945, 1, No. 4, p. 3.

In the fiscal year ending June 30, 1953, the Red
Cross obtained 4,121.250 pints of blood in the
United States (383,852 pints of this total were
received from cooperating blood banks) and dis-
tributed 2,329.600 pints for national defense pur-
poses and 1,791,650 pints to civilian hospitals
(J.A.M.A., 1954, 154, 702). It seems likely that
the amount of blood collected by blood banks in
hundreds of hospitals for current use in hospitals
exceeds that collected at Red Cross centers. These
figures illustrate the frequency with which blood
or plasma transfusions are performed in the prac-
tice of medicine. Although blood deteriorates dur-
ing storage and a limit of 21 days for its use is
necessary with current methods of collection and
preservation, wide experience has demonstrated
the safety and efficacy of "bank" blood for all the
common indications for transfusions. During stor-
age the concentration of hemoglobin and of potas-
sium increases in the plasma, the platelets and
the leukocytes disintegrate in a matter of hours,
and the complement, prothrombin and other com-

Part I

Blood, Citrated Whole Human

185

ponents decrease in the course of days, but Crosby
and Howard (Blood, 1954, 9, 439) reported use of
10 to 15 liters of stored blood in less than 6 hours
in exsanguinated, comatose battle casualties with-
out untoward effects.

Therapeutic Uses. — Blood transfusions are
used extensively in the treatment of severe hemor-
rhages, surgical shock, various anemias and bac-
terial infections. In conditions where the primary
need is for red blood corpuscles, it is often pos-
sible to obtain satisfactory results by the adminis-
tration of the corpuscles, resuspended in isotonic
sodium chloride solution or other suitable medium
(see Concentrated Human Red Blood Corpuscles,
in Part I). Kracke and Piatt (Kentucky M. J.,
1944, 42, 15) believe, for example, that certain re-
actions following transfusion of whole blood are
avoided when suspensions of red blood cells are
used. When the primary need is the restoration
of blood volume the readily available plasma or
a plasma expander is indicated. The economy of
using cells and plasma separately, if either can be
demonstrated to be as satisfactory as the whole,
is also an important consideration.

Erythroblastosis Fetalis (Hemolytic Disease of
the Newborn). — This disorder arises from the
presence in the fetus of a blood factor inherited
from the father which is not present in the mother
(v.s.). In 80 per cent of cases the Rh factor is
involved in the incompatibility (Allen et al., New
Eng. J. Med., 1952, 247, 379). Other blood fac-
tors may be involved, including a group A or B
infant with a group 0 mother, and the Kell, M, S,
Kidd, Duffy and possibly other factors (Allen
and Diamond. J.A.M.A., 1954, 155, 1212). The
fetus may not survive intrauterine life — so-called
"hydrops fetalis," which is characterized by
anasarca. In 15 to 20 per cent of infants with
blood factor incompatibility no untoward effects
on the infant have been recognized. In the re-
mainder, the infant usually appears normal at birth
but progressive jaundice and anemia appear in
about 24 hours and the condition known as
kernicterus develops and causes permanent dam-
age of the central nervous system, particularly
the extrapyramidal tracts. The prevention of
kernicterus requires prevention of the jaundice,
which can be accomplished by removing the sensi-
tized erythrocytes from the circulation of the
infant within the first 24 hours of extrauterine
life by means of an exchange transfusion. Since
advance preparation facilitates the accomplish-
ment of the exchange transfusion, it is recom-
mended that the blood type of both mother and
husband be determined at or before the third
month of pregnancy. If the mother is Rh negative
and the father Rh positive, an erythroblastotic
infant is possible and blood of the mother should
be studied at the seventh month of pregnancy. If
she shows an increase in anti-Rh titer at this time
an erythroblastotic infant is to be expected and a
donor with Rh negative blood which is compatible
with the mother's plasma should be selected to be
available at the time of delivery since no prenatal
therapy tried so far has proven of prophylactic
value. It is the impression of Allen and Diamond
that a female donor is preferable. At delivery,
blood is obtained from the infant (cord or heel)

for a Coombs test. If this test is positive, indi-
cating the presence of antibody attached to the
infant's erythrocytes, the exchange transfusion is
indicated immediately, particularly if the infant
is premature or the blood hemoglobin concentra-
tion is less than 14.5 Gm. per 100 ml. of cord
blood, the bilirubin concentration exceeds 20 mg.
per 100 ml. and the reticulocyte count exceeds 10
per cent of the erythrocytes (Sacks, J.A.M.A.,

1953, 153, 1570). The donor's cells must be com-
patible with the mother's (not the infant's) blood
serum by the indirect Coombs technic. With a
cannula in the umbilical vein under aseptic technic,
10 to 20 ml. of the fresh donor's blood is injected
and then the same amount of mixed blood is with-
drawn and discarded and another portion of donor
blood is injected until 50 to 60 ml. of blood per
pound of body weight has been exchanged. To
avoid hypocalcemia, 100 mg. of calcium gluconate
is injected for each 100 ml. of citrated blood used.
Among 106 cases, Feldman et al. (J. Pediatr.,

1954, 44, 181) reported only 7 deaths and 1 in-
stance of kernicterus with this treatment. If ane-
mia recurs, a small transfusion may be given; if
the bilirubin remains elevated the exchange trans-
fusion should be repeated. In infants requiring
transfusions because of hemorrhage or other non-
hemolytic disease, it may be noted that isoimmune
bodies are not well developed and group O, Rh
negative blood is usually safe but grouping and
cross-matching should be carried out as in the
adult unless the emergency demands immediate
transfusion to save life. The available safe and
effective plasma expanders (see discussion in Part
II) are often adequate during the short time re-
quired to conduct adequate selection of a donor.
In those less frequent cases of erythroblastosis
due to incompatibilities other than the Rh factor,
recognition of the factor responsible requires spe-
cial antisera and the experience of an expert but
the presence of abnormal antibody will be de-
tected by the Coombs procedure and a compatible
donor can be selected with this procedure. In cases
of sensitization with the group A or B factor, a
group O donor is recommended even though the
infant belongs to the A or B group.

Toxicology. — Properly prepared and carefully
tested, citrated whole human blood will cause a
minimum of reactions. Transient urticaria may be
expected in at least 0.5 per cent of cases. The
virus of homologous serum hepatitis may be trans-
mitted by whole blood transfusions. Hence, the
pooling of compatible blood from several donors
is not permissible. Wiener et al. (J.A.M.A., 1953,
151, 1435) estimated the mortality due to trans-
fusions of blood at 1 death in 1000 to 3000 trans-
fusions; since over 3 million transfusions are
given annually in the United States, blood trans-
fusion becomes as important a cause of death as
appendicitis or general anesthesia.

Transfusion Reactions. — The recognition and
elimination of pyrogens from solutions and equip-
ment employed in the handling of blood have cor-
rected the most frequent reaction, which is fever.
Reactions due to use of incompatible blood occur
less frequently as the knowledge and ability of
hospital personnel responsible for grouping and
matching blood prior to transfusion increase. In

186 Blood, Citrated Whole Human

Part I

emergencies lack of time and unavailability of
experts able to recognize the presence of intra-
group incompatibility may be a problem. Human
fallibility must be guarded against with the great-
est care in the busy hospital laboratory. Labels
must be read and re-read on bottles of blood, test
tubes of blood attached to the outside of the
bottle of bank blood for testing purposes, typing
solutions, matching mixtures, etc., with the same
care required in the handling of narcotic and other
potentially toxic drugs. Next to allergic reactions
(v.i.), which are usually not serious, the most fre-
quent type of blood transfusion reaction is the
hemolytic type. Hemolytic reactions cause chills,
fever, lumbar pain, myalgia and release hemo-
globin which, during excretion by the kidney,
causes damage to the renal tubules and may result
in albuminuria, anuria, uremia and death. To pre-
vent intergroup hemolytic reactions, three tests
should be performed: typing of the patient's red
blood cells with potent anti-A and anti-B group-
ing sera, testing of the isoagglutinin content of
the patient's plasma against known cells of group
A (preferably subgroup Ai) and group B, and
matching of recipient's cells with donor's plasma
and vice versa. If these tests are carefully per-
formed and interpreted, reactions due to inter-
group incompatibility will be rare. The initial
transfusion of incompatible red blood cells may
not cause significant reaction but this injection
will stimulate antibody formation and a second
transfusion of this incorrect type of red cell will
cause a serious reaction. The titer of isoantibody
in a given patient, however, may be high as a
result of a previous incompatible transfusion or
an injection of blood plasma, as a result of a preg-
nancy in which the fetus possessed a different
blood type than the mother or rarely as a result
of horse serum or vaccines; the first transfusion
in such an individual may cause a serious reaction
if complete compatibility of donor with recipient
has not been established. In adults quantities of
incompatible blood of less than 300 ml. seldom
cause serious reactions; if possible the first por-
tion of a transfusion should be injected slowly,
with careful observation of the pulse rate, blood
pressure and temperature. In the emergencies of
shock and hemorrhage, rapid injection is required
and during anesthesia the signs of incompatibility
are masked. Likewise, in the patient receiving
cortisone or corticotropin many of the manifesta-
tions of a transfusion reaction are masked but
the hemoglobin nephrosis is not prevented. Sub-
groups of A are characterized by weaker reactions
with anti-A grouping sera; the subgroup A2B,
with an incidence of about 1.5 per cent in the
population, has been incorrectly classified as
group B. Fortunately, the low titer of anti-A in
such blood seldom results in a serious degree of
hemolysis. Likewise the isoantibody titer in the
subgroups of A against other members of this sub-
group (Ai, A2, A3, etc.) is sufficiently weak so that
these subgroups of A are ignored in practical trans-
fusion work.

Intragroup incompatibility has come to be rec-
ognized and accounts for some hemolytic trans-
fusion reactions. Unlike group reactions, these
occur only after isosensitization from previous

blood transfusions or pregnancies with a different
type in the fetus. The most common and impor-
tant of these intragroup reactions arise from the
Rh (D, C and E) factors. For routine transfusion
purposes, it is sufficient to test for Rh only since
the many other Rh-Hr variants are not very anti-
genic. However, in the cross-match of the blood
of the patient with that of the donor a method to
detect so-called univalent antibody, such as the
conglutination or anti-globulin (Coombs test)
methods, is essential. This will detect any sig-
nificant titer of these less frequent Rh variants.
In the selection of Rh negative donors, the blood
should be typed also against anti-Rh' and anti-Rh"
typing sera and only those negative with all three
— anti-Rh, anti-Rh' and anti-Rh" — should be used.
However, as far as the recipient is concerned,
those belonging to Rh', Rh", or Rh'Rh" may be
considered as Rh negative because of the weak-
ness of these as antigens. The use of Rh variants
in Rh negative persons can give rise to isosensi-
tization but this will be detected if the Coombs
test technic is employed in the cross-matching. In
pregnancy and certain other diseases, particularly
hemolytic anemias, rouleau formation may be
prominent and make interpretation of the match-
ing tests difficult; if the slide tests are inconclu-
sive, test tube agglutination technics must be
employed and the opinion of an expert sought
unless the emergency requires immediate trans-
fusion to save fife. Difficulties in typing and cross-
ing the blood of patients who have received in-
jections of the plasma expanders such as dextran.
polyvinylpyrollidone, etc., are experienced; rou-
leau formation (pseudoagglutination) is prominent
in such blood and makes interpretation of the
tests difficult (J.A.M.A., 1954, 154, 1398). Hence,
a sample of blood for crossing and typing should
be obtained prior to injection of such colloidal
substances.

Universal Donors. — It is generally recognized
that transfusion of group 0 blood into a recipient
of A, B or AB group is usually well-tolerated be-
cause the limited amount of the incompatible
donor's plasma is diluted with the large volume
of recipient's plasma and adsorbed on the large
mass of the recipient's erythrocytes. The selection
of group 0 donors in advance eliminates the
danger of inaccurate blood grouping in the haste
of emergencies when expert technicians may be
off duty. However, group 0 should be used in-
discriminately only in emergencies and seldom in
excess of 500 ml. since high titers of isoantibodies
in some group 0 donors may result in coating of
a significant proportion of the recipient's erythro-
cytes with antibody and a slow but prolonged
hemolytic process which may resemble acquired
hemolytic anemia. The use of many liters of
group 0 blood in the resuscitation of severe casu-
alties (Crosby and Howard, Blood, 1954. 9, 439)
amounts to an exchange transfusion; if further
transfusions are needed during the ensuing two
weeks group O blood rather than blood of the
group to which the patient normally belongs
should be used. In selecting group 0 donors for
universal use in emergencies, the titer of anti-A
and anti-B should be determined and only those
with low titers should be selected. Some have

Part I

Blood, Citrated Whole Human 187

advocated the addition of A and B blood group
substances to group 0 blood to neutralize the
isoantibodies present; if this is done the absence
of isoantibody should be actually demonstrated
rather than being taken for granted. For uni-
versal use, the group 0 blood should also be Rh
negative. In general, transfusion of Rh negative
blood of the proper blood group is safe in either
an Rh positive or negative person but it is scarce
and compatible Rh positive blood is preferred.
During the child-bearing period, Rh positive
blood, even after a compatible cross-match, should
be transfused into a woman only when the danger
to life without a transfusion exceeds the danger
of preventing a future successful pregnancy as a
result of sensitization to the Rh antigen. Rh nega-
tive blood containing a high titer of anti-Rh
could cause untoward effects in an Rh positive
individual; hence, careful testing with the Coombs
technic of all Rh negative donors for anti-Rh
antibody is essential.

Other intragroup incompatibilities may arise
as a result of isosensitization (transfusion, preg-
nancy, etc.). The antibodies for M, N, S, P,
Lewis, Kell, Duffy, Lutheran, etc., are seldom of
sufficient titer to cause trouble in routine trans-
fusion practice (Allen, New Eng. J. Med., 1952,
247, 379). However, in individuals previously
sensitized to these intragroup factors by previous
transfusions, pregnancies, etc., serious hemolytic
transfusion reactions may occur. Reaction due to
Kell factor in the nineteenth transfusion was re-
ported by Ottensooser and Taunay (J.A.M.A.,
1954, 155, 853) and to U factor by Wiener et al.
(ibid., 1953, 153, 1444). The Coombs technic is
essential to demonstrate the presence of these
factors.

Blood damaged during collection or storage will
break down rapidly in the circulation and may
result in hemoglobin nephrosis. If the plasma
above the settled erythrocytes in the bottle of
blood in the bank shows hemolysis, it must not be
injected. Exposure to heat or freezing may dam-
age the red cells, as does storage beyond 21 days
in the acid citrate dextrose solution. Sack et al.
(Surg., Gynec. Obst., 1952, 95, 113) studied the
survival of erythrocytes in the blood stream of
the recipient after storage in all plastic equip-
ment for various periods of time. After 10 clays'
storage 88 to 92 per cent of the red blood cells
survived normally; after 14 days, 84 to 88 per
cent; after 20 days, 76 to 84 per cent; after 25
days 70 to 80 per cent. The remaining cells were
rapidly removed from the recipient's circulation.
A rough correlation was found between the sus-
ceptibility to hemolysis in an hypotonic solution
of sodium chloride and survival in the body. The
mixing of whole blood with aqueous dextrose solu-
tions is contraindicated. Such mixing, even for a
brief period during the flow from two reservoirs
through the same needle, may cause some hemoly-
sis and some clumping of erythrocytes, which,
although reversible, may cause reactions (Wilson,
Am. J. Clin. Path., 1950, 20, 667); Dreyfus and
Salmon (Presse med., 1952, 60, 845) described
increased fragility of erythrocytes as a result of
such mixing. The erythrocytes of patients with the
sickle cell trait may be used for transfusions;

their cells survive normally in the recipient despite
their tendency to formation of bizarre shapes
when exposed to a low oxygen tension (Singer
et al, J. Lab. Clin. Med., 1948, 33, 975; Callender,
ibid., 1949, 34, 90). Anemic patients with sickle-
cell disease should not be used as donors.

Allergic Reactions. — Urticaria occurs in 0.5
to 1 per cent of transfusions. Usually it is mild
and may be alleviated by subcutaneous injection
of 0.3 ml. of 1 : 1000 solution of epinephrine hydro-
chloride or prevented by the administration of an
antihistaminic drug at the time of giving the trans-
fusion (Catalano, Minerva Chir., 1953, 8, 544).
Angioneurotic edema, if it affects the larynx, can
prove fatal, as may also asthma; either of these
two developments during a transfusion calls for
cessation of the injection and the administration
of epinephrine. Allergic reactions can be mini-
mized by using only non-allergic and fasting per-
sons for donors. Persons with seasonal hay fever
may be employed at other seasons of the year.

Transmission of Disease. — This danger from
the transfusion of blood calls for routine exami-
nation of all donors and exclusion of those with
symptoms and signs of acute respiratory or other
infection. A serological test for syphilis is em-
ployed for all immediate transfusions and persons
with a history of syphilis should not be used as
donors; however, blood which has aged at least
3 days in the refrigerator is probably safe since
the treponema will not survive in the cold. Indi-
viduals with malaria and those in whom suppres-
sive therapy for malaria has not been terminated
for at least 2 years should not be used to provide
blood for immediate transfusions, although blood
stored for at least 5 days is probably noninfective.
During the past 20 years, homologous serum
hepatitis has presented the most serious problem
arising from the increased therapeutic use of blood
and pooled plasma (see discussion under Normal
Human Plasma, in Part I). During 1951, in Den-
mark, Madsen (J.A.M.A., 1954, 155, 1331)
studied 4687 hospitalized patients and found that
viral hepatitis occurred in 1 per cent of those
receiving whole blood but in 3 to 4 per cent of
those receiving pooled human serum; the inci-
dence in patients who had received neither whole
blood nor serum was only 0.14 per cent. No person
with a history of hepatitis or of exposure to this
disease within 6 months should be used as a
donor. Unfortunately the virus of hepatitis may
be present in blood without evidence of symptoms
and its detection presently requires use of human
volunteers since no chemical, bacteriological or
animal diagnostic procedure is available.

Contaminated blood has become a problem
since blood stored in banks has come into general
use. Even with the open technics of handling
blood formerly used in the direct or the indirect
citrated blood methods the normal bacteriostatic
action of fresh blood usually prevented any in-
fection. Despite development of improved closed
technics of collecting and handling blood for stor-
age in blood banks, contamination occurs. Braude
et al. (J. Lab. Clin. Med., 1952, 39, 902) found
5 to 10 per cent of bottles of blood in the hos-
pital bank contaminated. Most of these were with
gram-positive bacteria of low pyrogenicity and

188

Blood, Citrated Whole Human

Part I

pathogenicity which failed to multiply at refrig-
erator temperatures; hence, little if any trouble
was experienced. However, Pittman (ibid., 1953,
42, 273) pointed out that surgical asepsis em-
ployed in collecting blood could not assure bac-
teriological asepsis and some gram-negative
bacteria with the property of multiplying at re-
frigerator temperatures, have been found in bottles
of blood. These contaminations escape detection
because they do not cause hemolysis. Bacteria of
the Escherichia and Paracoli or Psendomonas
group have been found and Borden and Hall (New
Eng. J. Med., 1951, 245, 760) reported fatal
reactions due to such contamination. These reac-
tions are characterized by chill, fever, hypotension,
flushing and severe muscular pain and cramps;
anuria and uremia develop. Braude et al. (Arch.
Int. Med., 1953, 92, 75) reported recovery with
antibiotic, levarterenol bitartrate and cortisone
therapy. Geller and Jawetz (J. Lab. Clin. Med.,
1954, 43, 696) believe that death is due to a toxin
rather than an infection although the viable bac-
teria are more toxic than the isolated endotoxin.
Attempts to control bacterial contamination by
addition of antiseptics or antibiotics in non-toxic
concentrations have failed (Swedberg et al., Acta
med. Scandinav., 1947, 127, 480). Strict aseptic
technic and daily observation of the blood stored
in the refrigerator in the blood bank must be de-
pended upon. Donors with dermatitis must not be
used because of the increased danger of contami-
nating the blood during its withdrawal. The bottle
of blood in the bank must never be opened prior
to its use for transfusion. Iodine tincture should
be used on the donor's skin before inserting the
needle and the tube carrying the blood from the
vein to the bottle should be clamped before re-
moving the needle from the donor to avoid
aspirating material from the deeper layers of the
skin. Since gram-negative bacteria do not grow
well at usual incubator temperatures, Stevens
et al. (Ann. Int. Med., 1953, 39, 1228) suggested
that a film of the blood to be injected be stained
with Gram stain and examined for bacteria just
prior to the injection of the blood.

Other Reactions. — Other untoward responses
include embolism and thrombophlebitis. Since
fibrin precipitates progressively in stored blood,
blood must always be filtered before administra-
tion. This is usually done by means of a filter in
the apparatus employed for administration, al-
though Sussman and Cohen (J.A.M.A., 1954,
154, 82) advocate filtration into a fresh vacuum
bottle just before use. The use of air pressure in
the bottle of blood to speed its rate of flow into
the vein is dangerous since air embolism may
occur if the attendant is not alert at the instant
the last of the blood leaves the bottle. The use
of a two-way stopcock and a syringe is a safer
means of transferring the blood rapidly; the plas-
tic bag to contain the blood without any air which
can be squeezed or compressed by the weight of
the patient's body is useful. Phlebitis seldom de-
velops unless the needle remains in the recipient's
vein for many hours. Extravasation of blood
around the site of entry of the needle is not infre-
quent but is seldom troublesome. If the emer-
gency requires surgical exposure of a vein to

insert the needle, antibiotic therapy is indicated
prophylactically.

Overloading of the circulation may result from
rapid injection or excessive doses of blood. Cau-
tion is particularly necessary in infants or those
with myocardial damage. Immediately following
severe hemorrhage patients tolerate rapid injec-
tion of a large volume of blood until the deficit
in blood volume is corrected.

Citrate reactions were formerly much feared
and deplored, particularly by those who pre-
ferred direct transfusion technics. Citrate in the
amount present in 500 ml. of blood is metabolized
and excreted so rapidly as to be harmless. In
patients receiving 500 to 8000 ml. of blood during
a surgical procedure, Ludwig (Univ. Mich. Med.
Bull, 1953, 19, 259) found no deleterious effect
on the coagulability of the blood postoperatively.
In massive transfusions, particularly exchange
transfusions in erythroblastotic infants, hypo-
calcemia may result from citrate binding, with
resulting hypotension and tetany; intravenous in-
jection of 1 ml. of 10 per cent calcium gluconate
per 100 ml. of citrated blood administered will
correct any hypocalcemia.

Routes of Administration. — Blood is com-
monly injected intravenously. Rarely it is injected
intra-arterially in the treatment of profound shock
when the flow of blood is insufficient to carry
intravenously injected blood to the heart. In such
instances the radial artery, or an artery exposed
by a coincident surgical procedure, is selected,
and the blood injected through a 15-gauge needle
under a pressure of 200 to 300 mm. of mercury
(Seeley, U. S. Armed Forces M. J., 1954, 5, 229).
This route of administration should be used only
as a last resort as thrombosis of the artery may
occur and, if collateral circulation is inadequate,
gangrene may result. Injection into the marrow
cavity of the sternum or, in infants, of the tibia
has been used successfully when intravenous ad-
ministration is not feasible in cases of extensive
burns of the skin, severe dermatitis, etc. When
the veins at the bend of the elbow cannot be
found or entered satisfactorily with a needle for
injection of blood, the expert can usually enter a
vein on the back of the hand, anterior and supe-
rior to the medial maleolus of the ankle or in
infants in the scalp. The danger of fat embolism,
osteomyelitis and fracture must be considered
with the intramedullary route. Injection into the
longitudinal sinus of the skull in the infant is
dangerous and intraperitoneal injection of blood
is of little value in restoring blood volume or
hemoglobin rapidly.

Protection of the Blood Donor. — The
effect of venesection upon blood donors is a mat-
ter of practical interest. Fowler and Barrer
(J. A.M. A., 1942, 118, 421) reported that after
the donation of a pint of blood there is a marked
drop in the hemoglobin of the donors and that on
an average it is about 50 days before the blood
returns to normal, although the recovery period
can be materially shortened by administration of
iron. Wiener et al. (loc. cit.) recommend that
donation of a pint of blood should not be more
frequent than once in 10 to 13 weeks. The donor's
blood hemoglobin concentration should be at least

Part I

Blood Corpuscles, Concentrated Human Red 189

12.5 Gm. per 100 ml., or the specific gravity of
the blood should be 1.053 or higher. Cole et al.
(J. Aviation Med., 1953, 24, 165) studied the
effect of a donation of blood because it had been
noted that removal of 1 liter of blood decreased
the period of useful consciousness at the low
oxygen pressure of a simulated altitude of 35,000
feet. Following withdrawal of 500 ml., however,
the average maximum decrease in hematocrit was
only 11.7 per cent and of hemoglobin 13 per cent
between the second and the sixth day. It was con-
cluded that fliers need not be grounded after a
donation of blood. In blood centers, fainting
occurs in 1 to 6 per cent of donors. Emotional
factors are important and attention to reassur-
ance, diverting conversation, and light and airy
quarters will minimize the incidence of this nui-
sance. A fatigued or hungry person, particularly
during hot weather, is more susceptible to faint-
ing. Donors should be kept in the supine posture
until vasomotor adjustment to reduction of blood
volume has occurred. Persons involved in hazard-
ous occupations should not return to work for
about 12 hours after a donation of blood. Only
one fatality, due to coronary occlusion, was re-
ported during 13 million donations during World
War II; 10 cardiovascular accidents occurred
during the 2-day period after the donation. This
incidence is no greater than would be expected
without a blood donation. Hematomas at the
puncture site occur but can be minimized by
application of pressure after removing the needle
from the vein. In rare instances phlebitis has fol-
lowed the puncture.

Dose. — The usual dose is 500 ml. intraven-
ously, repeated as necessary, with a range of 250
ml. to several liters according to the needs of
the patient.

Labeling. — "The package label bears the name
Citrated Whole Blood (Human); the volume of
the whole blood before citration; the donor num-
ber and the expiration date, which is not more
than 21 days after date of bleeding the donor; the
name, license number, and address of the responsi-
ble laboratory; a designation of the blood group
and Rh type; a statement of the kind and quan-
tity of anticoagulant used; the statement, 'Keep
continuously at 4° to 10° C. (39.2° to 50° F.),
preferably below 6° C. (42.8° F.)'; and a state-
ment that the blood should not be warmed before
administration.

"The package label or accompanying circular
provides adequate directions for administration;
calls attention to the need for checking the label
for correct blood group, for careful cross-match-
ing, for rigidly observing the storage tempera-
tures, and for thoroughly mixing the blood before
transfusion; and states the necessity of using a
filter in the administration equipment and the
inadvisability of adding any medicament to the
blood for transfusion." U.S.P.

Packaging and Storage. — "Preserve Citrated
Whole Human Blood in the container into which
it was originally drawn. Use containers of color-
less, transparent glass of Type I, Type II, or Type
IV, or of a suitable plastic material. The container
is provided with a closure that will maintain a
contamination-proof seal until the contents are

used. Accessory equipment supplied with the blood
is sterile and pyrogen-free. Keep Citrated Whole
Human Blood during storage and in shipment at
a temperature between 4° and 10°, preferably at
the lower limit. Dispense it in the unopened con-
tainer in which it was placed by the manufac-
turer." U.S.P.

CONCENTRATED HUMAN RED
BLOOD CORPUSCLES. B.P.

"Concentrated Human Red Blood Corpuscles
is prepared from one or more preparations of
Whole Human Blood which are not more than
seven days old and each of which has already been
directly matched with the blood of the intended
recipient. A quantity of plasma and anticoagulant
solution equivalent to not less than 40 per cent
of the total volume is removed from the Whole
Human Blood." B.P.

In the United States red blood corpuscles are
available as Packed Red Blood Cells (Human)
and as Resuspended Red Blood Cells (Human).
In the latter preparation the plasma has been
removed and the cells resuspended in a suitable
isotonic diluent to restore the original blood
volume.

Description. — Concentrated human red blood
corpuscles (B.P.) is a dark red fluid which on
standing may form a sediment of the red cor-
puscles leaving a supernatant layer of yellow
plasma.

Uses. — Administration of red blood corpuscles
is indicated in many of the conditions for which
citrated whole human blood is used (see under
this title), and especially in cases where extension
of plasma volume is undesirable or unnecessary,
as in anemic states. In patients with paroxysmal
noctural hemoglobinuria, whole blood is contra-
indicated because a factor present in plasma
causes hemolysis of the patient's erythrocytes and
a hemolytic transfusion reaction results. In these
patients resuspended red blood cells (see above)
which have been washed free of plasma by sus-
pension in an isotonic diluent and centrifuged
several times may be used to correct anemia with-
out causing hemolysis and further anemia (Crosby,
Blood, 1953, 8, 769). Transfusion reactions char-
acterized by a chill, fever, headache, cramps in
legs, cyanosis and borborygmus without signs of
allergy or of hemolysis have been attributed to a
plasma factor in other types of anemia by Crosby
and Stefanini (/. Lab. Clin. Med., 1952, 40, 374);
washed red cells should be used in such cases if
further transfusions are required. Murray et al.
(J.A.M.A., 1943, 122, 1065) used 5 per cent dex-
trose in isotonic sodium chloride solution as the
suspending fluid for the cells, while Thalheimer
and Taylor (ibid., 1945, 127, 1096) reported suc-
cessful use of a 10 per cent aqueous solution of
corn syrup for this purpose.

Dried and powdered red blood cells have been
successfully used as an application to wounds to
stimulate healing (Seldon and Young, Proc. Mayo,
1943, 18, 385). From the erythrocytes left over
from preparation of plasma there has been pre-
pared a globin which has been found useful in
producing diuresis in patients suffering from

190 Blood Corpuscles, Concentrated Human Red

Part I

chronic glomerulonephritis; following administra-
tion of the globin the total circulating protein is
increased (see Strumia et al., J. A.M. A., 1946, 131,
1033; also under Plasma Extenders, in Part II).

Labeling.— Packed Red Blood Cells (Human)
and Resuspended Red Blood Cells (Human) are
subject to requirements of the National Institutes
of Health of the United States Public Health
Service. The label or an accompanying circular
must give adequate directions for administration,
call attention to the need for checking the label
for proper blood group (if other than "0" cells
are used), the need for careful cross-matching,
the need for rigidly observing the storage tem-
perature, the need for vigorously shaking the
bottle of cells before performing the transfusion
and the absolute necessity of using a filter in the
intravenous administration equipment.

Storage. — Red blood cells must be stored con-
tinuously, including the time of shipment, at 4° to
10° C, preferably 4° to 6° C. The expiration date
may not exceed 10 days from the date of bleeding
of the donor. The B.P. requires that the cells be
used within 24 hours of preparation and not more
than 8 days after the date of bleeding of the
donor.

BORIC ACID. U.S.P., B.P.

Boracic Acid, [Acidum Boricum]

"Boric Acid, dried over sulfuric acid for 5
hours, contains not less than 99.5 per cent of
H3BO3." U.S. P. The B.P. also requires not less
than 99.5 per cent of the H3BO3 but does not dry
the chemical.

Orthoboric Acid. Acidum Boracicum. Fr. Acide borique
cristallise; Acide borique officinal. Ger. Borsaure. It.
Acido borico. Sp. Acido borico.

Boric acid occurs in low concentrations, most
probably in combination as a magnesium salt, in
sea water and in certain mineral waters. It is
found in several mineral substances, such as
borocalcite which occurs in considerable quanti-
ties in the niter beds of Chile; in the natural
borax or tincal, first found in the basins of
dried-up lagoons in Central Asia, and afterward
in large amount in Clear Lake, California; in
rasorite (also known as kernite), a sodium borate
tetrahydrate occurring in large deposits in the
Mohave desert in California; in ulexite (sodium
and calcium borate) and in colemanite (calcium
borate).

Boric acid is extracted, under the name of
sassolin, from the lagoons of the volcanic districts
of Tuscany, and from the crater of Vulcano, one
of the Lipari Islands. In the volcanic mountains
there are found numerous hillocks and fissures,
the latter of which emit hot aqueous vapor con-
taining boric acid and certain gases. Around one
or several of these fissures, called suffioni, a circu-
lar basin of masonry is built, which is filled with
water and called a "lagoon." By means of the jets
of vapor constantly breaking through it. the water
becomes gradually impregnated with boric acid
and heated. A series of such 'iagoons" are made
to communicate with each other on the declivity
of a hill, and the lowest to discharge itself into
a reservoir, where the solution is allowed to rest

and deposit mechanical impurities. It is still dilute,
containing only about 2 per cent of boric acid.
From this reservoir the solution is run into evapo-
rators, heated by the natural vapor, where it is
concentrated and finally transferred to vessels in
which it is allowed to cool and crystallize. The
crude acid thus obtained may be refined to remove
impurities. The steam issuing from the suffioni is
sufficient to be utilized on a vast scale for the pro-
duction of electrical energy.

The native borax minerals of California supply
the American demand for boric acid. The acid is
obtained from borax by acidulating a hot satu-
rated solution of the borax with hydrochloric or
sulfuric acid. Upon cooling the mixture, crystals
of boric acid separate; the product is purified by
recrystallization from water.

Description. — "Boric Acid occurs as colorless,
odorless scales of a somewhat pearly luster, as
crystals or as a white powder, slightly unctuous
to the touch. It is stable in air. One Gm. of Boric
Acid dissolves in 18 ml. of water, in 18 ml. of
alcohol, and in 4 ml. of glycerin. One Gm. dis-
solves in 4 ml. of boiling water, and in 6 ml. of
boiling alcohol." U.S.P.

Heated to about 108°, boric acid loses water,
forming metaboric acid (HBO2), which slowly
volatilizes at that temperature; heated to about
139°, boric acid fuses to a glassy mass of tetra-
boric or Pyroboric acid (H2B4O7). At about 185°
the fused mass swells, loses all of its water, and
becomes boron trioxide (B2O3), which fuses into
a transparent, non-volatile, hygroscopic mass.
Boric acid volatilizes from a boiling aqueous or
alcoholic solution.

Boric acid is such a weak acid in aqueous solu-
tion that it cannot be neutralized by alkali in
stoichiometric proportion. However, it can be
converted into a relatively strong acid by adding
certain polyhydroxy organic compounds, such as
glycerin, mannitol, dextrose, or invert sugar.
These polyvalent alcohols form complex acids
with boric acid which are much stronger than
boric acid itself, and which are capable of reaction
with alkali. The official assay method uses glyc-
erin for this purpose.

The tendency of crystals of boric acid to slip
presents a problem when pulverization by tritura-
tion is attempted. It is essential, of course, that
the acid be in the form of an impalpable powder
when it is used to make an ointment. Dropwise
addition of ether to the acid has been suggested
as an aid to trituration. Manufacturers also supply
boric acid precipitated as an impalpable powder.

In an investigation of the "cottony" material
sometimes found in solutions containing boric acid
and zinc sulfate, Skauen and Burroughs (Pharm.
Arch., 1940, 11, 72) found the deposit to consist
of living organisms of Fusarium and Torida spe-
cies. The chief source of these contaminants was
distilled water. Sterilization by boiling or auto-
claving, or inclusion of methyl or butyl para-
hydroxybenzoate, may delay or prevent such
growth in solutions containing small concentra-
tions of boric acid.

Standards and Tests. — Identification. — Boric
acid responds to tests for borate. Water-insoluble
substances. — One Gm. dissolves in 25 ml. of water

Part I

Boric Acid

191

to form a clear solution. Alcohol-insoluble sub-
stances.— One Gm. is completely soluble in 10 ml.
of boiling alcohol. Arsenic. — The limit is 10 parts
per million. Heavy metals. — The limit is 20 parts
per million. U.S.P.

The B.P. provides a limit test for sulfates, an
arsenic limit of 4 parts per million, and a lead
limit of 25 parts per million.

Assay. — As mentioned above, boric acid is too
weak an acid to be titrated directly with standard
alkali solution. On adding glycerin, however, a
more highly ionized complex acid is formed, which
can be quantitatively titrated with one equivalent
of base. In the U.S.P. assay 2 Gm. of boric acid,
previously dried over sulfuric acid for 5 hours,
is dissolved in a mixture of equal volumes of
glycerin and water, previously neutralized to
phenolphthalein, and the solution titrated with
1 N sodium hydroxide. If addition of more neu-
tralized glycerin discharges the pink color of the
solution, sufficient alkali is added to restore it.
Each ml. of 1 N sodium hydroxide represents
61.84 mg. of H3BO3. U.S.P.

Incompatibility. — Occasionally boric acid and
glycerin are prescribed together in an aqueous
solution; in such instances it should be kept in
mind that the glycerin will produce a more
strongly ionizing complex acid and that the result-
ing acidity may be irritant if the solution is to
be applied to the eye.

Uses. — Boric acid has fallen into disrepute
because of the occurrence of fatal poisoning, par-
ticularly in infants, from its use on abraded skin
or granulating wounds and because of the avail-
ability of more effective and less toxic antibac-
terial agents. It is of interest to recall that boric
acid was introduced into medicine by Godlee
(Lancet, 1873, 1, 694) as a companion to Lister's
use of carbolic acid just before the dawn of the
bacterial era in medicine. Boric acid has not been
used internally, except as a preservative in food,
but it has been extensively employed topically
by the medical profession and the public in self-
medication as a non-irritant, detergent, mildly
antiseptic solution or protective ointment for in-
flammations of the skin, mucous membranes and
for wounds. Data on the antibacterial action of
boric acid and boron compounds have been col-
lected and reviewed by Novak (Bull. N. F. Com.,
1950, 18, 94). Boric acid is not absorbed from
intact skin (Pfeiffer, et al., J.A.M.A., 1945, 128,
266) but it is absorbed from abraded skin or
granulating wounds (see Ann. Surg., 1943, 117,
885).

Boric acid possesses fungicidal activity. Dosa
(Arch. Dermat. Syph., 1937, 176, 261) found
that concentrations varying from 0.25 to 1 per
cent will completely inhibit the growth of several
species of fungi. Solutions have been used for the
treatment of thrush. In epidermophytosis, 10 per
cent boric acid in powdered talc was found to be
as efficient as Whitfield's ointment or metacresyl
acetate (J.A.M.A., 1945, 128, 805) and neither
irritation nor aggravation of dermatitis was ob-
served. Boric acid is used in dusting powders as an
absorbent.

Boric acid ointment was advocated for the treat-
ment of burns with pressure dressings (J.A.M.A.,

1943, 122, 813 and 909) but excretion of as much
as 2 Gm. of boric acid in the urine in the first 24
hours was observed (Ann. Surg., 1943, 117, 885).
Experimentally, damage to the central nervous
system is caused by the application of boric acid
ointment to a burn of only 4 per cent of the body
surface. Deaths (J.A.M.A., 1945, 128, 266 and
129, 332) have been reported from the local ap-
plication of the ointment or the powder to granu-
lating wounds, especially in infants (Fellows et al.,
J. Maine Med. Assoc, 1948, 39, 339; Bumbalo,
N. Y. State J. Med., 1952, 52, 1913), and from
the irrigation of body cavities, such as empyema.
From observations of poisoning in infants, one
terminating fatally, following use of powders con-
taining boric acid in treatment of diaper rash,
Brooke (G.P., 1953, 7, June, 43) urges education
of physicians and public against use of boric acid
for general treatment of such rashes. Poisoning
has followed the use of enemas of boric acid solu-
tion and inadvertent oral (Young, et al., Can.
Med. Assoc. J., 1949, 61, 447) or parenteral ad-
ministration. Phagocytosis is inhibited by con-
centrations of boric acid higher than 2 per cent,
at body temperature (Novak and Taylor, /. A.
Ph. A., 1951, 40, 428). Boric acid powder or solu-
tion has been mistaken for other material in com-
mon use, such as solution of sodium chloride.

Boric acid and borates were used at one time
as food preservatives, in concentrations up to 0.5
per cent. Skin eruptions have been reported from
continued use of boron derivatives over long
periods of time. In the elaborate investigations
of the U. S. Department of Agriculture, under
Wiley (Circidar 15, Bureau of Chemistry, 1904,
p 27), it was found that quantities of less than
0.5 Gm. daily, if continued over long periods of
time, cause disturbances of digestion and assimi-
lation (see also Lindet, Pharm. J., 1920, 104, 46).

Prompted by an interest in the possible toxicity
of riboflavin-boron complexes (/. Biol. Chem.,
1942, 145, 693), which are more soluble in water
than riboflavin alone, Frost and Richards (/. Lab.
Clin. Med., 1945, 30, 138) investigated the toxic
and preservative properties of boric acid when
used in injectable solutions; they found that from
0.5 to 1.5 per cent of the acid showed no toxic
effect in rats and dogs when injected over long
periods and that the bacteriostatic effect against
selected bacteria and molds appeared satisfactory
for preserving at least solutions containing the B
complex vitamins, [v]

Toxicology. — (See also the preceding dis-
cussion.) When taken by mouth boric acid is ab-
sorbed, somewhat slowly but completely, and
eliminated through the kidney. According to Rost
(Arch, internal, pharmacodyn. therap., 1905, 15,
291), it may be detected in the urine for several
days after a single dose and, when taken repeat-
edly, tends to accumulate in the body. The fatal
dose of boric acid is about 20 Gm. for an adult
and 5 Gm. for an infant. Within a few hours
vomiting, diarrhea, abdominal cramps and rapidly
progressive prostration develop. An erythematous
rash forms ("boiled lobster" appearance) and is
followed by desquamation; similar changes occur
in the mucous membranes. Shock with hypoten-
sion, tachycardia, cyanosis and subnormal tern-

192

Boric Acid

Part I

perature follows, with delirium, convulsions and
coma. Death often occurs after 3 to 5 days. His-
tologic examination shows hyperemia and in-
flammation of the skin, proliferation of microglia
and shrinkage of the nerve cells of the central
nervous system; gastroenteritis, hepatitis, ne-
phrosis and often bronchopneumonia are ob-
served. The highest concentration of boron is
found in the gray matter of the brain; this is
associated with a decrease in the phosphorus con-
tent of the brain. Treatment is symptomatic and
supportive, including oxygen inhalation, trans-
fusion, parenteral fluids, adrenal cortical extract
and antibiotics (Brooke and Boggs, Am. J. Dis.
Child., 1951, 82, 465). For additional toxicity data
see Pfeiffer and Jenney (Bull. N. F. Com., 1950,
18, 57). Goldbloom and Goldbloom (J. Pediatr.,
1953, 43, 631), in reporting on 4 cases of poison-
ing resulting from topical use of boric acid prep-
arations on young infants, reviewed 109 other
cases of poisoning accumulated from the world
literature.

Labeling. — "The container label bears a warn-
ing that Boric Acid is not for internal use, and
that it should not be applied to extensive areas of
broken skin." U.S.P.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep.— Boric Acid Ointment, N.F., B.P.;
Boroglycerin Glycerite, Boric Acid Solution,
N.F.; Antiseptic Solution, N.F.; Kaolin Poultice;
Surgical Solution of Chlorinated Soda, B.P.

BORIC ACID OINTMENT. N.F. (B.P.)

Unguentum Acidi Borici

"Boric Acid Ointment contains not less than
9 per cent and not more than 11 per cent of
H3BO3." N.F. The B.P. ointment contains boric
acid equivalent to 1.0 per cent of H3BO3 (limits
0.9 to 1.1).

B.P. Ointment of Boric Acid. Pomatum cum Acido
Borico; Unguentum Boricum; Pomatum Acidi Borici. Fr.
Pommade a l'acide borique ; Pommade boriquee; Vaseline
boriquee. Ger. Borsalbe. It. Unguento borico. Sp. Pomada
de acido borico; Vaselina boricada; Unguento de Acido
Borico.

Levigate 100 Gm. of boric acid, in very fine
powder, with 50 Gm. of liquid petrolatum to make
a smooth paste and incorporate the mixture with
850 Gm. of white ointment. U.S.P.

The B.P. prepares this ointment by sifting 1
per cent by weight of boric acid into melted para-
ffin ointment and stirring until cold; formerly the
B.P. ointment was of 10 per cent strength but
since its only use is as a protective, being as
effective without boric acid as with it (Brit. M. J.,
1949, 2, 871), the concentration of acid was re-
duced to 1 per cent which, of course, reduces the
chance of its being toxic.

Assay. — The boric acid in 5 Gm. of ointment
is extracted with hot water, the mixture filtered,
and an aliquot portion of the filtrate titrated with
0.1 N sodium hydroxide in the presence of glycerin
and using phenolphthalein T.S. as indicator (see
assay under Boric Acid). Each ml. of 0.1 N
sodium hydroxide represents 6.184 mg. of H3BO3.
U.S.P. The B.P. assay is similar in principle,
except that the heated mixture of ointment, water

and glycerin is titrated directly, without filtration.

Uses. — This ointment is widely used both as
an emollient to the skin and for its protective
effect on superficial wounds and abrasions. Be-
cause of the possibility of absorption of boric
acid, use of the ointment in the treatment of burns
and granulating wounds may be dangerous — even
fatal (see under Boric Acid).

Although the ointment is popularly supposed to
be antiseptic the experiments of many investiga-
tors indicate that is possesses no antibacterial
properties. Foley and Lee (/. A. Ph. A., 1942, 31,
105) reported, however, that while boric acid is
not bacteriostatic in fatty bases it is bacteriostatic
in hydrophilic bases containing large amounts of
water. Gels made with methyl cellulose and
sodium alginate were most effective as bases.

BORIC ACID SOLUTION. N.F.

"Saturated" Boric Acid Solution, Liquor Acidi Borici

"Boric Acid Solution contains, in each 100 ml.,
not less than 4.25 Gm. of H3BO3." N.F.

Solutum Acidi Borici; Aqua Borica. Fr. Solute d'acide
borique; Eau boriquee. It. Acqua borica.

Dissolve 50 Gm. of boric acid in 350 ml. of
boiling purified water, immediately add sufficient
cold purified water to make 1000 ml., and filter,
if necessary, until the product is clear. Note:
Boric Acid Solution must be dispensed perfectly
clear, without any deposit of boric acid crystals
such as may occur on chilling the Solution or
evaporation of water from it. N.F.

Description. — "Boric Acid Solution is a clear,
colorless, odorless liquid, with a faintly bitter
taste. It is acid to litmus." N.F.

Standards and Tests. — Identification. — Boric
acid solution responds to the test foj borate.
Arsenic. — The solution meets the requirements of
the test for arsenic. Heavy metals. — The limit is
10 parts per million. N.F.

Accurately speaking, this is not a saturated
solution of boric acid. At the official temperature
of 25° boric acid is soluble in 18 parts of water,
which would make the saturated solution repre-
sent about 5.3 per cent of boric acid, whereas the
N.F. directions result in an approximately 5 per
cent solution. Especially when the solution is to
be used in the eye it is desirable that it be slightly
undersaturated to minimize the possibility of
forming crystals at lower temperatures.

Uses. — Boric acid solution is used for applica-
tion to inflamed mucous membranes of the eye,
nose, or throat. It is probably a mistaken notion
that as commonly employed it exerts any useful
antiseptic action. The use of the solution is not
without potential danger in some instances (for
details, see under Boric Acid). The N.F. indicates
that for ophthalmic use the solution may be diluted
with an equal volume of distilled water. In ac-
cordance with the present concept that lachrymal
fluid has the same osmotic pressure as blood
serum, a boric acid solution of 2.2 per cent con-
centration is isotonic with lachrymal fluid; this is
almost exactly the concentration of the diluted
solution. Novak and Taylor (/. A. Ph. A., 1951,
40, 430) found that the bacteriostatic concentra-
tion of boric acid for the common pyogenic bac-

Part I

Brilliant Green

193

teria in the conjunctival sac varied from 0.5 to
2 per cent in broth cultures and further studies,
in vitro, showed that phagocytosis was not in-
hibited at body temperatures by concentrations
below 2 per cent. Boric acid is pharmaceutical^
incompatible with benzalkonium chloride.

Storage. — Preserve "in tight containers, and
avoid temperatures below 20°." N.F.

BOROGLYCERIN GLYCERITE.

[Glyceritum Boroglycerini]

N.F.

"Boroglycerin Glycerite contains not less than
47.5 per cent and not more than 52.5 per cent
of boroglycerin (C3H5BO3)." N.F.

Glycerin of Boric Acid; Solution of Boroglyceride ;
Glycerite of Glyceryl Borate; Glycerinura Acidi Borici;
Glyceritum cum Acido Borico; Boroglycerinum. Fr. Glycere
a l'acide borique. It. Boroglicerina; Borogliceride. Sp.
Glicerito de Boroglicerina.

Heat 460 Gm. of glycerin in a tared porcelain
dish on a sand bath, to a temperature between
140° and 150°, and add 310 Gm. of finely pow-
dered boric acid, in portions, and stirring con-
stantly. When solution is effected, continue heat-
ing the liquid at the same temperature until the
mixture weighs 500 Gm., meanwhile stirring it
and breaking the film that forms on the surface.
Add 500 Gm. of glycerin, mix thoroughly, and
transfer the product at once to suitable con-
tainers. N.F.

Milne and Todd (Pharm. J., 1932, 128, 186)
made boroglycerin glycerite under reduced pres-
sure, and obtained a colorless product; the official
process yields a yellowish solution.

This preparation is a viscous, yellowish liquid,
sweet to the taste and providing boric acid in a
concentrated solution. If an excess of water is
added to boroglycerin glycerite, but not enough
to dissolve the boric acid it contains, the acid will
precipitate; if dilution in this range is necessary
some glycerin should also be added. It is probable
that a definite chemical compound, perhaps
C3H5BO3, is produced in making the boroglycerin;
in aqueous solution, however, it is much more
strongly ionized than is boric acid, as a conse-
quence of which aqueous solutions of boroglyc-
erin glycerite may be quite irritant. Boroglycerin
glycerite, usually diluted with glycerin, is occa-
sionally applied locally for its antiseptic effect.

Storage. — Preserve ."in tight containers/' N.F.

BRANDY. N.F.

Spiritus Vini Vitis

"Brandy is an alcoholic liquid obtained by the
distillation of the fermented juice of sound ripe
grapes and containing not less than 48 per cent
and not more than 54 per cent, by volume, of
C2H5OH, at 15.56°. It must have been stored in
wood containers for a period of not less than 2
years." N.F.

Spiritus Vini. Fr. Eau-de-vie. Ger. Weinbrand. It.
Cognaco. Sp. Brandy.

The term "brandy" is applied generically to the
spirit obtained by the distillation of a fermented
fruit juice. More frequently it is used in the
official sense to designate grape brandy, that is,

the liquor distilled from wine. For definitions and
requirements for other brandies see Regulations
No. 5 of the U. S. Treasury Department, Bureau
of Internal Revenue, Alcohol Tax Unit (as
amended to June 5, 1948).

The process of manufacturing brandy is essen-
tially the same as that for making whisky (q.v.)
except that it is distilled from fermented grape
juice instead of the products of grains.

During the storage of the brandy the liquor
undergoes changes analogous to those which take
place in whisky. As brandy is not made from
cereals or starchy materials, fusel oil is never
present in the genuine article. As the wood con-
tainers are not charred, brandy is of a paler color
than whisky and is likely to contain a larger pro-
portion of tannic acid. Usually the color is in-
creased by adding caramel.

Description. — "Brandy is a pale amber-col-
ored liquid, having a characteristic odor and taste.
It is acid to litmus paper. The specific gravity of
Brandy is not less than 0.921 and not more than
0.933 at 25°." N.F.

Standards and Tests. — Acidity. — A 25-ml.
portion of brandy, diluted with 50 ml. of distilled
water, requires not more than 3.8 ml. of 0.1 N
sodium hydroxide for neutralization, using phenol-
phthalein T.S. as indicator. Non-volatile residue.
— The residue from the evaporation of 20 ml. of
brandy, dried at 105° for 1 hour, is not over 300
mg. Storage in wood. — On dissolving the residue
from the preceding test in 5 ml. of water, filter-
ing, and adding 1 drop of a 1 in 10 dilution of
ferric chloride T.S. to the filtrate, a greenish black
color results. Other tests. — Brandy meets the re-
quirements of the tests for Acetone, Other
ketones, Isopropyl alcohol, Tertiary butyl alcohol,
Alkaloids, Formaldehyde, and Heavy metals under
Whisky. N.F.

Uses. — It is popularly believed that brandy has
a more constipating effect than whisky but there
is no convincing evidence of the truth of this
tradition. The medicinal virtues of the two liquors
are probably essentially the same (see under Alco-
hol). Brandy has a somewhat more pleasing flavor
to some persons and is therefore often preferable
in its acceptability to the stomach.

Storage. — Preserve in "tight containers." N.F.

BRILLIANT GREEN.

Viride Nitens
C27H34O4N3S

B.P.

The B.P. defines Brilliant Green as the sulfate
of di-(/>-diethylamino)triphenylcarbinol anhydride.
It may be prepared by oxidizing the product of
condensation between diethylaniline and benzalde-
hyde and forming the sulfate (more accurately
bisulfate) salt. It contains not less than 96.0 per
cent of C27H34O4N2S, calculated with reference
to the substance dried to constant weight at 110°.

Description. — Brilliant green occurs as small,
glistening, golden crystals. It is soluble, at 20°, in
5 parts of water, and also in alcohol. A clear green
solution is produced on dissolving 50 mg. of bril-
liant green in 100 ml. of water. B.P.

For tests, standards and assay, the last being
based on reduction of the dye with 0.1 N titanous

194

Brilliant Green

Part I

chloride in an atmosphere of carbon dioxide, see
the B.P.

Uses. — Brilliant green is an antiseptic tri-
phenylmethane dye employed in treating infected
wounds and burns. Aqueous solutions are em-
ployed in 0.05 to 0.1 per cent concentration; oint-
ments are used in 1 to 2 per cent concentration.
A paint containing 0.5 per cent each of brilliant
green and crystal violet in approximately 50 per
cent alcohol solution is used in Great Britain for
sterilizing skin. Another paint, containing 2.29
Gm. each of crystal violet and brilliant green and
1.14 Gm. of proflavine hemisulfate in sufficient
water to make 1 liter, is used for treatment of
burns. This latter solution is similar to the "triple
dye" described under Methylrosaniline Chloride. S

Storage. — Preserve in a well-closed container.
B.P.

FIVE BROMIDES ELIXIR. N.F.

Elixir Bromidorum Quinque

"Five Bromides Elixir contains, in each 100 ml.,
the equivalent of not less than 18.5 Gm. and not
more than 20.0 Gm. of Br." N.F.

Mix 87 Gm. of sodium bromide, 70 Gm. of
potassium bromide, 52 Gm. of calcium bromide,
35 Gm. of lithium bromide, and 17 Gm. of am-
monium bromide with 250 ml. of purified water;
add 225 ml. of glycyrrhiza syrup, 150 ml. of rasp-
berry syrup, and 200 ml. of aromatic elixir, and
agitate until solution of the bromides has been
effected. Add enough purified water to make
1000 ml., mix well, and filter, if necessary, to
obtain a clear product. N.F.

Assay. — A 10-ml. portion of the elixir is
diluted to 250 ml. and the content of bromide
determined in a 25-ml. aliquot of this solution by
adding 50 ml. of 0.1 A7 silver nitrate and titrating
with 0.1 A7 ammonium thiocyanate, in the pres-
ence of nitric acid and using ferric ammonium
sulfate T.S. as indicator. Each ml. of 0.1 AT silver
nitrate represents 7.992 mg. of Br. N.F.

Alcohol Content. — From 4 to 6 per cent, by
volume, of C2H5OH. N.F.

There is no evidence to demonstrate the superi-
ority of this mixture of bromides over any other
preparation of an equivalent content of bromide
ion, but it remains a fairly popular form of
bromide medication. The usual dose of 4 ml. (ap-
proximately 1 fluidrachm) contains about 1 Gm.
(approximately 15 grains) of the mixed bromides.

Storage. — Preserve "in tight containers." N.F.

THREE BROMIDES ELIXIR. N.F.

Elixir Bromidorum Trium

"Three Bromides Elixir contains, in each 100
ml., not less than 23 Gm. and not more than 25
Gm. of total bromides." N.F.

Elixir of Triple Bromides.

Dissolve 80 Gm. each of ammonium bromide,
potassium bromide and sodium bromide in 800
ml. of compound benzaldehyde elixir, add 3 ml. of
amaranth solution, and enough compound benz-
aldehyde elixir to make 1000 ml. Filter, if neces-
sary, until the product is clear. N.F.

Assay. — This elixir is analyzed in the same

manner as Five Bromides Elixir. Each ml. of
0.1 N silver nitrate represents 10.59 mg. of the
total bromides. N.F.

Alcohol Content. — From 3 to 5 per cent, by
volume, of C2H5OH. N.F.

Guth (Bull. N. F. Com., 1943, 11, 224) re-
ported that this elixir is unstable at a pH above
5.8, the color gradually changing to amber and
a black sediment being formed. Iron also affects
the color.

Incompatibility. — Alkaline salts liberate am-
monia from the ammonium bromide of this elixir;
phenobarbital sodium thus reacts and is itself
precipitated as phenobarbital.

The usual dose of this elixir is 4 ml. (approxi-
mately 1 fluidrachm) in which is represented
about 320 mg. (approximately 5 grains) of each
bromide. The mixture of bromides is not thera-
peutically superior to an equivalent amount of any
of its components.

Storage. — Preserve "in tight containers." N.F.

BROMIDES SYRUP.

[Syrupus Bromidorum]

N.F.

Dissolve 80 Gm. of potassium bromide, 80 Gm.
of sodium bromide, 50 Gm. of ammonium bro-
mide, 25 Gm. of calcium bromide, 8 Gm. of
lithium bromide in 225 ml. of purified water, with
the aid of heat, and dissolve 425 Gm. of sucrose
in the hot solution. Cool the solution, add 32 ml.
of vanilla tincture, 16 ml. of compound amaranth
solution and enough compound sarsaparilla syrup
to make 1000 ml. Mix well. N.F.

Alcohol Content. — From 4 to 6 per cent, by
volume, of C2H5OH. N.F.

This is an agreeable preparation for administer-
ing bromides. The usual dose of 4 ml. (approxi-
mately 1 fluidrachm) contains about 1 Gm. (ap-
proximately 15 grains) of the mixed bromides.

Storage. — Preserve "in tight containers and
avoid excessive heat." N.F.

THREE BROMIDES TABLETS. N.F.

Triple Bromide Tablets, Tabellae Bromidorum Trium

"Three Bromides Tablets (consisting of am-
monium bromide, potassium bromide, and sodium
bromide in equal proportions) show a content of
bromine not less than 70 per cent and not more
than 81 per cent of the labeled amount of total
bromides, including all tolerances. The tablets
show a content of ammonium bromide not less
than 30.8 per cent and not more than 35.8 per cent
of the labeled amount of total bromides." N.F.

Storage. — Preserve "in tight containers." N.F.

Usual Sizes. — ll/2 or 15 grains (approximately
0.5 or 1 Gm.) of total bromides consisting of
equal parts of the three salts.

BROMISOVALUM. N.F.
CH3.CH(CH3).CHBr.CO.NH.CO.NH2

"Bromisovalum consists chiefly of alpha-
bromisovaleryl urea with trace amounts of the
next higher and lower homologs and their isomers.
It yields not less than 97 per cent and not more
than 100 per cent of C6HuBrN202." N.F.

Bromvaletone, B.P.C. BromuraJ (Bilhuber-Knoll) ;
Bromyl; Brovalurea; Dormigene; Isobromyl; Pivadonn.

Part I

Bromoform

195

Bromisovalum, one of the early hypnotics and
sedatives, may be prepared by the interaction of
urea and a-bromoisovaleryl bromide; details of
synthesis are described in U. S. Patent 914,518
(1909).

Description. — "Bromisovalum occurs as
small, white, needle-shaped or scale-like crystals
having a faintly bitter taste. It sublimes upon
heating. Bromisovalum is soluble in alcohol, in
ether, and in hot water, but is less readily soluble
in cold water. It is soluble in a solution of sodium
hydroxide (1 in 10), from which it is precipitated
by acids. Bromisovalum melts between 147° and
150°." N.F.

Standards and Tests. — Identification. — (1)
A yellowish white precipitate is produced on add-
ing 2 ml. of nitric acid, followed by 3 drops of
silver nitrate T.S., to about 100 mg. of bromi-
sovalum. (2) A white precipitate of sodium bro-
mide forms on heating bromisovalum with a solu-
tion of sodium ethylate, and dimethylacrylic acid
obtained in the filtrate melts at about 70°. (3)
Ammonia is evolved on boiling 1 Gm. of bromiso-
valum with 10 ml. of a 1 in 10 solution of sodium
hydroxide; on acidifying the cooled liquid, ex-
tracting it with ether, an odor of valeric acid is
observed on evaporating the ether. Loss on drying.
— Not over 0.1 per cent, when dried over phos-
phorus pentoxide for 16 hours. Residue on igni-
tion.— Not over 0.1 per cent. N.F.

Assay. — About 350 mg. of bromisovalum is
hydrolyzed by digestion with sodium hydroxide at
elevated temperature; the bromide thus released
is determined by adding a measured excess of 0.1
N silver nitrate and titrating with 0.1 N ammo-
nium thiocyanate using ferric ammonium sulfate
T.S. as indicator. Each ml. of 0.1 N silver nitrate
represents 22.31 mg. of CeHnBrN202. N.F.

Uses. — Bromisovalum has long been used as
a sedative and mild hypnotic. In ordinary doses
it is non-toxic (Eeckhout, Arch. exp. Path. Pharm.,
1907, 57, 338), although Sollmann and Hatcher
{J.A.M.A., 1908, 51, 487) found that in propor-
tion to its hypnotic power it is almost as toxic
as chloral hydrate and more fugacious in action.
The theory of Eeckhout that its effects were es-
sentially those of bromide ion seems to have been
disproved by Takeda {Arch, internat. pharma-
codyn. therap., 1911, 21, 203), who found that
only a small proportion of the compound was
decomposed by the body.

While it is often effective in milder types of
insomnia, its most important use is as a general
nerve sedative in hysteroid states. Like carbromal,
it appears to have some anodyne power in neu-
ralgic pain. While bromisovalum has been sug-
gested as a motor sedative in treatment of epi-
lepsy, other agents are more effective. All action
of the drug ceases after 3 to 5 hours. Bromiso-
valum is not effective in cases of insomnia as-
sociated with pain, cough, angina pectoris or
delirium.

The usual sedative dose of bromisovalum is
300 mg. (approximately 5 grains), while the
usual hypnotic dose is 600 mg. at bedtime, re-
peated if advisable after 3 to 4 hours.

Storage. — Preserve "in well-closed containers."
N.F.

BROMISOVALUM TABLETS. N.F.

"Bromisovalum Tablets contain not less than
92.5 per cent and not more than 107.5 per cent
of the labeled amount of CeHnBr^Cte." N.F.

Usual Size. — 300 mg. (approximately 5
grains).

BROMOFORM. LP.

Bromoformium

CHBrs

Bromoform is tribromomethane containing 1.0
to 2.0 per cent v/v of ethanol. LP.

Bromoformum, U.S. P. IX.

Bromoform is the bromine analog of chloro-
form and may be prepared by similar reactions,
using bromine or its derivatives in place of
chlorine.

Description. — Bromoform is a clear, color-
less liquid, smelling and tasting like chloroform.
It is slightly soluble in water but is miscible in all
proportions with alcohol, with ether, with fixed
oils, and with volatile oils. Its density is between
2.813 and 2.817. LP. Bromoform is not flammable
but its vapors may be ignited.

Standards and Tests. — Congealing tempera-
ture.— Not below 6°. Refractive index. — Between
1.586 and 1.588, at 20°. Non-volatile residue.—
No residue remains from the evaporation of 3 ml.
The LP. also provides tests for identification,
bromide, free bromine, acidity, carbonyl bro-
mide, and foreign odor.

Uses. — Bromoform produces rapid narcosis
when inhaled but it is too dangerous to use as
a general anesthetic. Taken orally it has the
action of bromides but it has no advantage over
inorganic bromides and may be dangerous to use.
In the latter part of the 19th century bromoform
was advocated as a remedy for whooping cough.
For a time it was rather extensively employed
for this purpose but in the United States it is
rarely if ever used as it is more toxic than other
sedative cough preparations; it appears still to
be used in such preparations in some other coun-
tries. It has been used for treatment of mania,
and Desesquell (Bull, mid., 1907) recommended
it for relief of seasickness.

Cases of poisoning with bromoform have been
recorded (see Brit. M. J., 1900; Therap. Gaz.,
1903) ; three drops are said to have produced
very serious symptoms in a child of four years,
and two drops in one of fifteen months. Symp-
toms of poisoning, as recorded in the literature,
have been pallor, titubation, dilatation of the
pupils, coma, heart failure, and collapse.

The LP. gives the usual single dose as 100 mg.,
ranging to a maximal dose of 500 mg. ; the usual
daily dose is given as 500 mg., ranging to a
maximal daily dose of 1.5 Gm. It should be
remembered that because of the relatively high
density of bromoform a dose of 100 mg. corre-
sponds to approximately 0.035 ml. or 0.5 minim.

Storage. — Preserve in small, well-filled,
tightly-closed containers, specially protected from
light. LP.

196

Buchu

Part I

BUCHU. N.F.

[Buchu]

"Buchu is the dried leaf of Barosma betulina
(Thunberg) Bartling et Wendland, known in
commerce as Short Buchu, or of Barosma cre-
nulata (Linne) Hooker, known in commerce as
Oval Buchu, or of Barosma serratijolia (Curtis)
Wildenow, known in commerce as Long Buchu
(Fam. Riitacecs). Buchu yields not less than 1.25
ml. of volatile buchu oil from each 100 Gm. of
drug." N.F.

Buchu Folia; Folia Bucco; Folia Diosmse. Fr. Buchu;
Feuilles de buchu. Ger. Buccoblatter; Buchublatter. Sp.
Buchu; Bucco.

The Hottentots of South Africa first acquainted
the white man with the medicinal properties of
buchu. In 1821, it was imported into England
and introduced to the medical profession by
Reece and Co. of London. It became official in
the U.S. P. of 1840 under the Latin title "Diosma,"
which was changed to Buchu in the revision of
1850 and continued to be recognized therein until
the revision of 1940, when it became official in
the National Formulary.

The leaves of the official and other Barosmas
(so named from P<xqu;, heavy, and 6a\ir\, odor),
and of some Agathosmas, are collected by the
Hottentots, who value them on account of their
odor, and under the name of bookoo or buchu,
rub them, in the state of powder, upon their
greased bodies.

The medicinal species of Barosma are all erect,
slender xerophytic shrubs with opposite leaves,
dotted with conspicuous pellucid oil glands,
smooth, angular, purplish branches, white flowers,
and a fruit of five erect follicles. They are chiefly
distinguished by their leaves.

Barosma betulina is a small shrubby plant in-
digenous to Cape Colony. The leaves, which vary
in outline from rhomboidal, ovate to rhomboidally
obovate, are collected while the plant is in flower
and fruit, then dried. B. serratijolia is a well-
developed shrub growing in the mountains of the
southwest of Cape Colony. Its leaves are lanceo-
late with apex acute, base cuneate, margin sharply
serrate with oil glands at the tooth bases, the
upper surface glandular-punctate.

Barosma crenulata (L.) Hook, commercially
called oval buchu, has leaves oblong-ovate, ser-
rated and glandular, punctate above, with a
gland at the base of each tooth, apex rounded
and occasionally recurved, base obtuse or cuneate.
texture coriaceous. The flowers are white or of
a reddish tint, and stand solitarily at the end of
short, lateral leafy shoots.

The leaves of all three of these species are
collected in the Cape Colony district of South
Africa when the plants are in flower or fruit.
In pre-war years most of the supply used in the
United States came from Cape Town, South
Africa, a small amount through London. In
1952, a total of 67,143 pounds of buchu was
imported into the U. S. A. from the Union of
South Africa.

Non-official species, which have been seen in
European markets occasionally, are said to be

used in South Africa as substitutes for the official
buchu. For their descriptions see U.S.D., 24th
ed.. p. 172.

Description. — "Unground Short Buchu oc-
curs as rhomboidally oval or obovate leaves from
9 to 30 mm. in length and from 4 to 20 mm. in
breadth. The apex is obtuse or rounded and
sometimes recurved; the base wedge-shaped or
obtuse; and the margin finely dentate, glandular
punctate, with an oil gland at the base of each
tooth. The surface is papillose and longitudi-
nally striate beneath. The texture is coriaceous;
and the petiole about 1 mm. in length. The leaf
has a pale olive to dusky yellow-green color; has
an aromatic, mint-like odor, and a camphora-
ceous taste. Unground Oval Buchu occurs as
oblong-ovate leaves, from 7 to 28 mm. in length
and from 3 to 12 mm. in breadth having a serrate
margin, and a petiole about 2 mm. in length.
The color is light olive-brown to dusky yellow-
green. Otherwise it resembles Short Buchu.
Unground Long Buchu occurs as linear-lanceolate
leaves with 3-nerved venation from 8 to 40 mm.
in length and from 4 to 10 mm. in breadth, having
an acute apex, somewhat rounded, and a sharply
serrate margin. Otherwise it resembles Short
Buchu." N.F. For histology see N.F. X.

"Powdered Buchu is dusky greenish yellow to
moderate greenish yellow. It shows fragments of
epidermis with sphero-crystals. or crystal aggre-
gates of hesperidin in the cells, rosette aggre-
gates of calcium oxalate from 15 to 30 n in
diameter; a few non-glandular hairs (from stems)
up to 180 n in length; fragments of chlorenchyma
with oil secretion sacs and oil globules; and
fragments of fibrovascular bundles." N.F.

For additional information on the pharmacog-
nosy of buchu, see Feldman and Youngken (/. A.
Ph. A., 1944, 33, 277).

Standards and Tests. — Buchu contains not
over 8 per cent of buchu stems and not ovet
2 per cent of foreign organic matter other than
stems, and yields not more than 1 per cent of
acid-insoluble ash. N.F.

Assay. — The volatile oil in about 100 Gm. of
buchu. coarsely comminuted, is determined by
the official Process A for volatile oil content of
vegetable drugs. N.F.

Constitutents. — Buchu leaves yield a volatile
oil with a peppermint-iike odor. The amount of
oil present in the short buchu ranges from 1.5
to 2.5 per cent, but in the long buchu is much
less, usually not over 1 per cent. For data on
the content of oil in buchu and on the constants
of the former see the report of the A. Ph. A.
Laboratory {Bull. N. F. Com., 1940, 8, 221).
This oil on chilling deposits a ketonic stearopten
which is known as Barosma camphor or dios-
phenol (it is, however, said not to occur in the
oil from B. serratijolia). This substance, which
composes about 30 per cent of the oil, forms
crystals which melt at 82° and boil at 232°, with
partial decomposition. The residue of the oil
after extraction of the diosphenol contains a
hydrocarbon, CioHis, and a ketone, CinHisO,
which is probably levorotatory menthone. Spica
(Pharm. J., 1885) found in the leaves of B. ere-

Part I

Butacaine Sulfate

197

nulata, from which the oil had been extracted, a
solid principle diosmin (also called barosmin)
which is a glycoside closely related to hesperidin
found in orange peel. Oesterle and Wander (Helv.
Chitn. Acta, 1925, 8, 519) found it to yield glu-
cose, rhamnose and diostnetin on hydrolysis. The
last-named may be prepared from hesperetin by
ring closure (see also Nakaoki, Chem. Abs., 1939,
33, 602). Diosmin is now known to occur in
many plants.

Adulterants. — Buchu is subject to many
adulterations by the leaves of other species of
the genus as well as by more distantly related
leaves. The most important of these adultera-
tions are as follows: Psoralea obliqua E. Mey, or
P. bracteata (Pharm. J., 1910, pp. 69 and 464),
and Empleurum serrulatum Ait. The leaves of the
latter have a more acrid taste, are lanceolate or
narrowly linear, about 4 cm. in length, yellowish-
green and very acute at the summit. They fur-
ther do not contain any oil canals at the base of
the teeth. For description of many other adul-
terants and substitutes, see Holmes (Pharm. J.,
1910, 85, 464) and Wallis and Dewar (Quart.
J. P., 1933, 6, 347).

Uses. — Buchu was formerly extensively em-
ployed as a mild diuretic and in the treatment
of inflammatory conditions of the urinary organs,
especially in cystitis. Although its volatile oil is
probably antiseptic, the quantity present is so
small that it seems unlikely that it would exert
any antibacterial action in the bladder; within
recent years the drug has been almost completely
abandoned by the medical profession, [vj

Dose, 2 to 4 Gm. (approximately /2 to 1
drachm) .

BUCHU FLUIDEXTRACT.

[Fluidextractum Buchu]

N.F.

Prepare the fluidextract from buchu, in moder-
ately coarse powder, by Process C, as modified
for assayed fluidextracts (see under Fluidex-
tracts), using a menstruum of 9 volumes of
alcohol and 1 volume of water. Macerate during
24 hours, and percolate at a moderate rate.
Adjust the concentrated fluid by dilution with
alcohol, or a mixture of alcohol and water, so
that the fluidextract contains 75 per cent, by
volume, of C2H5OH. N.F.

Alcohol Content. — From 71 to 78 per cent,
by volume, of C2H5OH. N.F.

This preparation is representative of buchu;
formerly it was used in the treatment of cystitis
in a dose of 2 to 4 ml. (approximately 30 to 60
minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

BUCHU, JUNIPER AND POTASSIUM
ACETATE ELIXIR. N.F.

[Elixir Buchu, Juniperi et Potassii Acetatis]

Mix 10 ml. of compound orange spirit with
400 ml. of alcohol, add 400 ml. of distilled water,
and use this mixture as menstruum I for extract-
ing a mixture of 150 Gm. of buchu and 75 Gm.

of juniper, both in moderately coarse powder, by
Process P (see under Tinctures). For menstruum
II use diluted alcohol. Macerate the mixed drugs
for 24 hours, then percoiate at a moderate rate.
Dissolve 225 Gm. of sucrose and 50 Gm. of po-
tassium acetate by agitation in the first 850 ml.
of percolate, then add sufficient of the percolate
to make the product measure 1000 ml. Mix well;
filter, if necessary, to obtain a clear product.
N.F.

Alcohol Content. — From 35 to 38 per cent,
by volume, of C2H5OH. N.F.

This was once a popular preparation for the
treatment of cystitis and for use as a diuretic.
Since official dose of 4 ml. (approximately
1 fluidrachm) represents one-fifth the official
dose of potassium acetate, a little less than one-
third the official dose of buchu, and one-twelfth
the official dose of juniper it is not apparent how
the preparation functions therapeutically.

Storage. — Preserve "in tight containers."
N.F.

BUTACAINE SULFATE.

N.F. (B.P.) LP.

Butacainium Sulfate, 3-Di-n-butylaminopropyl-
p-aminobenzoate Sulfate, [Butacaina; Sulfas]

C4H9

COCXCH ) — NH

23 I
C4H

'4n9_

S04
Z

The B.P. defines this compound as the sulfate
of 3-di-n-butylaminopropyl p-aminobenzoate ; the
LP. identifies it as the sulfate of 3'-dibutylami-
nopropyl 4-aminobenzoate.

B.P. Butacaine Sulphate; Butacaina; Sulphas. I.P.
Butacaini Sulfas. Butyn Sulfate (.Abbott). Sp. Sulfate de
B utacaina.

Butacaine sulfate, originally introduced under
the trade name of butyn, is />-aminobenzoyl-Y-
dinormalbutyl-aminopropanol sulfate, or y-di-n-
butylaminopropyl-p-aminobenzoate-N-sulfate, the
sulfate of a base resembling procaine base; the
former contains a butyl group in place of the
ethyl group in procaine base, and a propanol
group in place of the ethanol group. Butacaine
may be prepared by refluxing a benzene solution
of p-nitrobenzoyl chloride and v-dibutylamino-
propyl alcohol, followed by reduction with tin
and hydrochloric acid. The sulfate of the product
is the official compound. The B.P. states that it
may be prepared by the interaction of 1-chloro-
3-di-rt-butylaminopropane and sodium p-amino-
benzoate.

Description. — "Butacaine Sulfate occurs as a
white, odorless, crystalline powder which is af-
fected by light. It rapidly produces numbness
when placed upon the tongue. Its solutions are
practically neutral to litmus. Butacaine Sulfate
dissolves slowly in less than its own weight of
water, solution occurring more rapidly upon
heating. It is very soluble in warm alcohol and
in acetone, is slightly soluble in chloroform, and

198

Butacaine Sulfate

Part I

is insoluble in ether. Butacaine Sulfate melts be-
tween 100° and 103°." N.F.

Standards and Tests. — Identification. — (1)
The free base, a colorless oil, is precipitated
from solutions of butacaine sulfate by alkali
hydroxides and carbonates; a crystalline car-
bonate of the base is precipitated by solutions
of alkali bicarbonates. (2) A 1 in 10 solution
of butacaine sulfate yields a white precipitate
with mercuric potassium iodide T.S., a yellow
precipitate with trinitrophenol T.S., and a brown
precipitate with iodine T.S. and with gold chlo-
ride T.S. (3) A scarlet red precipitate is formed
on diazotizing 100 mg. of butacaine sulfate in
5 ml. of water by the addition of 2 drops each of
diluted hydrochloric acid and 1 in 10 sodium
nitrite solution, then adding to 200 mg. of beta-
naphthol dissolved in 10 ml. of 1 in 10 sodium
hydroxide solution (phenacaine yields a yellow
precipitate in the same test). (4) A 1 in 10
solution of butacaine sulfate responds to tests
for sulfate. Residue on ignition. — Not over 0.2
per cent. Readily carbonizable substances. — A
solution of 500 mg. of butacaine sulfate in 5 ml.
of sulfuric acid has no more color than matching
fluid G. N.F.

Incompatibilities. — Alkalies or substances
producing alkalinity liberate the free base as an
oily liquid from solutions of butacaine sulfate.
Soluble bicarbonates react with it to produce an
insoluble carbonate; chlorides form the difficultly
soluble butacaine chloride.

Uses. — Butacaine sulfate is a more active local
anesthetic than is either cocaine or procaine
(Bulson, JAMA., 1922, 78, 343; Schmitz and
Loevenhart, /. Pharmacol., 1924, 24, 167). A
general consideration of the comparative pharma-
cology of these substances is provided in the
monograph on Local Anesthetic Agents, in Part
II. Butacaine sulfate acts through intact mucous
membranes and it is one of the more frequently
employed of surface-acting local anesthetics. It
is one of the lesser offenders among topical local
anesthetic agents in causing dermatitis; Lane and
Luikart (J.A.M.A., 1951, 146, 717), in a review
of 107 cases of dermatitis caused by these
agents, found butacaine sulfate to have been
responsible in 8 cases. Its action is more pro-
longed and rapid than that of cocaine. Locally
it is more toxic than procaine but less poisonous
than cocaine; parenterally it is more toxic than
cocaine, but it is seldom used in this manner.
Several deaths have been reported from use of
butacaine sulfate. A 0.1 to 0.4 per cent solution
has been employed for infiltration anesthesia, but
it is not advocated for spinal or infiltration
anesthesia.

Butacaine sulfate is recommended especially
for the eye in a 2 per cent solution {JAMA.,
1922, 78, 343). It does not affect the pupil or
cause drying or ischemia of the tissue. Within
one minute after a single application to the eye
minor procedures, such as removal of most for-
eign bodies from the cornea, may be conducted.
Several instillations, about three minutes apart,
permit most surgical procedures to be applied.
The 2 per cent solution may also be used in the

nose and throat. Butacaine sulfate solutions may
be sterilized by boiling, [v]

Storage. — Preserve "in tight, light-resistant
containers." N.F.

BUTALLYLONAL. N.F.

0-Bromoallyl-sec.-butylbarbituric Acid

H °

yN — (^ CH2CBr = CH2

H' 0 CH3

"Butallylonal yields not less than 98.5 per cent
and not more than 101.5 per cent of C11H15-
BrN203." N.F.

Pernoston {Ames).

Butallylonal, which is 5-(2-bromoallyl)-5-jec-
butylbarbituric acid, may be prepared by heating
iec.-butylmalonic acid and l,2-dibromo-2-pro-
pene or 1,2.3-tribromopropane in the presence of
sodium hydroxide to give the sodium derivative,
which is converted to the official acid form by
acidification, according to U.S. Patent 1,739,662
(1929).

Description. — "Butallylonal occurs as a fine,
white, crystalline powder, with a slightly bitter
taste. Its solutions are acid to litmus paper.
Butallylonal is completely soluble in alcohol and
in ether, very slightly soluble in cold water, and
insoluble in paraffin hydrocarbons. Butallylonal
melts between 130° and 134°/' X.F.

Standards and Tests. — Identification. — (1)
This is essentially identical with test (2) under
Barbital and most other barbituric acid com-
pounds. (2) Following fusion with potassium hy-
droxide, during which ammonia is evolved, the
residue yields with silver nitrate a precipitate of
silver bromide. (3) Bromine T.S. is decolorized by
a saturated solution of butallylonal. Residue on
ignition. — Not over 0.1 per cent. Chloride. — No
opalescence is produced on adding diluted nitric
acid and silver nitrate T.S. to a saturated aque-
ous solution of butallylonal. Sulfate. — No tur-
bidity develops on adding diluted nitric acid and
barium nitrate T.S. to a saturated aqueous solu-
tion of butallylonal. Heavy metals. — No color or
precipitate is produced on saturating an aqueous
solution of butallylonal with hydrogen sulfide.
Readily carbonizable substances. — A solution of
100 mg. of butallylonal in 1 ml. of sulfuric acid
has a yellow color which changes slowly to brown-
ish red and finally to red. X.F.

Assay. — The assay is identical with that de-
scribed under Butethal. Each ml. of 0.1 N sodium
hydroxide represents 30.32 mg. of CnHi5BrN203.
N.F.

Uses. — Butallylonal has been classified, ac-
cording to the schema of Fitch and Tatum
(/. Pharmacol., 1932, 44, 325), as having a
moderate or intermediate duration of action (for
general discussion see the monograph on Bar-
biturates, in Part II). With respect to duration
of action and indications for utility it is similar

Part I

Butethal Tablets

199

to amobarbital; butallylonal is notable for hav-
ing an atom of bromine in it.

It is well absorbed, whether in acid form or as
the sodium salt, when administered orally. Its
action is almost immediate when the soluble
sodium salt is administered, carefully and
slowly, intravenously.

Although butallylonal is employed primarily as
a sedative to combat insomnia, it has been
recommended by Bernhard and Friedlander (Am.
J. Surg., 1931, 11, 485) for preanesthetic medi-
cation. Butallylonal is essentially completely
metabolized. Only trace amounts are excreted as
such; 5 to 17 per cent has been accounted for
in urine as 5-acetonyl-S-jec-butylbarbituric acid
(Fretwurst et al., Munch, med. Wchnschr., 1930,
77, 1573).

The usual dose is 200 mg. (approximately
3 grains) orally one-half hour before sleep is
desired.

Storage. — Preserve "in well-closed contain-
ers." N.F.

BUTALLYLONAL TABLETS. N.F.

"Butallylonal Tablets contain not less than 94
per cent and not more than 106 per cent of the
labeled amount of CiiHi5BrN203." N.F.

Assay. — The assay is based on the principles
of the method described under Barbital Tablets.
N.F.

Usual Size. — 3 grains (approximately 200
mg.).

BUTETHAL. N.F.

5-Ethyl-S-n-butylbarbituric Acid

VAhi

"Butethal, dried at 105° for 2 hours, contains
not less than 98 per cent of C10H16N2O3." N.F.

Butobarbitone, B.P.C. Neonal {Abbott).

Butethal may be prepared by condensing the
ethyl ester of butylethylmalonate with urea (U.S.
Patent 1,609,520, December 7, 1926).

Description. — "Butethal occurs as white,
crystalline granules or as a white powder. It is
odorless, and has a slightly bitter taste. A satu-
rated solution is acid to litmus paper. One Gm.
of Butethal dissolved in about 5 ml. of alcohol
and in about 10 ml. of ether. It is soluble in
solutions of fixed alkali hydroxides or carbonates,
and very slightly soluble in water. Butethal melts
between 124° and 127°." N.F.

Standards and Tests. — Identification. — (1)
About 300 mg. of butethal is shaken with 1 ml.
of sodium hydroxide T.S. and 5 ml. of water
and the mixture filtered. On adding 1 ml. of
mercury bichloride T.S. to one-half of the fil-
trate a white precipitate, soluble in ammonia
T.S., is produced; on adding 5 ml. of silver
nitrate T.S. to the remainder of the filtrate a
white precipitate, soluble in excess of ammonia

T.S., is produced. (2) The melting point of a
sample of butethal, mixed with an equal portion
of pentobarbital, is depressed (differentiation
from pentobarbital). Loss on drying. — Not over
1 per cent, when dried at 105° for 2 hours.
Residue on ignition. — Not over 0.1 per cent.
N.F.

Assay. — About 500 mg. of butethal, previ-
ously dried at 105° for 2 hours, is dissolved in
neutralized alcohol, diluted with water, and
titrated with 0.1 N sodium hydroxide to a dis-
tinct blue end point with thymolphthalein indi-
cator. Each ml. of 0.1 N sodium hydroxide
represents 21.23 mg. of C10H16N2O3. N.F.

Uses. — Butethal (see article on Barbiturates,
in Part II, for general discussion) has been
classified as a barbiturate having intermediate
duration of action, according to the classification
basis suggested by Fitch and Tatum (/. Pharma-
col., 1932, 44, 325). Its duration of action and
indications for usage place it alongside of amo-
barbital; it is substantially more potent than
barbital. It is employed most frequently as one
of the more effective of barbiturate hypnotic
agents.

In recent years butethal has been studied espe-
cially for its effects on brain respiration. Buchel
and Mcllwain Nature, 1950, 166, 269) reported
that it caused a fall in cerebral respiration, in
vitro, accompanied by a decrease in phospho-
creatinine and an increase in inorganic phosphate.
This depression in cerebral respiration was re-
ported to be substantially greater than for chloral
or chorobutanol, and was accompanied by an
increase in glucose consumption and lactic acid
production (Rosenberg et al., Compt. rend. soc.
biol., 1950, 230, 480).

Butethal is well absorbed following oral ad-
ministration. Apparently it is almost completely
destroyed normally in the body (Herwick, /.
Pharmacol, 1930, 39, 267; ibid., 1931, 42, 268).
One of the metabolites of butethal is 5-ethyl-5-
(3-hydroxybutyl) barbituric acid (Maynert and
Dawson, /. Biol. Chem., 1952, 195, 389).

Toxicology. — The toxic effects from butethal,
and the treatment thereof, are essentially those
discussed in the monograph on Barbital.

Dose. — The recommended dosage, for pur-
poses of sedation, is 50 mg. to 100 mg. (approxi-
mately }i to lyi grains); the total of divided
doses administered during 24 hours should not
exceed 400 mg.

Storage. — Preserve "in well-closed contain-
ers." N.F.

BUTETHAL TABLETS. N.F.

"Butethal Tablets contain not less than 95
per cent and not more than 105 per cent of the
labeled amount of C10H16N2O3." N.F.

Assay. — A representative sample of powdered
tablets, equivalent to about 600 mg. of butethal,
is digested with alcohol to dissolve the butethal.
An aliquot portion of the mixture is treated with
barium hydroxide solution, which precipitates
stearate lubricants, in a centrifuge tube, after
which the mixture is centrifuged and the super-
natant liquid containing the butethal barium is

200

Butethal Tablets

Part I

decanted. The residue in the centrifuge tube is
treated with another portion of barium hydroxide
solution, to remove any butethal in the residue,
and this liquid is added to the first solution. The
combined alkaline solutions are acidified, the
liberated butethal is extracted with chloroform,
and the solvent evaporated, after which the resi-
due is dissolved in neutralized alcohol and titrated
with 0.1 N sodium hydroxide, as in the assay of
Butethal. N.F.

Usual Size. — 100 mg. (approximately 1^2
grains).

BUTETHAMINE HYDROCHLORIDE.
N.F.

Butethaminium Chloride, 2-Isobutylaminoethyl-p-
aminobenzoate Hydrochloride

n +

C-0-CH2CH2NH2CH2CH(CH3)2

CI"

"Butethamine Hydrochloride, dried at 105° for
2 hours, yields not less than 98.5 per cent of
C13H20N2O2.HCI." N.F.

Monocaine Hydrochloride (Novocol).

Butethamine base, a local anesthetic, may be
synthesized by reacting />-nitrobenzoyl chloride
and 2-isobutylaminoethanol and reducing the nitro
ester thus formed to the amine. For details of
synthesis see U. S. Patent 2,139,818 (1938). The
hydrochloride of the base is obtained by neu-
tralization with hydrochloric acid. Butethamine
formate (N.N.R.) is the formic acid salt of the
same base; this salt is described as being freely
soluble in water (the hydrochloride is only spar-
ingly soluble) and, also, somewhat less acid (pH
6) than a solution of the hydrochloride (pH 5)
of the same strength.

Description. — "Butethamine Hydrochloride
occurs as small, white crystals, or as a white,
crystalline powder. It is odorless, and is stable in
air. Butethamine Hydrochloride exhibits local
anesthetic properties when placed upon the tongue.
Butethamine Hydrochloride is sparingly soluble
in water, slightly soluble in alcohol and in chloro-
form, very slightly soluble in benzene, and prac-
tically insoluble in ether. Butethamine Hydro-
chloride melts between 192° and 196°." N.F.

Standards and Tests. — Identification. — (1)
A curdy, white precipitate, insoluble in nitric acid
but soluble in ammonia T.S., is produced on add-
ing silver nitrate T.S. to a solution of butetha-
mine hydrochloride. (2) An orange precipitate,
soluble in ether, is produced on adding betanaph-
thol in ammonia T.S. to an acid, diazotized solu-
tion of butethamine hydrochloride. (3) A white
precipitate forms on adding mercuric potassium
iodide T.S. to a solution of butethamine hydro-
chloride. pH. — The pH of a 1 in 100 solution is
about 5. Loss on drying. — Not over 0.2 per cent,
when dried at 105° for 2 hours. Residue on igni-
tion.— Not over 0.1 per cent. U.S. P.

Assay. — About 150 mg. of dried butethamine
hydrochloride is dissolved in water, the solution
made alkaline with ammonia T.S. and the buteth-

amine base thereby released extracted with sev-
eral portions of chloroform. Most of the chloro-
form is evaporated, after which neutralized
alcohol is added along with 40 ml. of 0.02 N
sulfuric acid. After evaporating the remaining
chloroform the excess acid is titrated with 0.02 N
sodium hydroxide. Each ml. of 0.02 N sulfuric
acid is equivalent to 5.455 mg. of C1.3H20N2O2.-
HC1. N.F.

Uses. — Butethamine hydrochloride is a local
anesthetic (for general discussion see mono-
graph on Local Anesthetic Agents). Hamilton et
al. {J. Pharmacol., 1948, 94, 299), including
butethamine in a comparative study of nine local
anesthetic agents, reported its acute intraperi-
toneal toxicity for mice to be 175 ± 5.9 mg. per
Kg. as compared with procaine at 185 ± 4.0 mg.
per Kg. and cocaine at 67 ± 4.7 mg. per Kg.
Thus, it is of essentially the same order of toxicity
as procaine. Its intradermal irritation was similar
in degree to that of procaine, but it was approxi-
mately twice as active an intradermal anesthetic
agent as procaine. They considered its therapeutic
ratio to be about 2.5 times that of procaine or 6
times that of cocaine when comparing infiltration
anesthesia versus toxicity. Buetner {Anesth. &
Analg., 1948, 27, 197) reported that butethamine
produced essentially the same vasodepressor re-
sponse as procaine administered in equal doses to
anesthetized dogs. Bennett and Chinburg (/.
Pharmacol, 1946, 88, 72) studied the effect of
butethamine and a number of other commonly
employed local anesthetics on the resting and on
the demarcation potential in the isolated sciatic
nerve. They found that the compounds blocked
conduction without depolarizing the nerves. This
they considered to support the view that anes-
thetics in general block nerves because they sta-
bilize the cell membrane potential which normally
shifts during impulse conduction in response to
pain. In general the above reports on the experi-
mental local anesthetic effects of butethamine are
in agreement with the earlier description of its
pharmacology by Abramson and Goldberg (/.
Pharmacol., 1938, 62, 69) except for some dif-
ference in interpreting the vascular response to
the agent. This discrepancy between the depressor
effect reported by Beutner and the pressor effect
indicated by Abramson and Goldberg perhaps is
resolved by the observation of Schamp et al.
{Anesth., 1942, 3, 295, 398) that the compound
produced a slight rise in blood pressure on some
occasions and a slight fall at other times in the
same animal or different animals. They reported
that the compound depressed respiratory rate
and depth.

Butethamine has been employed as an especially
useful agent in conduction anesthesia in dentistry.
Although earlier authors reported even more fa-
vorably, Tainter and Throndson (/. A. Dent. A.,
1941, 28, 1209) indicated that 1 per cent buteth-
amine produced a longer duration of anesthesia
than did 2 per cent procaine when administered
in essentially the same amounts for oral surgery
on some 251 patients. Brenner (/. A. Coll. Proc-
tol., 1939, 10, 331) reported that it was satisfac-
tory for use in proctological and rectal procedures,
and Meyersburg {Med. Rec, 1940, 151, 231) pub-

Part I

Butopyronoxyl 201

lished favorably on its use in some 4000 tonsil-
lectomies.

In other than dentistry butethamine is most
frequently associated with the field of spinal
anesthesia, as was first reported by Burdick and
Rovenstine (Anesth., 1942, 3, 514). They indi-
cated that it diffused more rapidly than did pro-
caine and that it was useful in somewhat smaller
doses. The incidence of toxicity was low, includ-
ing primarily headache (4.2 per cent), urinary re-
tention (3.2 per cent), and respiratory complica-
tions (4.2 per cent). Rovenstine and Apgar (ibid.,
1944, 5, 40), summarizing their experience with
butethamine in 2230 cases of spinal anesthesia,
indicated that when employed in the same dosage
as for procaine its spinal anesthetic effects were
more rapid in onset and longer in duration. Motor
paralysis following subarachnoid injections was
slower in onset and less profound than with pro-
caine. They observed that the incidence and de-
gree of toxicity attributable to butethamine was
no greater than for procaine and that the manage-
ment of toxicity was not different from that for
procaine. Nesbit and Butler (ibid., 1948, 9, 430)
reported that 75 mg. of butethamine formate
produced about the same duration of spinal anes-
thesia in 97 cases as did 100 mg. of procaine hy-
drochloride in 120 cases. Otherwise, they found
no difference between the efficacy of the two
agents except that butethamine was thought to
diffuse more rapidly.

Dose and Dosage Forms. — Butethamine hy-
drochloride is used for nerve block anesthesia in
dentistry and other minor surgery in a 1 per cent
solution containing also 1:75,000 of epinephrine;
in major surgery or other procedures requiring
nerve block anesthesia equivalent to that pro-
duced by 2 per cent of procaine hydrochloride,
a 1.5 per cent solution of butethamine hydro-
chloride containing also 1:100,000 of epinephrine
may be used. For usual sizes see following mono-
graph. Butethamine formate, N.N.R. (Monocaine
Formate, Novocol), more soluble in water and
less acid than the hydrochloride, is proposed for
use in spinal anesthesia; its action is also qualita-
tively identical with that of procaine hydrochlo-
ride. Both butethamine formate and butethamine
hydrochloride have about one-third more anes-
thetic and toxic potency than procaine hydro-
chloride and are, accordingly, used in about three-
fourths the dosage of procaine hydrochloride for
the purposes mentioned. Butethamine formate is
supplied in ampuls containing 50, 100, 150 and
200 mg. of crystals, also in 2-ml. ampuls con-
taining 50 mg. of butethamine formate in each
ml. of a solution in sterile distilled water.

Storage. — Preserve "in well-closed containers."
N.F.

BUTETHAMINE HYDROCHLORIDE
AND EPINEPHRINE INJECTION.

N.F.

"Butethamine Hydrochloride and Epinephrine
Injection is a sterile solution of butethamine hy-
drochloride and epinephrine in water for injec-
tion. It contains not less than 95 per cent and not
more than 105 per cent of the labeled amount of

C13H20N2O2.HCI and not less than 90 per cent
and not more than 120 per cent of the labeled
amount of epinephrine (C9H13NO3)." N.F.

The pH of the injection is required to be be-
tween 3.3 and 5.5. The assay for butethamine
hydrochloride is the same as that for the bulk
substance. The assay for epinephrine is a colori-
metric procedure in which the absorbance of the
product of interaction of epinephrine with a re-
agent containing ferrous sulfate and sodium citrate
at 530 mix is determined in a photoelectric color-
imeter and compared with the absorbance of a
standard solution prepared from U.S. P. Epine-
phrine Bitartrate Reference Standard, similarly
treated.

Storage. — Preserve "in single-dose or multiple-
dose containers, preferably of Type I glass." N.F.

Usual Sizes. — 1 per cent butethamine hydro-
chloride and 1 in 75,000 epinephrine in 5-ml.
cartridges; and in 30-, 60-, and 12 5-ml. bottles;
1.5 per cent butethamine hydrochloride and 1 in
100,000 epinephrine in 1-, 2-, 2.5-, and 5-ml. cart-
ridges; in 2- and 3-ml. ampuls; and in 30-, 60-,
and 125-ml. bottles; 1.5 per cent butethamine
hydrochloride and 1 in 30,000 epinephrine in 5-
ml. cartridges; 2 per cent butethamine hydro-
chloride and 1 in 50,000 epinephrine in 1-, 2-,
and 2. 5-ml. cartridges; in 2- and 3-ml. ampuls;
and in 60- and 125-ml. bottles.

BUTOPYRONOXYL. U.S.P.

n-Butyl 3,4-Dihydro-2,2-dimethyl-4-oxo-l,2H-pyran-
6-carboxylate

COCXCH^CH,

Butyl mesityl oxide. Indalone.

Butopyronoxyl may be prepared by the con-
densation of mesityl oxide and dibutyl oxalate in
the presence of a sodium alkoxide catalyst.

Description. — "Butopyronoxyl is a yellow to
pale reddish brown liquid, having a characteristic
aromatic odor. It is reasonably stable in air and
is slowly affected by light. Butopyronoxyl is
insoluble in water; it is miscible with alcohol,
with chloroform, with ether and with glacial
acetic acid. The specific gravity of Butopyro-
noxyl is between 1.052 and 1.060." U.S.P.

Standards and Tests. — Distilling range. —
Not less than 90 per cent distils between 256°
and 270°. Refractive index. — Between 1.4745 and
1.4755. Clarity of solution. — A solution of 2 ml.
of butopyronoxyl in 10 ml. of alcohol is clear,
and no precipitate or turbidity develops on
standing in a refrigerator for 2 hours. U.S.P.

Uses. — Butopyronoxyl, better known as Inda-
lone, has been widely used as an insect repellent
and toxicant, both by itself and in combination
with other agents of similar effect. It is not a
particularly good mosquito repellent but it is
very effective against the biting stable, or dog,
fly (Stomoxys calcitrans L.). In combination
with ethohexadiol and dimethyl phthalate, in the
form of the official Compound Dimethyl Phthalate
Solution (q.v.), it is especially effective.

202 Butopyronoxyl

Part I

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

Off. Prep. — Compound Dimethyl Phthalate
Solution. US.P.

BUTYL AMINOBENZOATE.
X.F., B.P., LP.

n-Butyl p-Aminober.zoate, [Butylis Aminobenzoas]
H2N.C6H4.COOC4H9

The B.P. defines this compound as n-butyl
^-aminobenzoate, the LP. as butyl 4-aminoben-
zoate.

Bntesin (Abbott). Fr. Para-aminobenzoate de butyle;
Paratonne; Scuroforme. Sp. Aminobensoato de Butilo.

The official butyl aminobenzoate is the normal
butyl analogue of ethyl aminobenzoate and is
prepared in a similar manner, normal butyl al-
cohol being used in place of ethyl alcohol to
produce the ester of Pc:rj-aminobenzoic acid.
The B.P. gives as a method of preparation the
interaction of n-butyl chloride with sodium
p- aminobenzoate.

Description. — "Butyl Aminobenzoate occurs
as a white, crystalline powder. It is odorless and
tasteless. One Gm. of Butyl Aminobenzoate dis-
solves in about 7000 ml. of water. It is soluble
in dilute acids, in alcohol, in chloroform, in ether,
and in fatty oils. It is slowly hydrolyzed when
boiled with water. Butyl Aminobenzoate melts
between 57° and 59°." N.F.

Standards and Tests. — Identification. — (1) A
scarlet precipitate is formed when a few drops
of 1 in 10 solution of sodium nitrite are added to
2 ml. of a 1 in 100 solution of butyl aminoben-
zoate in 0.1 -V hydrochloric acid, and this solution
is added to a solution of 200 mg. of betanaph-
thol in 10 ml. of a 1 in 10 solution of sodium hy-
droxide. (2) A dark brown precipitate, changing
into large, reddish brown prisms, is formed on
adding a few drops of iodine T.S. to 1 ml. of a
1 in 100 solution of butyl aminobenzoate in 0.1 N
hydrochloric acid, the mixture being allowed to
stand for 10 minutes with occasional shaking
(ethyl aminobenzoate gives lustrous scales in
the same test). Residue on ignition. — Not over
0.15 per cent. Completeness and color of solu-
tion.— 1 in 30 solutions of butyl aminobenzoate
in alcohol and in ether are complete and colorless.
Chloride. — Xo turbidity is produced on adding
1 ml. of diluted nitric acid and a few drops of
silver nitrate T.S. to a solution of 200 mg. of
butyl aminobenzoate in 10 ml. of alcohol. Heavy
metals. — The limit is 10 parts per million. X.F.

Incompatibilities. — Butyl aminobenzoate has
the same incompatibilities as ethyl aminoben-
zoate.

Uses. — Butyl aminobenzoate is used as a local
anesthetic. Being insoluble in water, it is not
suitable for many of the uses to which the local
anesthetics are put. It has been used as an anes-
thetic dusting-powder for the same purposes as
ethyl aminobenzoate and is thought to be more
effective. An ointment containing butyl amino-
benzoate was described by Yeager and Wilson
(J. Lab. Clin. Med., 1944.' 29, 177); it contains
benzyl alcohol for solution and sodium lauryl
sulfate for dispersion of the anesthetic. It is ap-

plied in a thick layer to moistened skin and al-
lowed to dry to powder, providing prolonged
local anesthesia in such conditions as insect bites,
dermatitis venenata, and tropical fungus in-
festations.

Butyl aminobenzoate is used chiefly in the form
of a combination with trinitrophenol supplied
under the trade-marked name Butesin Picrate
(Abbott). According to Thayer (Am. J. Pharm.,
1925 (p. 39) butesin picrate is a compound of
one molecule of trinitrophenol with two molecules
of butesin. It is conceivable that in presence of
moisture the acid radical separates and acts as
free trinitrophenol. Taylor reported that the com-
bination is actively germicidal, a solution of one
part in 2000 killing Staphylococcus aureus in five
minutes; but Meredith and Lee (J. A. Ph. A.,
1939, 28, 369) found that a 2 per cent ointment,
in a cold cream base, had no antiseptic action.
Xitromersol, 1 in 5000, has been added to this
ointment.

An injection containing 1.5 per cent of pro-
caine base, 6 per cent of butyl aminobenzoate,
and 5 per cent of benzyl alcohol in sterilized al-
mond oil has been used, in doses of 1 to 5 ml. or
more, for infiltration or nerve block anesthesia
where prolonged action for the relief of pain is
desired. For the pains of tabes dorsalis. Fowler
(Brit. J. Vener. Dis., 1947, 23, 90) reported good
results from use of this injection. Wright (Proc.
Roy. Soc. Med., 1950, 43, 263) cautioned against
the danger of abscess formation in perianal tis-
sues from injections into infected tissues in this
area.

Butesin picrate (Butamben Picrate, X.X.R.
1951) occurs as a yellow powder, odorless, with a
slightly bitter taste, soluble in about 2000 parts
of water, and about 100 parts of cottonseed oil.
Its aqueous solution (1:2000") is markedly anes-
thetic and Parsons (Xorthwest Med., June, 1926)
found it useful for anesthetizing the eye in the
removal of foreign bodies. It is chiefly employed,
however, in the form of a 1 per cent ointment for
the treatment of burns. An ointment containing
1 per cent each of butyl aminobenzoate and its
picrate in petrolatum is used in ophthalmology.
A minor disadvantage of the ointment is its ten-
dency to stain. Lane and Luikart (J. A. MA.,
1951, 146, 718), reviewing the literature on der-
matitis from local anesthetics, listed fourteen
cases of epidermal sensitization to Butesin pic-
rate. and indicated that the dermatitis could be
severe and generalized at times. Trinitrophenol. a
component of this ointment, may be a possible
sensitizer; Jackson (Arch. Dermat. Syph., 1930,
21, 40) described three cases of picric acid sensi-
tivity of the skin. If a reddened, pruritic contact-
type dermatitis occurs with topical use of this
ointment, it should be immediately discontinued.

Storage. — Preserve "in well-closed contain-
ers." NJ.

BUTYL CHLORIDE. X.F.

n-Butyl Chloride

CH3(CH2)2CH2C1

"Butyl Chloride contains not less than 99 per
cent of C4H9CI. Caution. — Butyl Chloride is very

Part I

Cacao

203

flammable. Do not use where it may be ignited."
N.F.

l-Chlorobutane.

Butyl chloride may be prepared by the inter-
action of n-butyl alcohol and hydrochloric acid
in the presence of zinc chloride.

Description. — "Butyl Chloride occurs as a
clear, colorless, volatile liquid, having a charac-
teristic nonresidual odor. It is flammable. Butyl
Chloride is insoluble in water, but is miscible
with dehydrated alcohol and with ether. The spe-
cific gravity of Butyl Chloride is not less than
0.880 and not more than 0.885." N.F.

Standards and Tests. — Identification. — On
boiling butyl chloride with sodium hydroxide
solution the resulting solution responds to tests
for chloride. Distilling range. — Between 77° and
79°. Acidity. Sot more than 0.1 ml. of 0.02 N
sodium hydroxide is required to neutralize any
acid present in the equivalent of 25 ml. of butyl
chloride. Non-volatile residue. — Not over 1 mg.
from 10 ml. Chloride. — The limit is 7 parts per
million. N.F.

Assay. — About 1.5 ml. of butyl chloride is
hydrolyzed by heating with 0.5 N alcoholic potas-
sium hydroxide and the excess alkali titrated with
0.5 N hydrochloric acid using phenolphthalein as
indicator. A residual blank titration is performed.
Each ml. of 0.5 N alcoholic potassium hydroxide
represents 46.29 mg. of C4H9CI. N.F.

Uses. — Butyl chloride is employed as a veter-
inary anthelmintic. Details of use and of dose are
discussed under Veterinary Uses and Doses of
Drugs, in this volume.

Storage. — Preserve "in well-closed, light-
resistant containers, remote from fire." N.F.

CACAO. U.S.P.

Cocoa, [Cacao]

"Cacao is a powder prepared from the roasted,
cured kernels of the ripe seed of Theobroma
Cacao Linne (Fam. Sterculiacece). Cacao yields
not less than 10 per cent and not more than 22
per cent of non-volatile, ether-soluble extractive."
U.S.P.

Prepared Cacao. Cacao Prsparatum, N.F. VI. Fr. Cacao.
Ger. Kakao; Cacao. It. Cacao. Sp. Cacao.

The seeds of the Theobroma Cacao L. were
used by the Mexican aborigines to prepare a
beverage, which they called chocolatl, before the
discovery of America by Columbus. The tree is a
handsome evergreen from 12 to 20 feet in height,
growing in Mexico, the West Indies, and South
America. It is largely cultivated in all tropical
countries, particularly in the Gold Coast of
Africa, West Indies, Ecuador, Venezuela, Mexico,
Trinidad, and the Philippines. It possesses alter-
nate, elliptic-oblong, entire leaves and fascicles of
small, rose-colored flowers, the latter appearing
on the trunk and larger branches. The fruit is an
oblong-ovate, ten-ribbed capsular nut, six to ten
inches in length, with a thick, coriaceous, some-
what ligneous rind, enclosing a whitish, mucilagi-
nous pulp, in which numerous seeds are embedded.
These are ovate, somewhat compressed, about as

large as an almond, and consist of an exterior
thin shell and a brown oily kernel. Separated
from the matter in which they are enveloped,
they constitute the cacao, or chocolate nuts, of
commerce. The cacao tree, as usually cultivated,
is grown in the shade of the banana or other large
plant, and develops its fruits from the stem con-
tinually, so that the harvest goes on all the time,
although the product is greater in the spring and
in the autumn. The pods are cut off, opened, and
the "beans" contained in the glutinous sweet acid
pulp are allowed to ferment in boxes, tubs or
cavities in the earth for from 3 to 9 days at a
temperature less than 60° and usually between
30° and 43°, and the seeds with some adherent
pulp change in color from white or red to purple
and also in odor and taste. They are then washed
and roasted at between 100° and 140° or in some
instances merely dried in the sun, sometimes by
means of a steam drying shed. If the sweating
process is carried too far, or the beans during
drying are wetted by rain, they blacken and are
much lowered in value. These blackened beans
are sometimes artificially whitened. Cacao beans
have a slightly aromatic, bitter, oily taste, and,
when bruised or heated, an agreeable odor, but
the full chocolate flavor is developed only after
they are roasted.

According to Winton's Structure and Compo-
sition of Foods, Vol. 4, 1939, the average com-
position of different varieties of roasted cacao
nibs (beans freed from germ and from shell or
husk) is as follows: Water, 2.72 per cent; pro-
tein, 12.12 per cent; theobromine, 1.04 per cent;
caffeine, 0.40 per cent; fat (cacao butter), 50.12
per cent; pure starch, 8.07 per cent; crude starch,
11.16 per cent; fiber, 2.64 per cent; other nitro-
gen-free matter, 19.57 per cent; ash, 3.32 per
cent; soluble ash, 1.16 per cent; sand, 0.02 per
cent. It is noteworthy that roasted cacao shells
contain an average of 0.49 per cent of theobro-
mine and 0.16 per cent of caffeine.

Chocolate is the solid substance prepared from
the cacao bean after roasting. In Great Britain
and the United States it is usually made, when
pure, exclusively of the kernel of the cacao or
chocolate nuts, which are first roasted, then de-
prived of their shells, and lastly reduced, by
grinding between heated stones, to a paste, which
is molded into oblong cakes. Sometimes rice flour
or other farinaceous substance, with foreign fats,
is added, but these must be considered as adul-
terations. In the compounded form known as
sweet chocolate, sugar is generally incorporated
with the paste, and spices, especially cinnamon,
are often added; vanilla is a favorite addition in
America, France, and Spain. The well-known
confection known as "milk chocolate" contains
either whole or skim milk powder in addition to
the foregoing ingredients.

The Federal Food and Drug Administration
definitions for certain cacao products are, in part,
as follows (for the complete definitions and
standards of purity see Federal Register, Decem-
ber 6, 1944) :

Cacao nibs, cocoa nibs, cracked cocoa is the
food prepared by heating and cracking dried or
cured and cleaned cacao beans and removing shell

204

Cacao

Part I

therefrom. Cacao nibs or the cacao beans from
which they are prepared may be processed by
heating with one or more of the following optional
alkali ingredients, added as such or in aqueous so-
lution: Bicarbonate, carbonate, or hydroxide of
sodium, ammonium, or potassium; or carbonate
or oxide of magnesium; but for each 100 parts by
weight of cacao nibs used, as such or before shell-
ing from the cacao beans, the total quantity of
such alkalis used is not greater in neutralizing
value (calculated from the respective combining
weights of such alkalis used) than the neutraliz-
ing value of 3 parts by weight of anhydrous potas-
sium carbonate. The cacao shell content of cacao
nibs is not more than 1.75 per cent by weight
(calculated to an alkali-free basis if they or the
cacao beans from which they were prepared have
been processed with alkali).

Chocolate liquor, chocolate, baking chocolate,
bitter chocolate, cooking chocolate, chocolate
coating, bitter chocolate coating is the solid or
semiplastic food prepared by finely grinding cacao
nibs. To such ground cacao nibs, cacao fat or a
cocoa or both may be added in quantities needed
to adjust the cacao fat content of the finished
chocolate liquor. Chocolate liquor may be spiced,
flavored, or otherwise seasoned with one or more
of the following optional ingredients, other than
any such ingredient or combination of ingredients
specified in subparagraphs (1), (2), and (3)
which imparts a flavor that imitates the flavor of
chocolate, milk, or butter: (1) Ground spice. (2)
Ground vanilla beans; any natural food flavoring
oil, oleoresin, or extract. (3) Vanillin, ethyl va-
nillin, coumarin, or other artificial food flavoring.
(4) Butter, milk fat, dried malted cereal extract,
ground coffee, ground nut meats. (5) Salt. The
finished chocolate liquor contains not less than 50
per cent and not more than 58 per cent by weight
of cacao fat.

Breakfast cocoa, high fat cocoa is the food pre-
pared by pulverizing the residual material remain-
ing after part of the cacao fat has been removed
from ground cacao nibs. It may be spiced,
flavored, or otherwise seasoned with one or more
of the following optional ingredients, other than
any such ingredient or combination of ingredients
which imparts a flavor that imitates the flavor of
chocolate, milk, or butter: (1) Ground spice. (2)
Ground vanilla beans; any natural food flavoring
oil, oleoresin, or extract. (3) Vanillin, ethyl va-
nillin, coumarin, or other artificial food flavoring.
(4) Salt. The finished breakfast cocoa contains
not less than 22 per cent of cacao fat.

Cocoa, medium fat cocoa conforms to the defi-
nition and standard of identity, and is subject to
the requirements for label statement of optional
ingredients, prescribed for breakfast cocoa, except
that it contains less than 22 per cent but not less
than 10 per cent of cacao fat.

Low-fat cocoa conforms to the definition and
standard of identity, and is subject to the require-
ments for label statement of optional ingredients,
prescribed for breakfast cocoa, except that it con-
tains less than 10 per cent of cacao fat.

During 1952 there were imported into the
United States 572,421,218 pounds of cacao beans.

These came from the Gold Coast, French West
Africa, Spanish Africa, Nigeria, Portugal, Azores,
Cameroons, Central America, British West Indies,
Trinidad, Venezuela, Brazil, Cuba, Mexico, and
Panama.

Description. — "Cacao occurs as a weak red-
dish brown, purplish brown to moderate brown
powder having a chocolate-like odor and taste,
free from sweetness. It shows numerous broken
parenchyma cells of the cotyledons containing a
reddish brown, purplish brown to yellowish
orange pigment; numerous starch grains; oil
globules; aleurone grains; and occasionally, acic-
ular or prismatic crystals of fat. The starch
grains are simple and 2- to 3-compound, the indi-
vidual grains up to 15 n in diameter, and they
stain slowly with iodine T.S." U.S.P.

Standards and Tests. — Ether-insoluble resi-
due.— The ether-insoluble residue obtained in the
assay shows few or no cacao shells and no cereal
starch grains. Crude fiber. — The ether-insoluble
residue, dried at 105° for 2 hours, yields not over
7 per cent of crude fiber. Total ash. — The ether-
insoluble residue, dried at 105°. for 1 hour, yields
not over 8 per cent of total ash. Acid-insoluble
ash. — The ether-insoluble residue, dried at 105°
for 1 hour, yields not over 0.4 per cent of acid-
insoluble ash. U.S.P.

Assay. — A 10-Gm. portion of cacao is ex-
tracted with dehydrated ether in a continuous
extraction apparatus for 8 hours. The ether ex-
tract is evaporated spontaneously and the residue,
representing non-volatile, ether-soluble extractive,
is dried at 105° for 1 hour. The ether-insoluble
residue is retained for the tests referred to in the
preceding section.

Uses. — Chocolate is a very concentrated form
of nutriment. One hundred grams {iYz ounces)
represents between five and six hundred Calories;
a mutton chop of the same weight would repre-
sent approximately two hundred and fifty Cal-
ories. Of the nutritional elements in chocolate
more than 70 per cent is fat. The fatty
matter of chocolate (see Theobroma Oil) is not
easily digested and the free use of chocolate in
many persons produces gastric disturbances.
Cocoa contains considerably less fat and, there-
fore, a lower proportion of nutriment but, at the
same time, is correspondingly more readily di-
gested. The addition of sugar to chocolate lowers
its caloric value because of the much higher
energy yield of fat. As a beverage cocoa is fre-
quently of value in cases in which it is desired
■to add to the patient's intake of food; as usually
served by mixing with warm milk it not only
modifies the flavor but adds materially to the
caloric value of the milk, and the theobromine
which it contains is sufficient to have a mild
stimulating influence upon the muscular system.
It differs from the caffeinic beverages, such as
tea or coffee, in producing less excitation of the
nervous system and is, therefore, less likely to
cause wakefulness.

It is officially recognized because of its use as
a flavoring agent.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Part I

Caffeine

205

CACAO SYRUP. U.S.P.

Cocoa Syrup, [Syrupus Cacao]

Mix intimately 180 Gm. of cacao and 600 Gm.
of sucrose, and to this mixture gradually add a
solution of 180 Gm. of liquid glucose, 50 ml. of
glycerin, 2 Gm. of sodium chloride, 0.2 Gm. of
vanillin, and 1 Gm. of sodium benzoate in 325
ml. of hot purified water. Bring the mixture to
a boil, and maintain at boiling temperature for
3 minutes. Allow the product to cool to room
temperature, and add enough purified water to
make the product measure 1000 ml. Note: Cacao
containing not more than 12 per cent of non-
volatile, ether-soluble extractive, commonly re-
ferred to as fat, will provide a syrup with
minimum degree of separation; so-called break-
fast cocoa should not be used in preparing the
syrup, as it contains over 20 per cent of fat. U.S.P.

The formerly official formula for cacao syrup
gave a product which fermented readily and
which upon standing for several days increased
in viscosity to such an extent that it could not be
poured from bottles used for dispensing liquid
medicinal preparations. The viscosity increase
was all the more pronounced the higher the con-
tent of fat in the cacao; the gelatin formerly
included apparently contributed to the undesira-
ble changes that occurred. Seeking to improve
the product. Narinian et al. (J. A. Ph. A., Prac.
Ed., 1954, 15, 97) studied a number of variants
of the formula, and proposed the formula, now
officially recognized, as one which is an improve-
ment over the old formula. They suggest that
the content of fat in the cacao should be at the
lower limit of the official requirement in order
to obtain the most satisfactory syrup.

Cacao syrup has long been popular as a vehicle
for masking the taste of bitter substances. It is
anticipated that the greater degree of pharma-
ceutical elegance of the new preparation will
make it even more useful.

Storage. — Preserve "in tight containers, and
avoid excessive heat." U.S.P.

CAFFEINE. U.S.P., B.P., LP.

[Caffeina]

"Caffeine is anhydrous, or contains one mole-
cule of water of hydration." U.S.P. The B.P.
recognizes caffeine as 1 :3 : 7-trimethylxanthine or
its monohydrate, obtained from the dried leaves
of Camellia sinensis (L.) O. Kuntze or from cer-
tain other plants, or prepared synthetically.

I. P. Coffeinum. Theine; Trimethylxanthine; Methyl-
theobromine; Guaranine. Coffeinum. Fr. Cafeine. Ger.
Koffein; Coffein; Kaffein; Guarin. It. Caffeina; Teina.
Sp. Cafeina.

Caffeine was first isolated by Runge, from
coffee, in 1821. Through its synthesis from theo-

bromine, Strecker, in 1861, proved it to be a
methyltheobromine. Caffeine, theobromine and
theophylline are all closely related derivatives of
xanthine; caffeine is 1,3, 7-trimethylxanthine,
theobromine is 3,7-dimethylxanthine, and theo-
phylline is 1,3-dimethylxanthine. Xanthine, found
in urine, liver and muscle, as well as in tea
leaves, is 2,6-dihydroxypurine and is related to
uric acid (2,6,8-trihydroxypurine) and to the
many other purine derivatives occurring in the
plant and animal kingdom.

Caffeine may be obtained from a number of
plants, including coffee, tea, cola and guarana; tea
wastes, however, are the largest single source of
extracted caffeine, although decaffeination of
coffee also provides a sizeable amount of the sub-
stance. Various solvents are employed in the
several processes for extracting caffeine from tea
and coffee. Much caffeine is derived by methyla-
tion of theobromine (which see) ; the latter was
formerly imported from South America but is
now manufactured in this country. Caffeine may
be produced by synthesis starting with uric acid
or urea (see /. A. Ph. A., 1948, 37, 62). During
1953 a total of 292, 327 pounds of caffeine was
imported into the United States from West Ger-
many, the United Kingdom and the Netherlands.
Caffeine is a very weak base ; it appears doubt-
ful that any true salt of it may be prepared since
in aqueous solution its compounds with acids are
probably completely hydrolyzed into caffeine and
the acid component. The solubility of caffeine is
increased by admixture with citric acid, sodium
benzoate, or sodium salicylate; these mixtures are
officially recognized.

Description. — "Caffeine occurs as a white
powder, or as white, glistening needles, usually
matted together. It is odorless and has a bitter
taste. Its solutions are neutral to litmus. The
hydrate is efflorescent in air. One Gm. of hy-
drous Caffeine is soluble in about 50 ml. of water,
in 75 ml. of alcohol, in about 6 ml. of chloroform,
and in 600 ml. of ether. Caffeine, dried at 80° for
4 hours, melts between 235° and 237.5°." U.S.P.
Standards and Tests. — Identification. — (1)
The residue resulting when a solution of 5 mg. of
caffeine in 1 ml. of hydrochloric acid is mixed
with 50 mg. of potassium chlorate and evaporated
to dryness in a porcelain dish is colored purple
on inverting the dish over a vessel containing am-
monia T.S.; the color disappears on adding a
solution of a fixed alkali. (2) A precipitate, solu-
ble in an excess of the reagent, is produced when
tannic acid T.S. is added to a saturated solution
of caffeine. (3) No precipitate forms on adding 5
drops of iodine T.S. to 5 ml. of a saturated solu-
tion of caffeine; on adding 3 drops of diluted
hydrochloric acid, however, a red-brown precipi-
tate is produced; the latter dissolves on adding a
slight excess of sodium hydroxide T.S. Water. —
Not over 0.5 per cent for anhydrous caffeine, and
not over 8.5 per cent for the hydrate, when de-
termined by drying at 80° for 6 hours or by the
Karl Fischer method. Residue on ignition. — Not
over 0.1 per cent. Readily carbonizable sub-
stances.— A solution of 500 mg. of caffeine in 5
ml. of sulfuric acid has no more color than match-
ing fluid D. Heavy metals. — The limit is 20 parts

206

Caffeine

Part I

per million. Other alkaloids. — No precipitate
forms on adding mercuric potassium iodide T.S.
to a 1 in 50 solution of caffeine. U.S.P. The B.P.
and I. P. tests are essentially the same as those
of the U.S.P.

Uses. — Caffeine has four important physiologi-
cal actions: stimulation of a large group of cen-
ters in the central nervous system; a diuretic
effect upon the kidney; a stimulating action on
striated muscle; and a group of effects upon the
cardiovascular system. It is readily absorbed
orally and parenterally.

Nervous System. — The dominant action of
caffeine in the human being is upon the cerebrum.
The experiments of Hollingworth (Therap. Gaz.,
Jan., 1912) demonstrated that in those forms
of psychological tests which involve purely in-
tellectual processes there is a distinct increase in
the rapidity and accuracy of performance, an
observation which is corroborated by the daily
experience of millions of men. Not only is mental
activity temporarily stimulated, but the capa-
bility for prolonged work is also increased. The
effect on the control of voluntary movements
is less definite, some of these apparently being
improved and some deteriorated (Horst et al.,
J. Pharmacol., 1934, 52, 307). It was demon-
strated by Foltz and Schiffin (/. Lab. Clin. Med.,
1943, 28, 603) that caffeine enhances the re-
covery rate from exhaustive work in trained sub-
jects. There is a shorter reaction time and percep-
tion of sensory stimuli is improved. After large
quantities the cerebral excitation shows itself in
nervous restlessness and a tendency to insomnia.
In some individuals there may be subsequent de-
pression.

The effect of caffeine on cerebral blood flow
was studied by Moyer et al. (Am. J. Med. Sc,
1952, 224, 377). who found that following intra-
venous administration of 500 mg. of caffeine and
sodium benzoate increased resistance at the ar-
teriolar level results in a sharp decrease in cere-
bral blood inflow, diminishing blood volume in the
brain, and consequent lowering of cerebrospinal
fluid pressure. Richmond (/. Applied Physiol.,
1949, 2, 16) found that the ventilation minute
volume increased after administration of 250 mg.
of this drug subcutaneously when the subject is
breathing oxygen containing 3 to 5 per cent car-
bon dioxide, while its effect was variable in sub-
jects breathing atmospheric air. He concluded
that caffeine acts on the respiratory center by
increasing its sensitivity to carbon dioxide.

In the lower animals, when given in large
dose, caffeine causes convulsions, rapid respira-
tion, and a rise of temperature. The convulsions
are due to a stimulating action upon the spinal
cord. Although convulsions are not seen in human
beings, there is a similar stimulant effect on the
cord (Wood, Therap. Gaz., Jan., 1912 and Leu-
wen, Arch. ges. Physiol., 1913, 154, 306).

Muscle Function. — Caffeine increases the ir-
ritability and contractility of the voluntary mus-
cles and augments the amount of work which can
be performed before the occurrence of fatigue.
The action of the drug on muscle tissue has been
elaborately studied by Cheney (/. Pharmacol.,
1932, 45, 389, and /. A. Ph. A., 1934, 23, 143),

who found that the average increase in muscular
capacity produced by caffeine in the frog is about
11 per cent and that the primary stimulation is
not followed by any deleterious effect unless the
dose is extremely large. Huidobro and Amembar
(J. Pharmacol., 1945, 84, 82) found that in
decerebrate cats caffeine augmented the action
of neostigmine on muscle and that it lowered
the excitatory threshold of acetylcholine at the
neuromuscular junction.

Cardiovascular System. — The action of caf-
feine upon the circulation is less powerful than
its effect on the nervous system. After moderate
doses the blood pressure is usually slightly in-
creased (about 10 mm. of mercury), although not
infrequently there is little if any change.
Stimulation of the myocardium and of the vaso-
constrictor center are opposed by peripheral
vasodilatation. The rate of the heart is not
greatly altered unless the dose is large ; the ampli-
tude of the cardiac contractions is slightly in-
creased by caffeine (see Sollmann and Pilcher,
/. Pharmacol., 1911, 3, 19), and at the same time
there is an increased rapidity of blood flow
through the coronary artery (Heathcote, ibid.,
1920, 16, 327). These effects upon the heart are
similar in kind but less marked than those pro-
duced by theobromine. Caffeine caused a shght
increase in cardiac output in the observations in
humans of Starr et al. (J. Clin. Inv., 1937, 16,
799). Sebok (Deutsche med. Wchnschr., 1950,
75, 1067) found that dosages of 50 or 100 mg.
of caffeine given to patients with hypertension
lowered the systolic and diastolic blood pressures,
while its effect in normotensive individuals was
variable. It appears, therefore, that the use of
coffee or other beverages containing caffeine need
not be interdicted in hypertensive patients.

Renal Function. — In sufficient quantities, caf-
feine produces a very marked increase in the
quantity of urine. Although the increase is more
marked in the fluid component, the percentage of
solid matter decreasing, the total quantity of
solids eliminated in a given time is somewhat
increased. The diuresis is ordinarily accompanied
with a marked dilatation of the renal blood ves-
sels but this increased arterial flow is apparently
not the cause of the diuretic effect, for both
Richards and Cushny showed that even when
the increase in the flow of blood to the kidney
is prevented artificially caffeine will still augment
the urinary output. Using the inulin clearance
technic, Walker et al. (Am. J. Physiol., 1937,
118, 95) showed that the diuretic action was due
to retarded absorption of water by the tubules.
A small portion of the drug appears in the urine
as a dimethyl- or monomethylxanthine. After
large doses some caffeine may be excreted in the
urine unaltered.

Metabolism. — Although it seems well estab-
lished that caffeine does not exert any direct
action upon nitrogenous metabolism, Horst et al.
(J. Pharmacol., 1936, 58, 294) found that it
increased consumption of oxygen; the basal meta-
bolic rate increases about 10 per cent. About
80 per cent of the caffeine administered is me-
tabolized to urea in the body.

Gastric Function. — Grossman. Roth and Ivy

Part I

Caffeine, Citrated 207

{Gastroenterology, 1945, 4, 25) demonstrated that
caffeine stimulated production of pepsin and of
free hydrochloric acid in gastric juice and that
it acted in synergy with histamine. Roth and Ivy
{Am. J. Physiol., 1944, 141, 454) further demon-
strated that caffeine, administered intramuscu-
larly, stimulated gastric secretion, and called
attention to its role in the pathogenesis of peptic
ulcer, postulating that the vasodilatation pro-
duces increased capillary permeability and im-
paired cell nutrition. The response occurs,
according to these authors {Gastroenterology,
1945, 5, 129), even after hypodermic adminis-
tration of atropine sulfate, the effect being
probably upon the parietal cells of the gastric
mucosa. Musick et al. {J. A.M. A., 1949, 141, 839)
devised a simplified caffeine fractional test meal
for diagnosis of peptic ulcer, using 500 mg. of
caffeine and sodium benzoate in 200 ml. of dis-
tilled water. Over 90 per cent of their ulcer
patients secreted more than 300 mg. of hydro-
chloric acid during the 90-minute test period.

Therapeutic Action. — Caffeine is used in
clinical therapeutics as a diuretic, circulatory or
respiratory stimulant and in the treatment of
headaches. Its value as a diuretic is lessened by
its tendency to produce wakefulness, and because
of this objection it has largely been displaced
by the closely related drugs, theobromine and
theophylline. It is generally advisable, if using
caffeine freely, not to administer it in the latter
part of the day. Those who are habitual users
of caffeine-containing beverages acquire a toler-
ance to the diuretic effects (Myers, /. Pharmacol.,
1924, 33, 465) so that they require much larger
doses or may fail to respond altogether to the
drug.

Circulation. — As a circulatory stimulant, caf-
feine is employed in various forms of heart
failure during the course of a chronic cardiac
condition. Haskell, however, stated {J. A. Ph. A.,
1926, 15, 744) that on the heart poisoned by
alcohol, chloral or morphine its action was
harmful rather than beneficial. Heathcote (/.
Pharmacol., 1920, 16, 327), finding that it ac-
tively dilates the coronary vessels, suggested its
use in angina pectoris. Generally speaking, the-
ophylline and theobromine are usually given
preference over caffeine as cardiac remedies.

Respiration. — As a stimulant of the respiration
caffeine is very serviceable, especially when used
with other agents of this class. It is more espe-
cially employed in cases of poisoning with de-
pressants such as morphine, chloral or alcohol,
in which it is useful not only because of its direct
action upon the respiratory center but also be-
cause it counteracts, to some degree, the tendency
to sleep.

Headache. — The exact mode of action of caf-
feine in relieving headache is not clear. Moyer's
demonstration {Am. J. Med. Sc, 1952, 224,
243) that caffeine relieves hypertensive headache
while decreasing cerebral blood flow indicates
that it is due to the cerebral vascular constric-
tion. Horton et al. {Proc. Mayo, 1948, 23, 105)
and Cohen and Criep {New Eng. J. Med., 1949,
241, 896) used a combination of 1 mg. ergota-
mine tartrate and 100 mg. caffeine with success

in treating chronic vascular headaches of various
types, including migraine. Meerloo {Am. Pract.,
1952, 3, 605) found the same combination to be
effective in heat exhaustion. Dreisbach and
Pfeiffer (/. Lab. Clin. Med., 1943, 28, 1212)
reported that severe headache was produced by
sudden withdrawal of caffeine. In migrainous sub-
jects this differed in character from the usual
migraine and was relieved by caffeine.

Toxicology. — Although death due to large
doses of caffeine has not been recognized, unto-
ward reactions are not uncommon. Insomnia,
restlessness, excitement, tinnitus, scintillating sco-
toma, muscular tremor, tachycardia, extrasystoles
and diuresis are the more common manifestations.
The effects on the central nervous system are
readily counteracted by the short-acting barbitu-
rates such as sodium pentobarbital. Some degree
of tolerance and some habituation (psychic de-
pendence) seems to develop with the continued
use of the drug most commonly in the form of a
caffeine beverage such as coffee. An average cup
of coffee contains about 100 mg. of caffeine. S

Dose. — The usual dose is 200 mg. (approxi-
mately 3 grains), as necessary, with a range of
100 to 500 mg.; the maximum safe dose is 500
mg. and the total dose in 24 hours should not
exceed 2.5 Gm.

Labeling. — "Label Caffeine to indicate whether
it is anhydrous or hydrous. When the quantity of
Caffeine is indicated in the labeling of any prep-
aration of Caffeine, it is in terms of anhydrous
Caffeine." U.S.P.

Storage. — "Preserve hydrous Caffeine in tight
containers. Preserve anhydrous Caffeine in well-
closed containers." U.S.P.

Off. Prep. — Caffeine and Sodium Benzoate,
U.S.P., LP.; Caffeine and Sodium Benzoate In-
jection, U.S.P.; Caffeine and Sodium Salicylate,
N.F., LP.; Citrated Caffeine; N.F.

CITRATED CAFFEINE.

[Caffeina Citrata]

N.F.

"Citrated Caffeine is a mixture of caffeine and
citric acid containing, when dried at 80° for 4
hours, not less than 48 per cent and not more
than 52 per cent of anhydrous caffeine
(C8H10N4O2), and not less than 48 per cent
and not more than 52 per cent of anhydrous
citric acid (CeHsCh). The sum of the percent-
ages of anhydrous caffeine and anhydrous citric
acid is not less than 98.5 and not more than
101." N.F.

Caffeine Citrate. Caffeinas Citras; Coffeinum Citricum.
Fr. Cafeine citrate. Ger. Coffeincitrat. Sp. Cafeine citrica;
Cafeina Citratada; Citrato cafeico.

As indicated by the official definition this sub-
stance is a mixture, rather than a definite chem-
ical compound, of caffeine and citric acid. The
citric acid materially increases the solubility of
caffeine in water but it also introduces the possi-
bility of incompatibility when citrated caffeine is
combined with alkaline substances.

Description. — "Citrated Caffeine occurs as
a white, odorless powder, having a slightly bitter,

208

Caffeine, Citrated

Part I

acid taste. Its solutions are acid to litmus paper.
One Gm. of Citrated Caffeine dissolves in 4 ml.
of warm water. On diluting the solution with an
equal volume of water, a portion of the caffeine
gradually separates but redissolves on the further
addition of water." N.F.

Standards and Tests. — Identification. — (1)
The residue resulting when a solution of 20 mg.
of citrated caffeine in 1 ml. of hydrochloric acid
is mixed with 100 mg. of potassium chlorate and
evaporated to dryness in a porcelain dish is col-
ored purple on inverting the dish over a vessel
containing ammonia T.S.; the color disappears
on adding a solution of a fixed alkali. (2) A white
crystalline precipitate of calcium citrate forms
on adding 1 ml. of calcium chloride T.S. to a
solution of 100 mg. of citrated caffeine in 10 ml.
of water, adjusting the pH by the addition of
0.1 N sodium hydroxide to produce a blue color
with bromothymol blue T.S., and boiling the
mixture gently during 3 minutes. (3) A white
precipitate forms on adding 1 ml. of mercuric
sulfate T.S. to 5 ml. of a 1 in 100 solution of
citrated caffeine, heating the mixture to boiling,
and then adding 1 ml. of potassium permanganate
T.S. (4) The residue obtained in the assay for
caffeine, when recrystallized from hot water and
dried at 80° for 4 hours, melts between 235°
and 237.5°. Loss on drying. — Not over 5 per cent
when dried at 80° for 4 hours. Residue on igni-
tion.— Not over 0.1 per cent. Readily carbonizable
substances. — The solution resulting when 250 mg.
of citrated caffeine is heated with 5 ml. of sul-
furic acid in a porcelain dish on a water bath
for 15 minutes is not darker than matching
fluid K. Heavy metals. — The limit is 15 parts per
million. N.F.

Assay. — For caffeine. — About 1 Gm. of ci-
trated caffeine, previously dried at 80° for 4
hours, is dissolved in hot water, made alkaline
by the addition of sodium hydroxide T.S., and
the caffeine extracted with chloroform. The
chloroform is evaporated and the residue of caf-
feine dried at 80° for 4 hours. For citric acid. —
About 400 mg. of citrated caffeine, previously
dried at 80° for 4 hours, is dissolved in water and
the citric acid titrated with 0.1 N sodium hy-
droxide, using phenolphthalein T.S. as indicator.
Each ml. of 0.1 N sodium hydroxide represents
6.404 mg. of CgHsOt. N.F.

Uses. — Citrated caffeine possesses the physio-
logical and therapeutic properties of caffeine, but
is more likely to disturb the digestive functions.

Usual dose, 300 mg. (approximately 5 grains).

Storage. — Preserve "in tight containers." N.F.

CITRATED CAFFEINE TABLETS.
N.F.

[Tabellae Caffeinae Citratae]

"Citrated Caffeine Tablets yield an amount of
anhydrous caffeine (C8H10N4O2) not less than
45 per cent and not more than 55 per cent of
the labeled amount of citrated caffeine." N.F.

Usual Sizes. — 1 and 2 grains (approximately
60 and 120 mg.).

CAFFEINE AND SODIUM
BENZOATE. U.S.P., LP.

Caffeine with Sodium Benzoate, Caffeine Sodio-
Benzoate, [Caffeina et Sodii Benzoas]

"Caffeine and Sodium Benzoate is a mixture
of caffeine and sodium benzoate which, dried at
80° for 4 hours, contains not less than 47 per cent
and not more than 50 per cent of anhydrous
caffeine (C8H10N4O2); and not less than 50
per cent and not more than 53 per cent of sodium
benzoate (CiHsNaOs). The sum of the percent-
ages of anhydrous caffeine and sodium benzoate
is not less than 98 and not more than 102." The
LP. requires the same proportions of caffeine
and of sodium benzoate, differing only in the
requirement that the assay data are to be cal-
culated with reference to the substance dried
at 105°.

I. P. Coffeinum et Natrii Benzoas. Caffeinae Sodio-
benzoas; Caffeinumnatrium Benzoicum; Benzoas Natricus
cum Coffeino. Fr. Cafeine et benzoate sodique. Ger. Koffein-
natriumbenzoat. It. Benzoato di sodio e caffeina. Sp.
Cafeina y Benzoato de Sodio.

Caffeine and sodium benzoate is a mixture of
equal parts of caffeine and sodium benzoate; the
B.P. 1948 indicated that it might be prepared
by mixing equal parts by weight of the compo-
nents, moistening the mixture with water or
alcohol, and drying.

According to the studies of Chambon et al.
(J. pharm. chinv., 1937, 26, 216) no molecular
combination or definite double salt can exist
between caffeine and sodium benzoate in the
temperature range of 37° to 90°; only mixtures
of the two chemicals are obtained. Below 37°
the notable solubilization of caffeine by benzoate
seems to be due to the formation of several
complexes, such as one molecule of caffeine with
one molecule of sodium benzoate, and one mole-
cule of caffeine with two molecules of benzoate;
Higuchi and Zuck (/. A. Ph. A., 1953, 42, 132)
believe, however, that not more than one ben-
zoate ion is involved in the formation of the
complexes but that there may be more than one
molecule of caffeine involved.

Description. — "Caffeine and Sodium Benzo-
ate occurs as a white, odorless powder and has a
slightly bitter taste. One Gm. of Caffeine and So-
dium Benzoate dissolves in 1.2 ml. of water, a
portion of the caffeine usually separating on stand-
ing. It is soluble in about 30 ml. of alcohol and
is slightly soluble in chloroform." U.S.P.

Standards and Tests. — Identification. — (1)
The residue obtained in the assay for caffeine
responds to identification test (1) under Caf-
feine and, after recrystallization, melts between
235° and 237.5°. (2) White vapors of caffeine,
and a residue that effervesces with acids and
imparts a yellow color to a non-luminous flame,
result when caffeine and sodium benzoate is
heated. (3) A salmon-colored precipitate forms
on adding a few drops of ferric chloride T.S. to
a 1 in 10 solution of caffeine and sodium benzo-
ate; a white precipitate is produced on adding
diluted hydrochloric acid to another portion of
the same solution. Water. — Not over 3 per cent,
when determined by drying at 80° for 4 hours
or by the Karl Fischer method. Readily carboniz-

Part I

Caffeine and Sodium Salicylate 209

able substances.— A solution of 500 mg. of caf-
feine and sodium benzoate in 5 ml. of sulfuric
acid has no more color than matching fluid A.
Chlorinated compounds. — The benzoic acid ob-
tained by acidifying a solution of 2 Gm. of caf-
feine and sodium benzoate, extracting with ether,
and evaporating to dryness meets the require-
ments of the test for chlorinated compounds
under Benzoic Acid. Heavy metals. — The limit is
20 parts per million. U.S.P.

Assay. — For caffeine. — A sample of 1 Gm. of
caffeine and sodium benzoate, previously dried
at 80° for 4 hours, is dissolved in hot water,
made alkaline toward phenolphthalein T.S. by
the addition of 0.1 N sodium hydroxide, and the
caffeine extracted with chloroform. The chloro-
form is evaporated, the last traces being expelled
with the aid of alcohol, and the residue of caffeine
is dried at 80° for 2 hours. For sodium benzoate.
— The aqueous solution remaining after the ex-
traction of caffeine in the preceding part is ti-
trated with 0.1 N hydrochloric acid, in the
presence of ether, and using methyl orange T.S.
as indicator. The benzoic acid displaced by the
stronger acid is dissolved by the ether and an
equivalent amount of sodium chloride is formed
in the aqueous layer; when all of the sodium
benzoate has reacted the acid color of methyl
orange appears in the aqueous layer. Each ml.
of 0.1 N hydrochloric acid represents 14.41 mg.
of C7H5Na02. U.S.P.

The LP. assay process for caffeine is practi-
cally the same as that of the U.S.P. except that
the residue of caffeine is dried at 100°. The assay
for sodium benzoate is based on extraction of
benzoic acid, after acidification of the solution
remaining from the assay for caffeine, with ether,
followed by titration with 0.1 N sodium hy-
droxide of the residue remaining after evapora-
tion of the ether.

Incompatibilities. — The addition of acid to
aqueous solutions causes a precipitation of ben-
zoic acid and, sometimes, of caffeine.

Uses. — Caffeine and sodium benzoate has the
physiological effects and therapeutic uses of caf-
feine. It has the advantage over the alkaloid of
being freely soluble in water, and over citrated
caffeine of being less irritant to the stomach.
Caffeine and sodium benzoate is preferred for
parenteral administration. It is frequently given,
by intravenous injection, in emergencies charac-
terized by respiratory failure.

Holder (J.A.M.A., 1944, 124, 56) recom-
mended intravenous injection of the drug in
500 mg. doses to alleviate post-spinal fluid punc-
ture headache. Adler (J.A.M.A., 1946, 130, 530)
advocated it for the treatment of excited or
comatose alcoholic patients. Drinker (J.A.M.A.,
1945, 128, 655) recommended it as a respiratory
stimulant in cases of electric shock. @

The usual dose is 500 mg. (approximately 7^
grains), by mouth or subcutaneously, as fre-
quently as directed by the physician, with a
range of dose of 200 to 500 mg. ; the maximum
safe dose is 500 mg. and the total dose in 24
hours should rarely exceed 2.5 Gm.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

CAFFEINE AND SODIUM BENZOATE
INJECTION. U.S.P. (LP.)

[Injectio Caffeinae et Sodii Benzoatis]

"Caffeine and Sodium Benzoate Injection is a
sterile solution of caffeine and sodium benzoate
in water for injection. It contains an amount of
anhydrous caffeine (C8H10N4O2) equivalent to
not less than 45 per cent and not more than 52
per cent, and an amount of sodium benzoate
(dHoNaCte) equivalent to not less than 47.5
per cent and not more than 55.5 per cent of the
labeled amount of caffeine and sodium benzoate."
U.S.P. The LP. requirements are identical with
those of the U.S.P.; the LP. indicates that steri-
lization may be effected by heating in an auto-
clave (30 minutes at 115° to 116°) or by filtra-
tion through a bacteria-proof filter.

LP. Injection of Caffeine and Sodium Benzoate; In-
jectio Coffeini et Natrii Benzoatis.

The U.S.P. requires that the pH of the injection
shall be between 6.5 and 8.5.

Storage. — Preserve "in single-dose contain-
ers." U.S.P.

Usual Sizes. — 2 ml. containing 250 and 500
mg. (approximately 4 or 7J^> grains).

CAFFEINE AND SODIUM BENZOATE
TABLETS. N.F.

[Tabellae Caffeinae et Sodii Benzoatis]

"Caffeine and Sodium Benzoate Tablets yield
an amount of anhydrous caffeine (C8H10N4O2)
not less than 43.5 per cent and not more than
53.5 per cent of the labeled amount of caffeine
and sodium benzoate." N.F.

Usual Size. — 5 grains (approximately 300
mg.).

CAFFEINE AND SODIUM
SALICYLATE. N.F., LP.

[Caffeina et Sodii Salicylas]

"Caffeine and Sodium Salicylate, when dried
at 80° for 4 hours, contains not less than 48
per cent and not more than 52 per cent of
anhydrous caffeine (C8H10N4O2) and not less
than 48 per cent and not more than 52 per cent
of sodium salicylate (CiHsNaOa)." N.F. The LP.
requires not less than 44.0 per cent and not more
than 46.0 per cent of anhydrous caffeine, and not
less than 49.5 per cent and not more than 50.5
per cent of sodium salicylate; the mixture is not
dried prior to assay and the assay results are
calculated to the substance in the state in which
it is weighed.

LP. Coffeinum et Natrii Salicylas. Caffeine with So-
dium Salicylate; Caffeine Sodio-salicylate. Caffeina cum
Sodii Salicylate; Caffeinae Sodio-salicylas; Coffeinum-
natrium Salicylicum. Fr. Cafeine et salicylate sodique. Ger.
Koffein-natriumsalizylat.

Triturate 500 Gm. of caffeine, previously dried
at 80° for 4 hours, with 500 Gm. of sodium sali-
cylate, and then with sufficient alcohol to produce
a smooth paste. Dry the mixture in air in a mod-
erately warm place, and reduce the dry mass to
powder. N.F.

As with caffeine and sodium benzoate, the addi-
tion of sodium salicylate to caffeine increases the

210 Caffeine and Sodium Salicylate

Part I

solubility in water of the latter; 1 Gm. of caf-
feine and sodium salicylate dissolves in about
2 ml. of water and in about SO ml. of alcohol.
Caffeine forms with salicylate one or more com-
plexes which appear to involve more than one
molecule of caffeine for each salicylate ion
(Higuchi and Zuck, /. A. Ph. A., 1953, 42, 138).

Standards and Tests. — Identification. — (1)
The residue, obtained in the assay for caffeine,
when recrystallized from water and dried at
80° for 4 hours, melts between 235° and 237.5°.
(2) A 1 in 10 solution of caffeine and sodium
salicylate responds to tests for sodium and for
salicylate. Loss on drying. — Not over 3 per cent,
when dried at 80° for 4 hours. N.F.

Assay. — For caffeine. — Caffeine and sodium
salicylate is assayed as directed in the assay for
caffeine under caffeine and sodium benzoate, with
the difference that a 2 Gm. sample of the former
is employed. For sodium salicylate. — The aque-
ous liquid remaining after the extraction of caf-
feine is treated with an excess of 0.1 N bromine
and acidified, whereby the salicylic acid is con-
verted to tribromophenol and carbon dioxide; the
excess of bromine is estimated by liberation of
an equivalent amount of iodine which is titrated
with 0.1 N sodium thiosulfate. Each ml. of 0.1 N
bromine represents 2.669 mg. of CrHsNaOa. N.F.
The LP. assays are identical with the assays
specified by that pharmacopeia for Caffeine and
Sodium Benzoate.

Uses. — This preparation has been used like
caffeine and sodium benzoate but it has no ad-
vantage over the latter. The usual dose is 200 mg.
(approximately 3 grains).

Storage. — Preserve "in tight containers." N.F.

CALAMINE. U.S.P., B.P.

[Calamina]

"Calamine is zinc oxide with a small amount
of ferric oxide, and contains, after ignition, not
less than 98 per cent of ZnO." U.S.P. The B.P.
defines Calamine as a basic zinc carbonate suit-
ably colored with ferric oxide.

Prepared Calamine, Artificial Calamine. Lapis Calami-
naris. Sp. Calamina.

The term calamine, besides referring to the
two different products recognized by the U.S. P.
and B.P., is sometimes used to designate a
hydrous zinc silicate and also a native form of
zinc carbonate. The latter occurs in masses or
concretions of a dull appearance, or crystallised
in rhombic form. Its color is variable being, in
different specimens, grayish, grayish-yellow,
reddish-yellow, and, when very impure, brown or
brownish-yellow. The purer forms of native zinc
carbonate are almost entirely soluble in dilute
mineral acids and, unless previously calcined,
evolve carbon dioxide. When heated, carbon diox-
ide is driven off, leaving an impure zinc oxide. The
product of calcination was called by the supple-
ment of the British Pharmacopoeia of 1867 "pre-
pared calamine." Most calamine supplied in the
United States is simply zinc oxide colored with
an iron oxide, such as jeweler's rouge. Calamine
may also be made by rotating a mixture of pre-
cipitated zinc carbonate and iron chloride.

Because of the variable color of calamine the
N.F. formerly recognized Prepared Neocalamine,
which is zinc oxide colored with definite amounts
of red ferric oxide and yellow ferric oxide; this
preparation did not prove to be as popular as
calamine and was deleted.

Description. — "Calamine is a pink, odorless,
and almost tasteless powder. It will pass through
a No. 100 standard mesh sieve. Calamine is
insoluble in water, but is almost completely
soluble in mineral acids." U.S.P.

Standards and Tests. — Identification. — (1)
1 Gm. of calamine is treated with 10 ml. of
diluted hydrochloric acid and filtered: the filtrate
responds to the test for zinc. (2) 1 Gm. of cala-
mine is boiled with 10 ml. of diluted hydrochloric
acid and filtered: the filtrate is colored reddish
on adding ammonium thiocyanate T.S. Loss on
ignition. — Not over 2 per cent. Acid-insoluble
substances. — Any insoluble residue from a solu-
tion of 2 Gm. of calamine in 50 ml. of diluted
hydrochloric acid, when washed with water and
dried at 105° for 1 hour, weighs not over 40 mg.
Alkaline substances. — The filtrate separated from
a mixture of 1 Gm. of calamine and 20 ml. of
water which has been digested on a steam bath
for 15 minutes requires not more than 0.2 ml. of
0.1 N sulfuric acid to discharge any color pro-
duced with phenolphthalein T.S. Calcium. — To a
solution of 1 Gm. of calamine in 25 ml. of diluted
hydrochloric acid is added sufficient ammonia to
dissolve the zinc hydroxide precipitate. To a
10-ml. portion of this solution 2 ml. of ammo-
nium oxalate T.S. is added: not more than a slight
turbidity should result. Calcium or magnesium. —
To another 10-ml. portion of the ammoniacal
solution from the preceding test is added 2 ml. of
sodium phosphate T.S.: not more than slight
turbidity should result. Arsenic. — The limit is
10 parts per million. Lead. — 1 Gm. of calamine
is dissolved in an acetic acid solution and the
latter filtered: addition of potassium chromate
T.S. to the filtrate produces no turbidity. U.S.P.

Assay. — A sample of 1.5 Gm. of freshly ig-
nited calamine is warmed gently with 50 ml. of
normal sulfuric acid. The mixture is filtered,
the residue washed with hot water, and the filtrate
and washings titrated with 1 N sodium hydroxide,
after adding ammonium chloride to prevent pre-
cipitation of zinc hydroxide, and in the presence
of methyl orange T.S. Each ml. of 1 N sulfuric
acid represents 40.69 mg. of ZnO. US.P. The
B.P. has no assay, as such, but requires that the
residue on ignition to constant weight be not less
than 68.0 per cent and not more than 74.0
per cent.

Uses. — Calamine is a mild astringent and
antacid protective powder. Its local action in
the treatment of skin diseases is similar to that
of pure zinc oxide. The particular advantage of
calamine is its property, where this is an impor-
tant consideration, of imparting a flesh color to
ointments, lotions, and powders. In an effort
to further standardize the color, the N.F. for a
while recognized Prepared Neocalamine, which
was made by mixing 30 Gm. of red ferric oxide
and 40 Gm. of yellow ferric oxide with 930 Gm.
of zinc oxide; prepared neocalamine simulates

Part I

Calciferol

211

what may be considered a "mildly sun-tanned"
complexion. The preparation did not receive
wide acceptance, and was not admitted to N.F. X.
Storage. — Preserve "in well-closed contain-
ers." U.S.P.

CALAMINE LOTION.

[Lotio Calaminae]
Sp. Lotion de Calamina.

U.S.P.

Dilute 250 ml. of bentonite magma with an
equal volume of calcium hydroxide solution. Mix
80 Gm. each of calamine and zinc oxide intimately
with 20 ml. of glycerin and about 100 ml. of the
dilute magma to form a smooth, uniform paste.
Gradually incorporate the remainder of the diluted
magma and finally add sufficient calcium hydrox-
ide solution to make 1000 ml. Shake well. The
lotion should be thoroughly shaken before dis-
pensing. U.S.P. The B.P. Calamine Lotion, being
a phenolated lotion, is described under Phenolated
Calamine Lotion.

It has become customary to speak of the "cala-
mine lotion problem" for perhaps no other of-
ficial mixture has been so troublesome to prepare
in a form which meets every one of many criteria
suggested for it — ranging from the requirement
that it be rather easily prepared with facilities
available in every prescription laboratory to that
of complete therapeutic acceptability by the
dermatologist and his patients. Every one of the
recent revisions of the U.S.P. has recognized a
different formula for calamine lotion. The one
currently official is a modification of the U.S.P.
XIII formula. For other formulas of calamine
lotion, recently proposed, see Goldstein (/. A.
Ph. A., Prac. Ed., 1952, 13, 250, 550, and 1953
14, 111); Gable et al. (ibid., 1953, 14, 287)
Marcus and Benton (ibid., 1953, 14, 290)
Celmins et al. (ibid., 1953, 14, 291); Cronk and
Zopf (ibid., 1953, 14, 302).

Uses. — Calamine lotion is widely employed in
the treatment of a variety of dermatoses. Its
chief use is in acute, exuding dermatitis typical
of plant or contact origin, where it exerts a
soothing, drying and protective effect; it is also
beneficial in the treatment of generalized eczemas
and other disseminated eruptions. Its superficial
action has the advantage that when more active
medicaments are incorporated in the lotion,
which medicaments might be dangerous because
of possible systemic effect through absorption,
any undesirable effect is limited by lack of pene-
tration of the mixture. By virtue of this calamine
lotion containing ingredients which might be
dangerous in more penetrating vehicles may usu-
ally be safely employed for treating generalized
dermatoses. The possibility of toxic effects is
still, however, to be considered, and special cau-
tion should be observed when such modified
calamine lotions are applied to large areas, or are
used on babies and children.

Calamine Liniment, long official in the N.F., is
a water-in-oil emulsion containing the same pro-
portion of calamine and zinc oxide represented
in the formula for calamine lotion. The N.F. IX
directed the liniment to be prepared by mixing
80 Gm. each of calamine and zinc oxide with

500 ml. of olive oil, then gradually adding suf-
ficient calcium hydroxide solution, with constant
agitation, to make 1000 ml.

Calamine lotion is applied topically as re-
quired.

Storage — "Preserve "in tight containers."
U.S.P.

PHENOLATED CALAMINE
LOTION. U.S.P. (B.P.)

Compound Calamine Lotion, [Lotio Calaminae Phenolata]

Mix 10 ml. of liquefied phenol with 990 ml. of
calamine lotion. Note: Shake Phenolated Cala-
mine Lotion thoroughly before dispensing. U.S.P.

Under the title Calamine Lotion the B.P. recog-
nizes a product prepared from 150 Gm. of cala-
mine, 50 Gm. of zinc oxide, 30 Gm. of bentonite,
5 ml. of liquefied phenol, 50 ml. of glycerin, and
distilled water, a sufficient quantity to make
1000 ml. of lotion.

The most serious disadvantage of the U.S.P.
XIV formula for calamine lotion, the vehicle of
which contained polyethylene glycol 400 and its
monostearate, was its incompatibility with
phenol, which destroyed the "emulsifying" power
of the polyethylene glycol monostearate. The
new U.S.P. formula, on the other hand, is com-
patible with phenol.

Uses. — Addition of liquefied phenol to cala-
mine lotion imparts to the lotion antipruritic
and local anesthetic effects and, since the time
of contact of the lotion with the area to which
it is applied is likely to be rather long, also anti-
septic action. Otherwise this lotion has the same
action, and uses, as calamine lotion.

Storage. — Preserve "in tight containers."
U.S.P.

CALAMINE OINTMENT. N.F.

Turner's Cerate, [Unguentum Calaminae]

Melt 40 Gm. of yellow wax with 40 Gm. of
wool fat and 750 Gm. of petrolatum and mix
170 Gm. of calamine thoroughly with the melted
mixture to produce a smooth, homogeneous oint-
ment. N.F.

Uses. — The action and uses of this ointment
are essentially the same as those of zinc oxide
ointment; a possible advantage, in certain cases,
is the pink color.

Storage. — Preserve "in tight containers and
avoid prolonged exposure to temperatures above
30°." N.F.

CALCIFEROL. U.S.P., B.P., LP.

Vitamin D2, [Calciferol]

CH3 CH3

I I

CHCH=CHCH-CH(CH3)2

Calciferol contains, in each gram, not less than
40,000,000 International Units of vitamin D. LP.

212

Calciferol

Part I

I.P. Calciferolum. Yiosterol. Davitin (Ives-Cameron),
Decaps (Cole), Deltalin (Lilly), Deratol (Brcuer) , Diactol
(Plessner), Doral (Massengill), Drisdol (Winthrop),
D-Vatine (Smith-Dorsey), 'D' Vitamin (.Squibb), Ertron
(Nutrition Research Labs.), Hi-Deratol (Brewer), Infron
Pcdriatic (H'hittier Labs.).

This form of vitamin D is obtained by ultra-
violet irradiation of ergosterol. the vitamin being
separated from other irradiation products by
precipitation as calciferyl 3,5-dinitrobenzoate,
which is subsequently hydrolyzed back to cal-
ciferol and further purified by recrystallization.
For further information concerning calciferol see
under Synthetic Oleovitamin D. Besides calciferol
the U.S. P. recognizes activated 7-dehydrocholes-
terol (vitamin Da), which is described in a
separate monograph.

Description. — "Calciferol occurs as white.
odorless crystals. It is affected by air and by
light. Calciferol is insoluble in water. It is soluble
in alcohol, in chloroform, in ether, and in fatty
oils. Calciferol melts between 115° and 118°."
U.S.P.

Standards and Tests. — Identification. — (1)
A bright red color, rapidly changing through
violet and blue to green, is produced when a
solution of 0.5 mg. of calciferol in 5 ml. of
chloroform is shaken vigorously with 0.3 ml. of
acetic anhydride and 0.1 ml. of sulfuric acid.
(2) The dinitrobenzoyl derivative of calciferol
melts between 147° and 149°. Specific rotation. —
Not less than +103° and not more than +106°,
when determined in an alcohol solution containing
150 mg. of calciferol in each 10 ml., the solution
being prepared without delay after opening the
container and the rotation quickly observed.
Absorptivity. — Not less than 445 and not more
than 485. determined in alcohol solution at 265
mn. Ergosterol. — A solution of 20 mg. of calciferol
in 2 ml. of 90 per cent alcohol, mixed with a solu-
tion of 20 mg. of digitonin in 2 ml. of 90 per cent
alcohol, shows no precipitate after standing 18
hours. U.S.P.

Assay. — Neither the U.S. P. nor B.P. provides
a method for assay of calciferol. The LP. states
that the vitamin D potency of calciferol is deter-
mined by the method required by the law of the
country concerned; a "suitable method"' is. how-
ever, described. The method is a biological pro-
cedure and consists in comparing the antirachitic
activity of the calciferol with that of the Inter-
national Standard Preparation of vitamin D
(which is crystalline vitamin D3). employing
rats as the experimental animals if the prepara-
tion to be tested is intended for human consump-
tion, and chicks if it is intended for administration
to poultry. Actually two methods are described,
one being a "curative" method in which the
amount of healing in rachitic rats receiving the
preparation being tested is compared with the
amount of healing in rats receiving the standard
preparation, the other being a "prophylactic"'
method in which the percentage of ash in the
dry extracted bone from rachitic rats receiving
the preparation being tested is compared with
the percentage of ash in the bone of rats receiv-
ing the standard preparation.

Uses. — Calciferol is vitamin D2; there is no
vitamin Di since the substance to which this

designation was originally given proved to be a
mixture of antirachitic substances. Calciferol
possesses the characteristic actions of vitamin D
and may be used wherever this vitamin is indi-
cated. Single massive doses of 50.000 to 600,000
units, by mouth, have been found effective in
preventing or treating rickets (Krestin. Lancet,
1945, 1, 781, and others) but daily administra-
tion of smaller doses has been found to be
preferable. The physiologic and therapeutic
properties of the vitamin are discussed under
Synthetic Oleovitamin D.

Is Lupus Vulgaris. — Calciferol is the form
of vitamin D which is most commonly used in
those conditions where large doses are indicated;
such uses may be described as utilizing the
pharmacologic rather than the nutritional action
of the vitamin. Aside from the rare cases of "re-
sistant" rickets in childhood which respond to
doses of vitamin D approaching toxic amounts
(see under Synthetic Oleovitamin D). calciferol
has found wide usage, in doses of 50.000 units
three times daily by mouth, in the treatment of
lupus vulgaris. Reports on the efficacy of such
treatment in this tuberculous infection of the
skin for which no previous therapy had been
effective have been given by Charpy (Ann. de
dermat. syph., 1946, 6, 310) and Dowling and
Thomas (Clin. J., 1946, 75, 180). Regression
and healing, but not cure of the lesions, was ob-
served in the majority of cases under treatment
for 3 to 12 months; a quart of milk daily, an
adequate intake of vitamin A, and alkali for
gastric distress are part of the treatment. The
blood serum calcium level should be observed
and treatment withdrawn if the concentration
exceeds 12 mg. per 100 ml.; the Sulkowitch
reagent test on urine may be used as a means of
estimating hypercalcemic action (see under Cal-
cium). Goldberg and Dexter (Arch. Dermat.
Syph., 1951, 63, 729) reported benefit, usually
during the first 3 weeks of treatment, from use
of the vitamin in some cases of atopic dermatitis,
chronic eczematoid dermatitis, psoriasis and acne
conglobata; cases of lupus erythematosus, granu-
loma annulare, parapsoriasis and mycosis fun-
goides showed no response. The potential toxicity
of this treatment when used in a non-fatal con-
dition tempers enthusiasm for its use.

Intracutaneous injection of 100.000 to 600.000
units, in ethyl oleate, directly into the lesions
of lupus vulgaris was found effective in 5 of 9
cases reported by Russell (ibid., 1951. 64, 676 1.
Dissemination of granuloma annulare, however,
in 2 cases was reported by Sawicky and Kanof
(ibid., 1951. 64, 58) and' Parkin (ibid., 1952,
65, 610) described appearance of a necrotic
tuberculid during calciferol therapy. Cornbleet
(ibid., 1950. 61, 1041) reported that oral use of
calciferol along with intramuscular injection of
1 Gm. of streptomycin daily (in divided doses)
was more effective than either substance used
alone; isoniazid has, however, largely replaced
the older forms of treatment of lupus vulgaris.

It has long been the custom to prescribe mod-
erate daily doses of vitamin D in treating tuber-
culosis of both pulmonary (Fielding and Maloney,
Lancet, 1951, 2, 614) and extrapulmonary (par-

Part I

Calcium

213

ticukrly bone and joint, and intestinal) forms;
the custom seems to continue notwithstanding
development of effective chemotherapeutic means
of treatment. The mechanism of action of vita-
min D in tuberculosis remains obscure. Provita-
min D2 or D3, *. e., the unirradiated steroid
precursor, was found to be without benefit in
lupus vulgaris and acne vulgaris (Cerri, Minerva
Derm., 1952, 27, 53).

In sarcoidosis calciferol gave good results in
15 cases (Lomholt, Acta Dermato-Venereol.,
1950, 30, 334). In tuberculoid leprosy improve-
ment in cutaneous lesions, but no relief in un-
differentiated forms and neuritis, was reported
by Floch and Destombes (Presse vied., 1950, 58,
11). Four patients with parapsoriasis improved
rapidly following administration of 50,000 units
of calciferol three times daily (Canizares et al.,
J. Invest. Dermatol, 1951, 16, 121). Benefit
has been reported following use of the vitamin
in acute and chronic pemphigus vulgaris and
vegetans {New Eng. J. Med., 1944, 231, 44).

Other Uses. — Calciferol, as well as dihydro-
tachysterol, have proved to be effective in the
control of hypoparathyroidism (/. Clin. Inv.,
1938, 17, 431); calciferol has many advantages
over parathyroid extract for this condition. Large
doses have been reported to prevent the "thyroid
crisis" syndrome in patients with hyperthyroidism
(Surg. Gynec. Obst., 1945, 81, 234). Snyder
et al. (Ind. Med., 1942, 11, 295) reported ob-
taining good results with it in patients with
rheumatoid arthritis who had failed to respond
to other forms of therapy, but Freyberg
(J.A.M.A., 1942, 119, 1165) and others have
deplored the overenthusiastic advertising of this
form of therapy, to which only a small percentage
of patients respond. Rapid improvement of pa-
tients with acute rheumatic fever followed
intramuscular injection of 15 mg. of calciferol,
followed by 7 mg. two days later (Rev. din.
espan., 1944, 12, 325). Alleviation of the unto-
ward effects of dimercaprol therapy by adminis-
tration of vitamin D, with high dosage of
calcium, has also been reported, [v]

Toxicology. — Large doses of vitamin D have
caused the hypervitaminosis D syndrome
(Abrams and Bauer, J.A.M.A., 1938, 111, 1632).
Reynolds (J. -Lancet, 1942, 62, 372) stated that
doses up to 10 mg. (400,000 units) of calciferol
have been administered daily without inducing
metastatic calcification, hypercalcemia, and other
toxic manifestations. Calcification of soft
tissues, osteoporosis, and periosteal thickening
were roentgen findings described by Swoboda
(Fortschr. Roentgenstrahlen u. Praxis, 1952, 77,
525) in cases of hypervitaminosis D. In conse-
quence of the use of large doses of calciferol in
treating tuberculosis of the skin, reports of
hypercalcemic toxemia have been numerous. The
impression that large doses of vitamin A, in fish
liver oil, minimize the intoxication is widespread
(Teulon et al., Compt. rend. soc. biol., 1951, 145,
542). By favoring calcium deposition in osteoid
tissue of bone, therapy with estrogens is worthy
of trial in cases of poisoning (Chaplin et al., Am.
J. Med. Sc, 1951, 221, 369).

Vitamin D Unit.— Formerly, crystalline cal-

ciferol (vitamin D2) was the standard for evalu-
ating vitamin D activity, 1 mg. of calciferol
representing 40,000 units (of antirachitic ac-
tivity). In 1949 the World Health Organization
of the United Nations adopted crystalline acti-
vated 7-dehydrocholesterol (vitamin D3) as the
international standard for vitamin D, 1 mg. rep-
resenting 40,000 international units (of anti-
rachitic activity). In harmony with this action
the U.S. P. adopted as its Vitamin D Reference
Standard a solution of crystalline vitamin D3
in cottonseed oil, containing 10 micrograms of
vitamin D3 per gram of solution, and rep-
resenting 400 U.S. P. units per gram (since
the U.S. P. unit is identical with the inter-
national unit). While there is some question that
1 milligram of vitamin D2 is equivalent to 1
milligram of vitamin D3 in antirachitic effect
on humans, equivalence of the two substances is
commonly assumed. In rats also the two sub-
stances appear to have the same potency, but
in chicks vitamin D3 is 30 to 35 times more
effective than the same weight of vitamin D2.

Dose. — The usual dose of calciferol for pre-
vention of rickets in an infant is 10 micrograms
(400 units) daily by mouth; the curative dose
in infancy is 30 to 37.5 micrograms (1200 to
1500 units) orally daily. In hypocalcemic tetany
up to 5 milligrams (200,000 units) is used. See
also above for other doses, as well as under
Synthetic Oleovitamin D.

Storage. — Preserve "in hermetically sealed
containers under nitrogen, in a cool place and
protected from light." U.S.P.

SOLUTION OF CALCIFEROL. B.P.

Solution of Vitamin D2, Liquor Calciferolis

The solution is required to contain in each
gram 3000 units of antirachitic activity (vitamin
D). It is prepared by warming to 40° a 1 per cent
suspension of calciferol in a suitable vegetable
oil, such as arachis oil, carbon dioxide being bub-
bled through the mixture to facilitate solution;
when the calciferol has dissolved sufficient oil is
added to make the solution of required strength.
It is assayed by the B.P. biological method for
vitamin D.

For uses of the solution see Calciferol, also
Synthetic Oleovitamin D.

The official daily doses, for infants and adults,
are: prophylactic, 0.3 to 1.2 ml. (approximately
1000 to 4000 units); therapeutic, 1.5 to 15 ml.
(approximately 5000 to 50,000 units).

Storage. — Preserve in a well-filled, well-
closed container, protected from light, and stored
in a cool place. B.P.

TABLETS OF CALCIFEROL. B.P.

Strong Tablets of Calciferol, Tablets of Vitamin D2

The tablets are required to contain not less
than 90.0 per cent and not more than 110.0
per cent of the prescribed or stated number of
units of antirachitic activity (vitamin D).

CALCIUM.

Ca (40.08)

Calcium is a very abundant element in nature,
existing in the mineral kingdom largely as a car-

214

Calcium

Part I

bonate, in the form of limestone, marble and
chalk; as a sulfate in gypsum and selenite; as a
phosphate and carbonate in the bones and shells
of animals; as a fluoride in fluorspar; and as a
constituent of many silicates.

The element was first isolated by Davy, in
1808, by electrolysis. Until the beginning of
World War II all of the calcium metal used in
the United States was manufactured in France
by electrolysis of fused calcium chloride. Plants
utilizing the electrolytic process are now in opera-
tion in this country. The roughly cylindrical
"carrots" of calcium produced in the electrolysis
of calcium chloride contain about 85 per cent
of the metal because of the necessity of main-
taining a protective layer of chloride to prevent
burning of the element. Purification of the metal
may be effected by melting and casting the carrots
in an atmosphere of argon; after separation of
the chloride the metal is 95 to 97 per cent pure.
Further purification may be effected by distilling
the metal under a high vacuum. More recently it
has been found that calcium metal can be pro-
duced economically by thermal reduction of
calcium oxide under high vacuum; the reducing
agent found most satisfactory is aluminum
powder {Chem. Met. Eng., 1945, 52, 94). In
this process the calcium metal is vaporized in
the hot section of the reaction retort and passes
to the cold end by diffusion, where it is condensed
to solid. When pure, calcium is a silvery-white
metal, ductile and malleable; it has a density of
1.54 and a melting point of 810°. The metal is
employed as an alloying element, as a deoxidant
and scavenger, and as a reducing agent in metal-
lurgical processes.

Metabolism and Uses. — It is obviously im-
possible at this place to consider in any detail
the calcium metabolism of the body, an under-
standing of which is essential for the compre-
hension of calcium therapy. A comprehensive
discussion of this subject is given by Snapper, in
Clinical Nutrition, edited by Jolliffe, Tisdall and
Cannon, 1950. The studies of Albright and Rei-
fenstein {The Parathyroid Glands and Metabolic
Bone Disease: Selected Studies, 1948) should be
consulted by the interested reader. The studies of
Deitrick, Shorr and Whedon (see Whedon, Med.
Clin. North America, 1951, 35, 545) on the
effect of immobilization on the metabolism of
many substances, including calcium, in the nor-
mal, healthy human provide much valuable infor-
mation (see also studies with radiocalcium in the
rat, by Harrison and Harrison, /. Biol. Chem.,
1951, 188, 83).

Distribution. — Calcium is an important ele-
ment of the body. It comprises almost two-
thirds of the dry weight of bone in which it is
present in combination with carbonate and phos-
phate, possibly structurally related to tricalcium
phosphate (Hendricks and Hill, Science, 1942,
96, 255). Frondel and Prien {Science, 1946, 103,
326) found carbonate-apatite to be the principal
inorganic constituent in certain pathological cal-
cifications. The skeleton and teeth contain about
99 per cent of the calcium of the body, the rest
being found in the extracellular fluids ; only traces

exist in the cells. Calcium is essential for normal
function of the heart and neuromuscular tissues
and for coagulation of the blood; it is also im-
portant in the acid-base equilibrium of the
tissues, proper proportions of sodium, potassium
and calcium being necessary. Bones serve the
mechanical function of support for soft tissues
and also as a mobilizable source of calcium. In
fact, bone calcium is not in a static state; from
fetal life until senility the osteoblasts are continu-
ously forming new bone matrix — osteoid tissue —
for calcification and the osteoclasts, with varying
rapidity, are dissolving bone. In the blood serum
of the adult, calcium is found in a concentration
of 9 to 11.5 mg. per 100 ml. or about 5 milli-
equivalents per liter. About half of this calcium
is attached loosely to serum proteins and is
unionized. For clinical purposes, serum protein
must be determined in order to evaluate a serum
calcium level. The remainder is present in solu-
tion in the form of soluble complex ions and
other unknown ionized forms; this portion is
affected by the hormone produced by the para-
thyroid glands. In cerebrospinal fluid there is
about 5 mg. of calcium per 100 ml., in ionized
form. The concentration of calcium in the spinal
fluid therefore indicates the amount of ionized
calcium in the blood. Acidosis increases the
proportion of ionized calcium. The concentration
of serum calcium is affected by the amount of
phosphate ion present — normally 3 to 4 mg. per
100 ml. of blood in the adult — in accordance
with the common ion effect, i.e., an increase in
phosphate is associated with a decrease in cal-
cium, and vice versa. The product of concentra-
tions of calcium and phosphate ions approaches
closely the solubility product of a calcium phos-
phate salt. This would seem to facilitate the
deposit in osteoid tissue, under the influence of
the alkaline phosphatase enzyme in the osteo-
blast, without a tendency to deposit in the soft
tissues of the body.

Absorption-Excretion. — Calcium is absorbed
from the upper gastrointestinal tract. In the alka-
line medium of the lower intestinal tract, it is
precipitated as insoluble phosphate, carbonate,
soaps, etc. Solubility and absorption are favored
by acid reaction of the chyme. After the ingestion
of 5 Gm. of calcium lactate, the serum calcium
level increases by about 1 mg. per 100 ml. within
2 to 4 hours, the increase persisting for about 12
hours. The absorption of calcium is decreased by
achlorhydria gastrica, chronic diarrhea, deficiency
of vitamin D, alkali therapy, high phosphorus diet
and in sprue and other conditions with increased
amounts of fatty acids in the feces. In normal
humans, calcium is excreted into the urine in
amounts representing about 25 to 35 per cent of
the calcium intake and the feces contain from
65 to 75 per cent of the ingested calcium; a part
of this represents unabsorbed calcium but some
of it has been excreted into the lower intestine
from the blood stream. The Sulkowitch reagent
{J.A.M.A., 1939, 112, 2592), consisting of 2.5
Gm. of oxalic acid, 2.5 Gm. of ammonium oxa-
late, 5 ml. of glacial acetic acid, and distilled
water to make 150 ml., provides a simple and

Part I

Calcium

215

roughly quantitative estimate of the amount of
urinary calcium. Equal volumes of this reagent
and urine of an acid reaction are mixed and al-
lowed to stand quietly for 2 minutes. A heavy
white precipitate indicates an abnormal amount
of calcium in the urine and, probably, a high
serum calcium level, provided the patient has not
ingested calcium salts or high-calcium foods, such
as milk, within the previous 12 hours. Normally
only a faint precipitate forms in the test. The
absence of any precipitate indicates decreased
urinary calcium excretion and hypocalcemia.

Nutritional Requirement. — Sherman (/.
Biol. Chem., 1920, 44, 21) estimated the daily
adult requirement of calcium as 450 mg.; criti-
cism of this estimate has arisen (Cathcart, Lancet,
1940, 1, 533, 586; McGowan, Brit. M. J., 1941,
1, 421) and the optional daily intake is perhaps
greater. It is agreed, however, that the require-
ment is greater during growth, pregnancy and lac-
tation. The recommended daily dietary allow-
ances by the Food and Nutrition Board, National
Research Council, U.S.A., revised in 1953, for
calcium are: For an adult male or female, age
25 to 65 years, 0.8 Gm. ; in the third trimester
of pregnancy, 1.5 Gm.; during lactation, 2 Gm.;
for an infant of 1 to 3 months, 0.6 Gm. ; 4 to 9
months, 0.8 Gm.; 10 months through 9 years,
1 Gm.; 10 to 12 years, 1.2 Gm.; 13 to 20 years,
for boys, 1.4 Gm. ; girls, 1.3 Gm. (Shank, J. A.
Dietet. A., 1954, 30, 105). The dietary in the
United States and elsewhere tends to be deficient
in calcium. Milk, containing 1.4 Gm. of calcium
per liter, cheese, green vegetables and egg yolk
are high in calcium but their high phosphorus
content may interfere with its absorption. Cal-
cium salts, such as the lactate or the gluconate,
are often therapeutically more effective; an ade-
quate supply of vitamin D is essential for calcium
absorption.

Hypocalcemia. — A deficiency of ionized cal-
cium in the blood serum results in the syndrome
known as tetany, characterized by irritability
of all the muscles. Carcopedal spasm is the most
characteristic feature; the thumb is drawn into
the cupped palm; the hands are abducted and
the wrists flexed; the fingers are flexed at the
metacarpophalangeal joints but extended at the
interphalangeal joints. The foot is rigidly flexed
and adducted. Laryngeal spasm is recognized
by the "crowing" inspiration and may cause
suffocation. Convulsions, which do not differ in
appearance from other convulsive states, may
occur. Smooth muscle in the iris, bronchi, stom-
ach, intestine, urinary tract, etc., is also affected.
Cardiac arrhythmia may also occur. The uterus
becomes atonic and is relatively insensitive to
oxytocic drugs. In perfusion experiments, insuffi-
cient calcium ion leads to arrest of the heart in
diastole, the effect which is produced by an excess
of potassium ion; an excess of calcium induces
systolic arrest of the heart. The site of action of
calcium is the neuromuscular junction rather than
the muscle or nerve. Tetany, latent or manifest,
is observed under many circumstances such as
dietary deficiency of calcium and vitamin D
(rickets in childhood, osteomalacia in adults, espe-

cially during pregnancy), deficiency of parathy-
roid function either idiopathic or as the result of
accidental removal of the glands at an operation
such as thyroidectomy, failure of absorption as
in sprue, steatorrhea, etc., excessive intake of
substances which precipitate or form unionized
complexes with calcium such as citrates, oxalates,
phosphates, etc., alkalosis due to hyperventilation,
protracted vomiting or alkali therapy.

Role of Parathyroid Glands. — This is the
important endocrine gland in the metabolism of
calcium and phosphate. The parathyroid hormone
(q.v.) exerts its chief action on the urinary
excretion of phosphate, although it has some
action on resorption of bone. The phosphorus
diuresis results in a decrease in blood serum
phosphate; reciprocal elevation in serum calcium
occurs and results in an increase in urinary cal-
cium excretion. In hypoparathyroidism, the con-
verse develops: there is a decrease in urinary
phosphate, increase in blood serum phosphate,
reciprocal decrease in serum calcium, and de-
creased urinary calcium. Parathyroid activity
seems to be regulated by the blood serum calcium
concentration; a decrease in serum calcium is
followed by increased parathyroid activity and
vice versa.

Hypercalcemia. — The result of an excess of
ionized calcium in blood serum is usually more
insidious than tetany; weakness, anorexia, loss
of weight, pains in the muscles and joints, con-
stipation, bradycardia, arrhythmia, renal lithiasis
and impaired kidney function are observed. The
high content of calcium blocks the transmission
of the nerve impulse at the synapse. Ventricular
fibrillation has been reported. The effect on the
heart is similar to that of digitalis and fatalities
have occurred when the two drugs have been used
simultaneously. Hyperparathyroidism, either pri-
mary or secondary to impaired renal function or
other causes, results in an elevation of the serum
calcium concentration, increased excretion of cal-
cium and demineralization of bone. The weakening
of bone produces a normal stimulus for formation
of osteoid tissue and an increase, in this tissue
and in the circulating blood, of alkaline phos-
phatase. The increased osteoid tissues results in
fibrocystic changes (osteitis fibrosa cystica, von
Recklinghausen's disease) in the bones. However,
if calcium intake is sufficient to balance the
increased excretion no bone changes appear but
the disease may manifest itself in the form of
renal lithiasis. The parenteral administration of
soluble calcium salts may cause a temporary
increase in blood calcium. Very large doses of
vitamin D and related substances cause hyper-
calcemia. In hyperthyroidism (see Surg. Gynec.
Obst., 1945, 81, 243), the excretion of calcium
is increased and, if this persists for many months,
demineralization of the skeleton occurs but the
serum calcium is not altered; in hypothyroidism
a diminished calcium excretion is associated with
a skeleton which is more dense than the normal.

Osteoporosis. — In old age, diminished osteo-
blastic action in forming osteoid tissue, with con-
tinued osteoclastic destruction of bone, results
in osteoporosis (Albright, Smith and Richardson,

216

Calcium

Part I

J.A.M.A., 1941, 116, 2465). This is a common
situation and spontaneous fractures, especially
of the bodies of the vertebra, are not an infre-
quent cause of severe pain in old people. The
fundamental defect is a deficiency of osteoid
tissue, which is the protein matrix of bone. Even
in the presence of normal calcium metabolism, a
deficiency in matrix formation results in loss of
bone and a loss of calcium from the body.
Mechanical stresses and strains of ambulation
and work provide the normal stimulus for the
formation of of osteoid tissue. Disuse, as in the
paralyzed extremity or in the limb immobolized
in a cast because of a fracture, results in defi-
cient osteoid and loss of bone (Flocks, J.A.M.A.,
1946, 130, 913). The sex steroids are essential
for normal formation of osteoid tissue through
their anabolic effect in protein metabolism. Osteo-
porosis is a disorder primarily of protein metabo-
lism and only secondarily of calcium and
phosphorous metabolism. Blood serum calcium
and phosphate are normal. The negative nitrogen
metabolism of Cushing's syndrome and during
the prolonged use of large doses of cortisone,
hydrocortisone or corticotropin results in a defi-
ciency of osteoid tissue and osteoporosis. Rickets
in infancy is discussed under Oleovitamin D.
Osteomalacia in adults is often related to a defi-
ciency of vitamin D and the resulting impaired
intestinal absorption of calcium. In this situ-
ation osteoid tissue is formed but the deficiency
in calcium and phosphate results in failure to
calcify.

Therapeutic Uses. — The therapeutic uses of
calcium are numerous. Its most frequent use is
as an antacid in the management of gastric hy-
peracidity in peptic ulcer and other conditions
(see Calcium Carbonate and Dibasic Calcium
Phosphate) . Its most specific use is in the control
of tetany due to hypocalcemia (see Calcium
Gluconate) . In rickets or osteomalacia, vitamin D
is the most important remedy; calcium is only
an adjunct. Calcium gluconate finds some use
as an antispasmodic in instances of biliary, renal
or intestinal colic. In disturbances of calcium
metabolism with latent tetany or serious de-
mineralization of the skeleton, calcium lactate
or gluconate is employed along with vitamin D
and other substances to increase absorption and
storage of calcium. The chloride has been used
at times in conditions of alkalosis and to acidify
the urine and even as a diuretic, but it is not as
well tolerated as ammonium chloride or ammo-
nium nitrate. Soluble calcium salts are widely
employed with the hope of correcting abnor-
mally increased capillary permeability as in
urticaria, dermatitis herpetiformis and other
conditions (see Calcium Chloride). Another use
is as an antidote for a variety of poisons such as
the arsphenamines, fluorides, oxalates, ergot,
carbon tetrachloride, etc. (see Calcium Gluco-
nate). It is also in frequent use in purpura and
other hemorrhagic states based on the fact that
calcium ion is essential in the process of blood
coagulation. However, tetany would be incom-
patible with life long before a sufficient lack of
blood calcium was reached to interfere with co-
agulation, s

CALCIUM AMINOSALICYLATE.
U.S.P.

Calcium Para-aminosalicylate

[C«H3(/>-NH2) (o-OH)COO]2Ca

"Calcium Aminosalicylate contains one-half
molecule or three molecules of water of hydra-
tion. It contains not less than 98 per cent of
Ci4Hi2CaN20e, calculated on the anhydrous
basis." U.S.P.

"Caution. — Prepare solutions of Calcium
Aminosalicylate within 24 hours of administra-
tion. Under no circumstances use a solution if its
color is darker than that of a freshly prepared
solution." U.S.P.

This salt is obtained by interaction of amino-
salicylic acid and calcium carbonate.

Description. — "Calcium Aminosalicylate oc-
curs as white to cream-colored crystals or pow-
der. It is odorless and has an alkaline, slightly
bitter-sweet taste. It is somewhat hygroscopic. Its
solutions decompose slowly and darken in color.
One Gm. of Calcium Aminosalicylate dissolves in
about 7 ml. of water; it is slightly soluble in
alcohol." U.S.P.

Standards and Tests. — Identification. — The
acid liberated from the calcium salt responds to
identification tests under Aminosalicylic Acid,
while the filtrate from the acid responds to tests
for calcium. Water. — The hemihydrate contains
not less than 2.5 per cent and not more than 3.5
per cent of water; the corresponding limits for
the trihydrate are 12.5 per cent and 14.5 per
cent. Clarity of solution. — A solution of 1 Gm.
of calcium aminosalicylate in 50 ml. of water
shows no more turbidity than is produced by 0.05
ml. of 0.02 N hydrochloric acid and 1 ml. of
silver nitrate T.S. in a mixture of 48 ml. of water
and 1 ml. of nitric acid. Chloride. — The limit is
420 parts per million. Heavy metals. — The limit is
30 parts per million. Hydrogen sulfide and sulfur
dioxide. — Lead acetate paper is not discolored
when held over an acid mixture containing cal-
cium aminosalicylate, m- Amino phenol. — Not over
0.2 per cent. Free aminosalicylic acid. — An ether
extract of the salt does not yield a residue which
shows more than a pale violet color with ferric
chloride T.S. U.S.P.

Assay. — The assay explained under Amino-
salicylic Acid is used. Each ml. of 0.1 M sodium
nitrite represents 17.22 mg. of Ci4Hi2CaN20e.
U.S.P.

Uses. — This salt is used in the treatment of
tuberculosis (see Aminosalicylic Acid). Patients
who cannot tolerate sodium aminosalicylate or
aminosalicylic acid in the doses required to be
effective are often able to take the calcium salt
without discomfort. It is also indicated where
sodium restriction is simultaneously desired in
the therapeutic program. Calcium aminosalicylate
is available in granules (Pasara Calcium Granu-
late, Smith-Dorsey) coated with a sialoresistant
substance; these granules contain 85 per cent of
the calcium salt and are equivalent to 75 per cent
of the free acid. Calcium aminosalicylate is com-
monly used in combination with streptomycin, the
latter given in a dose of about 1 Gm. twice
weekly intramuscularly.

Part I

Calcium Carbonate, Precipitated 217

The usual dose of calcium aminosalicylate is
3 Gm. (approximately 45 grains), four times daily
by mouth, with a range of 2 to 4 Gm. The maxi-
mum safe dose is 4 Gm., and the total dose in 24
hours should not exceed 16 Gm.

Labeling. — "Label Calcium Aminosalicylate
to indicate whether it is the hemihydrate or the
trihydrate." U.S.P.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

CALCIUM AMINOSALICYLATE
TABLETS. U.S.P.

"Calcium Aminosalicylate Tablets contain not
less than 95 per cent and not more than 105 per
cent of the labeled amount of Ci4Hi2CaN206."
U.S.P.

Usual Size. — 500 mg.

CALCIUM BROMIDE. N.F.

[Calcii Bromidum]

"Calcium Bromide is a hydrated salt, contain-
ing not less than 84 per cent and not more than
94 per cent of CaBr2." N.F.

Calcium Bromatum; Calcium Bromuretum. Fr. Bromure
de calcium officinal. Ger. Calciumbromid; Bromcalcium.

Calcium bromide may be made by the inter-
action of hydrobromic acid and calcium car-
bonate. Another process consists in heating a
mixture of ammonium bromide and milk of lime
until the odor of ammonia is no longer apparent,
followed by filtration and crystallization.

Description. — "Calcium Bromide occurs as a
white, granular salt, having no odor. It is very
deliquescent. An aqueous solution of Calcium
Bromide is neutral or alkaline to litmus paper.
One Gm. of Calcium Bromide dissolves in about
0.7 ml. of water and in about 1.3 ml. of alcohol.
One Gm. of Calcium Bromide dissolves in about
0.4 ml. of boiling water. It is insoluble in chloro-
form and in ether." N.F.

Standards and Tests. — Identification. — A 1
in 20 solution of calcium bromide responds to
tests for calcium and for bromide. Chloride. —
The limit is 1.4 per cent. In the test 100 mg.
of calcium bromide is dissolved in water, pre-
cipitated with silver nitrate T.S., the precipitate
washed and digested with ammonium carbonate
T.S., which dissolves the silver chloride but not
the silver bromide, and filtered. A one-fourth
aliquot of the filtrate is acidified with nitric acid
to precipitate any silver chloride present; the re-
sulting turbidity, if any, should not exceed that
produced by 0.5 ml. of 0.02 N hydrochloric acid
treated with silver nitrate T.S. in the same dilu-
tion. Br ornate. — No blue or violet color is pro-
duced within 10 minutes after adding 2 drops of
potassium iodide T.S., 1 ml. of starch T.S., and
5 drops of 1 N sulfuric acid to a solution of 1 Gm.
of calcium bromide in 10 ml. of recently boiled
and cooled water. Iodide. — No violet tint de-
velops in the chloroform layer on adding a few
drops of ferric chloride T.S. and 1 ml. of chloro-
form to 10 ml. of a 1 in 20 solution of calcium
bromide. Sulfate. — No turbidity is produced im-
mediately when 1 ml. of barium chloride T.S. is

added to 5 ml. of a 1 in 20 solution of calcium
bromide acidulated with 1 drop of hydrochloric
acid. Barium. — No turbidity is produced in 5
minutes when 5 drops of potassium dichromate
T.S. is added to a boiled and cooled solution of
1 Gm. of calcium bromide, 1 Gm. of sodium ace-
tate, and 3 to 5 drops of diluted acetic acid in
5 ml. of distilled water. Heavy metals. — The limit
is 10 parts per million. Iron. — No blue color is
produced immediately when several drops of po-
tassium ferrocyanide T.S. is added to 20 ml. of a
1 in 200 solution of calcium bromide. Magnesium
and alkali salts. — 1 Gm. of calcium bromide is
treated with ammonium oxalate T.S. to precipi-
tate calcium; after filtering off the precipitate
one-half of the filtrate is evaporated, in the pres-
ence of 0.5 ml. of sulfuric acid, to dryness and
the residue ignited to constant weight. The weight
of the residue should not exceed 4 mg. N.F.

Assay. — About 400 mg. of calcium bromide
is dissolved in water and the calcium precipitated
as oxalate by adding ammonium oxalate T.S.
and making alkaline with ammonia T.S. The
precipitate of calcium oxalate is filtered off,
washed, and treated with dilute sulfuric acid to
liberate an equivalent amount of oxalic acid
which is titrated with 0.1 N potassium permanga-
nate. Each ml. of 0.1 N potassium permanganate
represents 9.996 mg. of CaBr2. N.F.

Incompatibilities. — Insoluble calcium salts
are formed with citrates, carbonates, phosphates,
sulfates and tartrates. Oxidizing agents may
liberate bromine.

Uses. — Calcium bromide is used like the other
bromides (see Sodium Bromide) for the relief
of convulsive disorders. It has been used in
asthma. If calcium salts have anticonvulsant
properties (see under Calcium) then the combi-
nation in calcium bromide is a rational one, but
for chronic use the calcium may be objectionable.

Dose, 1 Gm. (approximately 15 grains) with
water after meals.

Storage. — Preserve "in tight containers hold-
ing not more than 120 Gm." N.F.

Off. Prep. — Five Bromides Elixir; Bromides
Syrup, N.F.

PRECIPITATED CALCIUM
CARBONATE. U.S.P. (B.P.)

Precipitated Chalk, [Calcii Carbonas Praecipitatus]

"Precipitated Calcium Carbonate, when dried
at 200° for 4 hours, contains calcium equivalent
to not less than 98 per cent of CaC03." U.S.P.
The B.P. requires not less than 98.5 per cent
CaC03, calculated with reference to the sub-
stance dried at 105°.

B.P. Calcium Carbonate; Calcii Carbonas. Precipitated
Carbonate of Lime, Calcium Carbonicum Praecipitatum;
Creta Prscipitata; Calcaria Carbonica Praecipitata. Fr.
Carbonate de calcium; Carbonate de chaux precipite;
Carbonate de chaux prepare. Ger. Gefalltse Kalzium-
karbonat; Kalziumkarbonat. It. Carbonato di calcio pre-
cipitato. Sp. Carbonato de calcio; Carbonato de Calcio
Precipitado.

Precipitated calcium carbonate may be pre-
pared by the reaction of a soluble calcium salt
and a soluble carbonate; generally calcium chlo-
ride and sodium carbonate are employed. If the
precipitation takes place at ordinary tempera-

218 Calcium Carbonate, Precipitated

Part I

tures the calcium carbonate forms as exceed-
ingly small crystals belonging to the hexagonal
system, of which the naturally occurring calcite
is an example. If precipitation is effected from
hot dilute solutions the crystals are of the
rhombic system, similar to the naturally occur-
ring calcium carbonate mineral known as
aragonite. The latter crystals slowly change to
the calcite form. The solubility in water of the
aragonite variety is greater than that of the cal-
cite form. Other physical properties, such as
density of the crystals, also vary.

Description. — "Precipitated Calcium Carbon-
ate is a fine, white, microcrystalline powder,
without odor or taste. It is stable in air. Pre-
cipitated Calcium Carbonate is practically insol-
uble in water. Its solubility in water is increased
by the presence of any ammonium salt and by
the presence of carbon dioxide. The presence of
any alkali hydroxide reduces its solubility. It is
insoluble in alcohol. It dissolves with efferves-
cence in diluted acetic, in diluted hydrochloric,
and in diluted nitric acids." U.S.P.

Standards and Tests. — Identification. — Pre-
cipitated calcium carbonate dissolves in acetic
acid with effervescence, and the resulting solu-
tion, after boiling to expel carbon dioxide and
neutralizing with ammonia T.S., responds to tests
for calcium. Loss on drying. — Not over 2 per
cent, when dried for 4 hours at 200°. Acid-insol-
uble substances. — 5 Gm. of precipitated calcium
carbonate, dissolved with hydrochloric acid,
yields not more than 10 mg. of residue. Barium.
— No green color is observed when a platinum
wire, dipped in the filtrate remaining from the
preceding test, is held in a non-luminous flame.
Heavy metals. — The limit is 30 parts per million.
Magnesium and alkali salts. — When 1 Gm. of
precipitated calcium carbonate is dissolved with
the aid of diluted hydrochloric acid and tested as
described under the corresponding test for cal-
cium bromide, not more than 5 mg. of residue
is obtained. U.S.P.

The B.P. provides a limit test for aluminum,
iron, phosphate and matter insoluble in hydro-
chloric acid; limit tests are also established for
soluble alkali, chlorides, sulfates, iron, arsenic,
and lead. The official substance should lose not
more than 1.0 per cent of its weight when dried
at 105°.

Assay. — About 1 Gm. of precipitated calcium
carbonate, previously dried for 4 hours at 200°,
is dissolved with the aid of diluted hydrochloric
acid and a one-fourth aliquot portion of the solu-
tion is analyzed according to the reactions
summarized under the assay for Calcium Bromide.
Each ml. of 0.1 N potassium permanganate
represents 5.005 mg. of CaC03. U.S.P.

In the B.P. assay the sample is dissolved in
an excess of 1 N hydrochloric acid and titrated
with 1 N sodium hydroxide using methyl orange
as indicator.

Uses. — Calcium carbonate is one of the best
antacids in the management of peptic ulcer and
other conditions with gastric hyperacidity. One
gram will neutralize about 200 ml. of 0.1 TV hydro-
chloric acid. In doses of 2 to 4 Gm. every hour,
together with milk and cream every hour and

1 mg. of atropine sulfate two to four times daily,
Kirsner et al. (Ann. Int. Med., 1951, 35, 785)
reported that the pH of gastric contents in cases
of duodenal ulcer remained between 4 and 5.5
throughout the 24 hours of the day and concluded
that it was the most effective antacid. It does
not impart an alkaline reaction to further stimu-
late secretion of gastric juice as is the case with
sodium bicarbonate. The calcium chloride formed
in the stomach is largely converted to insoluble
calcium salts in the lower intestine and the chlo-
ride may be absorbed. Calcium carbonate does
not cause any significant disturbance in mineral
metabolism (J. Clin. Inv., 1943, 22, 47). It does
not cause systemic alkalosis (Kirsner and Palmer,
Arch. Int. Med., 1943, 71, 415); however, hypo-
chloremia due to vomiting or aspiration of gastric
contents in cases with pyloric obstruction should
be corrected by the administration of sodium
chloride. Peptic activity of gastric juice is inhib-
ited by the decreased acidity produced by calcium
carbonate (Steigmann and Marks, Am. J. Digest.
Dis., 1944, 11, 173). Its constipating action in
large doses may be utilized in the treatment of
diarrhea or corrected in the patient with peptic
ulcer by the coincident administration of magne-
sium salts in sufficient dosage. A tablet or powder
containing 0.6 Gm. of calcium carbonate and

2 Gm. of sodium bicarbonate is a frequently
employed modification of the "Sippy powders"
in doses as frequent as every hour during the
day for 12 to 16 doses daily. Precipitated calcium
carbonate is the major constituent of N.F.
Dentifrice and other powder and paste denti-
frices. E

The usual dose is 1 Gm. (approximately 15
grains) with water four or more times daily, by
mouth, with a range of 1 to 2 Gm. The maximum
safe dose is usually 4 Gm., and 24 Gm. in 24
hours is seldom exceeded.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep. — Aluminum Subacetate Solution,
U.S.P.; Calcium Carbonate Tablets; N.F.
Dentifrice; Sodium Bicarbonate and Calcium
Carbonate Powder; Sodium Bicarbonate and
Calcium Carbonate Tablets, N.F.

CALCIUM CARBONATE TABLETS.

N.F.

[Tabells Calcii Carbonatis]

"Calcium Carbonate Tablets contain not less
than 92.5 per cent and not more than 107.5 per
cent of the labeled amount of CaC03." N.F.

Usual Size. — 10 grains (approximately 0.6
Gm.).

CALCIUM CHLORIDE. U.S.P., B.P.

[Calcii Chloridum]

"Calcium Chloride contains an amount of
CaCb equivalent to not less than 99 per cent
and not more than 107 per cent of CaCl2.2H20."
U.S.P.

Under this same title the B.P. recognizes the
anhydrous salt, although it is permitted to contain
up to 10.0 per cent of water. The B.P. states it
may be obtained by reaction between calcium

Part I

Calcium Chloride

219

carbonate and hydrochloric acid; the neutral
solution so obtained is evaporated, and the prod-
uct dried at a temperature not above 200°. This
dried material should contain not less than 98.0
per cent of CaCk>. In a separate monograph the
B.P. provides standards for Hydrated Calcium
Chloride, CaCl2.6H20.

Muriate of Lime; Hydrochlorate of Lime. Calcium
Chloratum Crystallisatum; Calcaria Muriatica; Calcii Chlo-
rurum. Fr. Chlorure de calcium cristallise. Ger. Kristalli-
siertes Kalziumchlorid; Salzsaures Kalk. It. Cloruro di
calcio. Sp. Cloruro de calcio.

Calcium chloride may be prepared by various
reactions. One of these involves interaction of
calcium carbonate and hydrochloric acid, as when
the latter is saturated with chalk or marble.
Calcium chloride is also obtained as a by-product
in certain industries, notably in the Solvay process
for manufacturing sodium carbonate; in this
process the ammonium chloride in the mother
liquor is treated with lime, which liberates am-
monia and produces calcium chloride.

Depending on the temperature and concentra-
tion of the solution from which calcium chloride
is crystallized one or another of several hydrates
may be obtained. Hydrates containing 6H2O,
4H2O, 2H2O, and IH2O are claimed to exist,
although different writers are not always in
agreement as to which hydrate is produced. If
any of these is heated strongly, an anhydrous
form of calcium chloride may be prepared.

Description. — "Calcium Chloride occurs as
white, hard, odorless fragments or granules. It is
deliquescent. One Gm. of Calcium Chloride dis-
solves in 1.2 ml. of water, and in about 10 ml. of
alcohol. One Gm. of it dissolves in 0.7 ml. of
boiling water, and in about 2 ml. of boiling al-
cohol." U.S.P.

Standards and Tests. — Identification. — A 1
in 10 solution of calcium chloride responds to
tests for calcium and for chloride. Reaction. — A
solution of 3 Gm. of calcium chloride in 20 ml. of
freshly boiled and cooled water, to which has been
added 2 drops of phenolphthalein T.S., requires
not more than 0.3 ml. of 0.02 N hydrochloric
acid to discharge any pink color or, if colorless,
not more than 0.1 ml. of 0.02 N sodium hydroxide
to produce a pink color. Heavy metals. — The limit
is 20 parts per million. Iron, aluminum, or phos-
phate.— No turbidity or precipitate results when
a 1 in 20 solution of calcium chloride is alkalin-
ized with ammonia T.S. and heated to boiling.
Magnesium and alkali salts. — When 1 Gm. of cal-
cium chloride is treated as described under the
corresponding test for calcium bromide, not more
than 5 mg. of residue is obtained. U.S.P.

The B.P. sets the limit of arsenic at 4 parts
per million, and that of lead at 20 parts per mil-
lion; a limit test for sulfates is also provided.
The substance should lose not more than 10
per cent of its weight when dried at 200°.

Assay. — About 200 mg. of calcium chloride
is dissolved in water and analyzed according to
the reactions summarized under the assay for
calcium bromide. Each ml. of 0.1 N potassium
permanganate represents 7.351 mg. of CaCb.-
2H2O. U.S.P.

Uses. — While calcium chloride has the advan-

tage of solubility in water and should theoreti-
cally be the most rapidly absorbed of all the
salts of calcium, it is locally so irritant that it
cannot be used for intramuscular injection and
when given in full dose by mouth is likely to so
disturb digestion as to hinder its absorption.
Although Wokes (/. Pharmacol., 1931, 43, 531),
from experiments on mice, concluded that it was
the best absorbed of the all the calcium salts,
most clinicians prefer one of the others. Calcium
chloride may be used for any of the purposes
for which the salts of this metal are employed
(see under Calcium). It is a component of
Ringer's solution.

Diuretic Action. — In cases of generalized
edema calcium chloride may be employed as an
acid-producing diuretic (Segal and White, Am. J.
Med. Sc, 1925, 170, 647) ; ammonium chloride or
nitrate is used more frequently for this purpose.
The calcium is excreted into the intestine or de-
posited in the bones leaving the chloride as an
acidic ion in the body which alters the buffer
systems. As a result, sodium from the extra-
cellular fluid (edema) is passed into the blood
stream and excreted along with water as sodium
chloride by the kidney. The mild acidosis in-
creases the effective osmotic pressure of the
blood and favors the absorption of edema fluid
into the capillaries. A similar depression of
tubular reabsorption in the kidney may also be
a factor in the diuresis. In patients with seriously
impaired renal function, acidifying diuretics are
contraindicated.

Antiallergic Action. — In some way not at
present evident calcium salts diminish the sus-
ceptibility of guinea-pigs to anaphylaxis follow-
ing injection of foreign protein. Calcium salts
have, therefore, been used clinically and with
apparent good results not only to prevent the
serum disease after injection of antisera (Beeson
and Hoagland, Proc. S. Exp. Biol. Med., 1938,
38, 160) and antitoxins, but also in the treatment
of hay fever, asthma, urticaria, laryngismus strid-
ulus, hemoglobinuria, purpura, and other "al-
lergic" disorders. Experimental studies (Tainter
and Van Deventer, J.A.M.A., 1930, 94, 546)
have failed to substantiate the theory that calcium
decreases permeability of capillaries. However,
calcium is widely employed for this purpose and
the fact that the chloride is more effective than
either the lactate or the gluconate suggests that
acidosis rather than calcium may be the impor-
tant factor. In fact, Chauchard et al. (Compt.
rend. acad. sc, 1943, 216, 744) reported that
the effect of calcium chloride on the chronaxia
of nerve was due to acidosis rather than the
calcium ion.

Antispasmodic Action. — A single intravenous
injection of 250 mg. is reported to have relieved
tubercular diarrhea (Saxtorph, Ugeskr. f. laeger,
1918, 80, 1763; Fishberg, J. A.M. A., 1919, 72,
1881). In one case reported by Fishberg there was
serious collapse. Intravenous calcium chloride is
the specific antidote for magnesium poisoning.
Renal colic responds to calcium injections {Urol.
Cutan. Rev., 1939, 43, 247).

Intravenous Administration. — Calcium chlo-
ride should never be injected hypodermically. Its

220

Calcium Chloride

Part I

intravenous use requires great caution because
of the danger of serious depression of cardiac
function (see Calcium) and of causing thrombo-
phlebitis of the vein. For intravenous injection a
5 per cent solution in sterile distilled water may
be used; the rate of injection should not exceed

1 ml. per minute, the average dose being about
30 ml. The maximum single dose is about 75 ml.
(Clinics, 1944, 2, 1310). Rapid administration
causes a burning sensation in the skin (an indi-
cation of circulation time) and a fall in blood
pressure. For cardiac resuscitation, Leeds
(J. A.M. A., 1953, 152, 1409) recommends injec-
tion of 2 to 4 ml. of 10 per cent aqueous solution
into the exposed left ventricle at operation (as
reported by Kay and Blalock, Surg. Gynec.
Obst., 1951, 93, 97). This is indicated after
epinephrine has failed in the presence of weak
contractions, regular rhythm and with caution
in the absence of any contractions (asystole). It
is contraindicated by ventricular fibrillation.
Calcium is safer than barium chloride for this
heroic use. El

The B.P. directs that when calcium chloride
(referring to the anhydrous salt of the B.P.) is
prescribed for injection, twice the prescribed
amount of the B.P. hydrated calcium chloride
shall be dispensed.

An electrode paste composed of 100 Gm. of
bentonite, 200 mesh, and 85 ml. of a saturated
solution of calcium chloride has been found very
satisfactory for electroencephalography (Turner
and Roberts, /. Lab. Clin. Med., 1944, 29, 81).

Dose. — The usual oral dose is 1 Gm. (approxi-
mately 15 grains) four times daily, with a range
of 1 to 2 Gm. The maximum safe dose is usually

2 Gm. and a total dose of 10 Gm. in 24 hours
should seldom be exceeded (for intravenous use,
see above). It should be given well diluted in
solution after meals to avoid irritating the
stomach.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Ringer's Solution; Lactated
Ringer's Solution, U.S.P.; Calcium Chloride In-
jection, N.F.

HYDRATED CALCIUM CHLORIDE.
B.P. (LP.)

Calcii Chloridum Hydratum

Hydrated calcium chloride is made by neu-
tralizing hydrochloric acid with calcium carbonate
and crystallizing the product. The B.P. and LP.,
which latter recognizes the salt as Crystallized
Calcium Chloride, both require not less than 98.0
per cent and not more than the equivalent of
102.0 per cent of CaCl2.6H20.

Calcium Chloride Crystals; Calcium Chloride Hexahy-
drate. Calcium Chloruretum Cristallisatum. Fr. Chlorure
de calcium cristallise. Ger. Kristallisiertes Calciumchlorid.
It. Cloruro di calcio cristallizzato.

Hydrated calcium chloride occurs as colorless,
odorless crystals with a slightly bitter taste. It is
soluble in 0.2 part of water, and in 0.5 part of
alcohol. It is very deliquescent. It yields the
characteristic reactions of calcium and of chlo-
ride. When heated, it melts and the water

evaporates. The same tests for purity are re-
quired as for Calcium Chloride but the arsenic
limit is two parts per million and the lead limit
ten parts per million. The assay process is the
same as that used for calcium chloride except
that the results are calculated to CaCl2.6H20. It
should be kept in a well-closed container. B.P.
The LP. tests and standards are substantially
the same as those of the B.P.

Uses. — This salt has the same therapeutic use
as calcium chloride. It is intended especially for
solutions for intravenous injection. Such solutions
may be sterilized by heating in an autoclave.
The official dose, intravenously, is 0.6 to 2 Gm.
(approximately 10 to 30 grains).

Off. Prep. — Compound Injection of Sodium
Chloride (Ringer's Solution for Injection), B.P.

CALCIUM CHLORIDE
INJECTION. N.F.

Calcium Chloride Ampuls, [Injectio Calcii Chloridi]

"Calcium Chloride Injection is a sterile solu-
tion of calcium chloride in water for injection.
It yields not less than 95 per cent and not more
than 105 per cent of the labeled amount of
CaCl2.2H20." N.F.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." N.F.

Usual Size. — 10-ml. containing 500 mg. and
1 Gm. (approximately 7^2 and 15 grains).

CALCIUM GLUCONATE.
U.S.P., B.P., LP.

[Calcii Gluconas]

[CH2OH(CHOH)4.COO]2Ca

"Calcium Gluconate, dried at 105° for 16 hours,
contains not less than 99 per cent of. C12H22-
CaOi4." U.S.P. The B.P. requires it to contain
not less than 99.0 per cent, and not more than the
equivalent of 104.0 per cent of Ci2H220i4Ca.-
H20. The LP. requires not less than 98.0 per cent
of (C6Hu07)2Ca.H20.

Calglucon (Sandoz). Fr. Gluconate de calcium. Sp.

Glitconato de Calcio.

The preparation of calcium gluconate is de-
scribed under gluconic acid (see in Part II).

Description. — "Calcium Gluconate occurs as
white, crystalline granules or powder without
odor or taste. It is stable in air. Its solutions are
neutral to litmus. One Gm. of Calcium Gluconate
dissolves slowly in about 30 ml. of water, and in
about 5 ml. of boiling water. It is insoluble in
alcohol and in many other organic solvents."
U.S.P.

Standards and Tests. — Identification. — (1)
A 1 in 50 solution of calcium gluconate responds
to tests for calcium. (2) Crystals of gluconic
acid phenylhydrazide form when 1 ml. of freshly
distilled phenylhydrazine is added to 5 ml. of a
warm 1 in 10 solution of calcium gluconate con-
taining 0.7 ml. of glacial acetic acid, the mixture
being heated on a water bath for 30 minutes,
cooled, and the inner surface of the container
scratched with a glass stirring rod. Loss on drying.
— Not more than 4 per cent, when dried at 105°
for 16 hours. Chloride. — The limit is 700 parts

Part I

Calcium Gluconate

221

per million. Sulfate. — The limit is 500 parts per
million. Arsenic. — The limit is 8 parts per million.
Heavy metals. — The limit is 20 parts per million.
Sucrose and reducing sugars. — After precipitating
the calcium from a solution of calcium gluconate,
as calcium carbonate, the filtrate is boiled with
alkaline cupric tartrate T.S.: no red precipitate
should be formed immediately. U.S.P.

As one of the tests for identity the B.P. and
I. P. direct that the melting point of recrystallized
phenylhydrazide of gluconic acid shall melt at
about 201°, with decomposition. The arsenic and
lead limits are 2 and 5 parts per million, respec-
tively.

Assay. — About 500 mg. of calcium gluconate
is assayed for calcium according to the method
described under calcium bromide. Each ml. of
0.1 N potassium permanganate represents 21.52
mg. of Ci2H22CaOi4. U.S.P.

Uses. — Calcium gluconate is used to obtain
the physiological actions of calcium ion (see Cal-
cium), e.g., in tetany, inadvertent parathyroidec-
tomy, and during rapid growth or pregnancy. It
is less irritating to the tissues than either the
chloride or the lactate and, therefore, can be
given in large dose by mouth, or by intravenous
or intramuscular injection. Lieberman {J.A.M.A.,
1931, 97, 15) found it distinctly superior to
calcium lactate for oral administration, being less
likely to cause intestinal disturbance. Beutner
(Anesth. & Analg., 1940, 19, 132) found that
solutions of calcium gluconate, when mixed with
procaine solution, had much less power of pre-
venting procaine convulsions than did other cal-
cium salts.

Therapeutic Uses. — Somewhat analogously to
the ubiquitous role of ascorbic acid, calcium
gluconate has been employed in the treatment
of all manner of disorders. Beneficial effects have
been reported following intravenous, and often
simultaneous oral, administration of calcium glu-
conate in the following: renal, biliary or intes-
tinal colic {J. A.M. A., 1921, 96, 1216); lead poi-
soning {Int. Med., 1940, 9, 505); intestinal
tuberculosis (see Calcium Chloride) ; eclampsia
{Brit. M. J., 1930, 2, 42) ; uterine inertia during
labor {Am. J. Obst. Gyn., 1941, 41, 948); as an
adjunct to oxytocins in postpartum hemorrhage
{ibid., 1951, 61, 1087); chills in malaria {Puerto
Rico J. Pub. Health, 1944, 19, 602); muscular
pains and cramps after only moderate exertion
(/. M. A. Alabama, 1945, 14, 165); nocturnal
muscular cramps in the extremities {J. A.M. A.,
1944, 124, 471); the hypocalcemia associated
with acute pancreatitis {Am. J. Med., 1952, 12,
34) ; poisoning following the bite of a black widow
spider {GP, 1951, 4, 34); serum sickness {New
Eng. J. Med., 1936, 214, 148); urticaria, hay
fever, asthma, etc.; transfusion reactions; edema
in the nephrotic syndrome (see Calcium Chlo-
ride); edema of congestive heart failure {Lancet,
1940, 2, 545). Calcium gluconate has also been
employed to decrease capillary permeability in
allergic conditions (see Calcium Chloride), in
non-thrombopenic purpura {Clinics, 1944, 2,
1310), in other exudative dermatoses such as
dermatitis herpetiformis, and for the pruritus of
dermatitis medicamentosa. Graham {N. Y. State

J. Med., 1952, 52, 1667) used a 10 per cent
ointment of calcium gluconate, in a water-soluble
vehicle, in cases of chronic atopic dermatitis.
Pelouze reported symptomatic benefit in gonor-
rheal epididymitis, arthritis, iritis, etc. Calcium
gluconate is indicated for muscular pains and
weakness associated with ergotamine tartrate
therapy of migraine {Med. Clin. North America,

1938, 22, 689). Prior to our knowledge of the
relation of vitamin K to postoperative bleeding
in patients with obstructive jaundice, intrave-
nous calcium was the customary therapy. Fol-
lowing exchange transfusions in the newborn,
Furman et al. {J. Pediatr., 1951, 38, 45) found
electrocardiographic changes which were cor-
rected by intravenous calcium gluconate. Kramer
et al. {U. S. Armed Forces M. J., 1953, 4, 761)
reported cessation of bleeding following dental
extraction in a patient with atypical hemophilia
after administering calcium gluconate. Crump
and Heiskell {Texas State J. Med., 1952, 48,
11) confirmed the report of Ochsner and Kay of
lessened postoperative incidence of thromboem-
bolism if calcium gluconate and alpha-tocopherol
were used preoperatively and during convales-
cence. Intravenous calcium therapy has both
prophylactic and therapeutic value for poisoning
with carbon tetrachloride (/. Pharmacol., 1932,
45, 209) or chlorophenothane {Science, 1945,
101, 434), and for hepatitis or dermatitis from
use of arsenicals of the type of arsphenamine. It
has also been used in infectious hepatitis. Cal-
cium gluconate or other soluble calcium salt is
the oral antidote for fluoride or oxalic acid poi-
soning, [v]

Toxicology.— Lamm {J.A.M.A., 1945, 129,
347) reported 3 cases of abscess and sloughing
following intramuscular injection in young in-
fants, and referred to several previous reports of
this nature. In each instance doses of 10 ml. of
the 10 per cent solution had been used. A deposit
of calcium phosphate was identified in the slough
in one instance. Smaller doses, given by the in-
travenous route, are recommended for infants.
The Food and Drug Administration proposed
{Trade Correspondence, 7 -A, March 12, 1946)
that labels of calcium preparations intended for
parenteral use bear a warning that the article
should not be injected intramuscularly in infants
and young children. Calcium should not be given
parenterally to patients who are receiving digi-
talis because the effect of hypercalcemia on the
myocardium is similar to that of digitalis, and
fatalities due to ventricular fibrillation have re-
sulted {Lancet, 1940, 2, 452; Arch. Int. Med.,

1939, 64, 322; /. Pharmacol, 1945, 83, 96).
Wall {Am. Heart J., 1939, 18, 229) reported,
however, that use of calcium gluconate in 15
digitalized patients was without untoward effect;
in 2 cases no electrocardiographic changes were
observed during intravenous injection of 2.5 to
5 ml. of 20 per cent calcium gluconate solution.
He suggested that much larger concentrations of
calcium were involved in the reported cases of
toxicity.

Dose. — The usual dose is 5 Gm. (approxi-
mately 75 grains) 3 times daily, by mouth, with a
range of 1 to 10 Gm. The maximum safe dose is

222

Calcium Gluconate

Part I

generally 10 Gm., and the total dose in 24 hours
should seldom exceed 30 Gm. For children, 1 to 2
Gm. (approximately 15 to 30 grains) is given
three times a day. Intravenously the usual dose
is 1 Gm., generally given as a 10 per cent solu-
tion; for children the intravenous dose is 200
to 500 mg. daily or less often.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

CALCIUM GLUCONATE INJECTION.

U.S.P. (B.P., LP.)

[Injectio Calcii Gluconatis]

"Calcium Gluconate Injection is a sterile solu-
tion of calcium gluconate in water for injection.
It contains not less than 92 per cent and not more
than 102 per cent of the labeled amount of
Ci2H22CaOi4. Calcium D-saccharate, or other
harmless suitable calcium salts, may be added to
Calcium Gluconate Injection as stabilizers. The
amount of added palcium salts, calculated as cal-
cium (Ca), does not exceed 5 per cent of the
calcium (Ca) present as calcium gluconate. To
insure greater stability of the Injection, sufficient
sodium hydroxide may be added to produce a pH
not above 8.2." U.S.P.

B.P., I. P. Injection of Calcium Gluconate. Sp. Inyec-
ci6n de Gluconato de Calcio.

The B.P. requires not less than 0.85 per cent
and not more than 0.94 per cent of Ca in the
injection, of which not less than 95 per cent is
present as calcium gluconate; the remainder is
calcium D-saccharate or other suitable harmless
calcium salt. The solution is directed to be steri-
lized by heating in an autoclave (maintaining
the temperature at 115° to 116° for 30 minutes).
The LP. permits 2.5 to 5.0 per cent of the total
calcium to be present as the saccharate.

Storage. — Preserve "in single-dose contain-
ers, preferably of Type I glass." U.S.P.

Usual Size. — 10 ml. containing 1 Gm. (ap-
proximately 15 grains).

CALCIUM GLUCONATE TABLETS.

U.S.P. (LP.)

[Tabellae Calcii Gluconatis]

"Calcium Gluconate Tablets contain not less
than 92 per cent and not more than 102 per cent
of the labeled amount of Ci2H22CaOi4." U.S.P.
The LP. requires not less than 95 per cent and
not more than 105 per cent of (CeHiiCh^CaLLO.

LP. Tablets of Calcium Gluconate; Compressi Calcii
Gluconatis.

Usual Sizes. — 0.5 and 1 Gm. (approximately
7 J/2 and 15 grains).

CALCIUM GLYCEROPHOSPHATE.

N.F.

[Calcii Glycerophosphas]

_ "Calcium Glycerophosphate is the normal cal-
cium salt of glycerophosphoric acid and, when
dried at 150° for 4 hours, contains not less
than 98 per cent of C3H7CaP06." N.F.

Calcium Glycerinophosphate ; Glycerophosphate of Lime;

Calcium Phosphoglycerate. Calcium Glycerinophosphoricum
Fr. Glycerophosphate de calcium officinal ; Glycerophos-
phate de calcium; Glycerophosphate de chaux. Ger. Glyzerin-
phosphorsaures Kalzium; Kalziumglyzerophosphat. It.
Glicerofosfato di calcio. Sp. Glicerofosfato de calcio.

Calcium glycerophosphate may be prepared by
neutralization of glycerophosphoric acid with
calcium hydroxide; the acid is obtained by the
interaction of glycerin and phosphoric acid and
represents glycerin in which one of its hydroxy]
groups is esterified with phosphoric acid. Since
two isomers of glycerophosphoric acid exist, i.e.,
the a-form in which the end hydroxyl of glycerin
is esterified and the 3-form in which the middle
hydroxyl is esterified, there are also two calcium
salts, the calcium a-glycerophosphate and the
calcium ^-glycerophosphate. The commercial ar-
ticle appears to be a variable mixture of the two
salts, according to Toal and Phillips (/. Pharm.
Pharmacol., 1949, 1, 869); these investigators
describe a method for preparing the individual
isomers.

Description. — "Calcium Glycerophosphate
occurs as a fine, white, odorless, almost tasteless
powder. It is somewhat hygroscopic. One Gm. of
Calcium Glycerophosphate dissolves in about
50 ml. of water. It is more soluble in water at a
lower temperature, and citric acid increases its
solubility in water. It is insoluble in alcohol."
N.F.

Standards and Tests. — Identification. — (1)
A saturated aqueous solution of calcium glycero-
phosphate responds to tests for calcium and for
glycerophosphate. (2) White, iridescent scales of
anhydrous calcium glycerophosphate form when
a cold, saturated aqueous solution of calcium
glycerophosphate is boiled. (3) Calcium glycero-
phosphate decomposes when heated above 170°
and evolves flammable vapors; at a red heat it
is converted into calcium pyrophosphate. (4) A
white, curdy precipitate, soluble in nitric acid,
is produced when lead acetate T.S. is added to a
saturated aqueous solution of calcium glycero-
phosphate. Alkalinity. — Not more than 1.5 ml.
of 0.1 N sulfuric acid is required to neutralize a
solution of 1 Gm. of calcium glycerophosphate
in 60 ml. of distilled water, using phenolphtha-
lein T.S. as indicator. Loss on drying. — Not over
12 per cent, when dried at 150° for 4 hours.
Alcohol-soluble substances. — Not over 10 mg. of
residue is obtained when 1 Gm. of calcium glycer-
ophosphate is shaken with 25 ml. of dehy-
drated alcohol, the mixture filtered, and the
filtrate evaporated to dryness and the residue
dried at 60° for 1 hour. Chloride. — The limit is
700 parts per million. Phosphate. — The turbidity
produced by ammonium molybdate T.S. with
10 ml. of a 1 in 10 diluted nitric acid solution of
calcium glycerophosphate is not greater than that
produced by 0.576 mg. of potassium biphosphate
when tested similarly. Sulfate. — The limit is 0.5
per cent. Arsenic. — Calcium glycerophosphate
meets the requirements of the test for arsenic.
Heavy metals. — The limit is 40 parts per million.
N.F.

Assay. — A sample of about 400 mg. of cal-
cium glycerophosphate, previously dried at 150°
for 4 hours, is dissolved in water with the aid
of hydrochloric acid and the calcium precipi-

Part I

Calcium Hydroxide Solution 223

tated as the oxalate by addition of ammonium
oxalate and ammonia T.S. The calcium oxalate
is collected, washed with hot water, and dried
at 105° for 2 hours. Each Gm. of CaC204.H20
represents 1.436 Gm. of C3H7CaP06. N.F.

Incompatibilities. — The limited solubility of
this compound in water is usually the cause of
compounding difficulties; either citric or lactic
acid may be used to increase its solubility or the
chemical may be suspended by suitable means.

Uses. — Calcium glycerophosphate provides not
only calcium ion which is, of course, therapeuti-
cally useful but also glycerophosphate, which
was formerly considered to have therapeutic
utility by virtue of its being a component of
certain body phosphatides, notably of the nervous
system (see Sodium Glycerophosphate, Part I,
and Glycerophosphoric Acid, Part II). While the
glycerophosphate as such probably has no special
value as a medicinal agent, it does provide, by
hydrolysis, more or less phosphate ion which
may be utilized by the body. To a degree then,
calcium glycerophosphate is a water-soluble
source of calcium and phosphate. Though not
employed as extensively as it once was, calcium
glycerophosphate still is used in conditions where
calcium is indicated; formerly it was prescribed
also for a supposed nutrient effect on the central
nervous system. H

Dose, 0.3 to 1.2 Gm. (approximately 5 to 20
grains).

Storage. — Preserve "in tight containers."
N.F.

Off. Prep. — Compound Glycerophosphates
Elixir, N.F.

CALCIUM HYDROXIDE. U.S.P., B.P.

Slaked Lime, [Calcii Hydroxidum]

"Calcium Hydroxide contains not less than 95
per cent of Ca(OH)2." U.S. P. The B.P. requires
not less than 90.0 per cent of Ca(OH)2.

Calcium Hydrate; Hydrate of Lime. Calcis Hydras;
Calcium Oxydatum Hydricum. Fr. Hydroxyde de calcium;
Chaux hydratee; Chaux delitee; Chaux eteinte. Ger. Kal-
ziumhydroxyd; Kalkhydrat. Sp. Hidrato de Calcio.

Calcium hydroxide is obtained by the action
of water on calcium oxide, the two substances
interacting in equimolecular proportion.

Description. — "Calcium Hydroxide occurs as
a white powder. It has an alkaline, slightly bitter
taste. One Gm. of Calcium Hydroxide dissolves
in 630 ml. of water, and in 1300 ml. of boiling
water. It is soluble in glycerin and in syrup, but
is insoluble in alcohol." U.S.P.

Tests and Standards. — Identification. — (1)
A smooth magma forms when calcium hydroxide
is mixed with 3 to 4 times its weight of water;
the clear, supernatant liquid from the magma is
distinctly alkaline to litmus paper. (2) A solu-
tion of 1 Gm. of calcium hydroxide in 20 ml.
of water with sufficient acetic acid to effect solu-
tion responds to tests for calcium. Acid-insoluble
substances. — Not over 10 mg. from 2 Gm. of
calcium hydroxide. Carbonate. — Not more than
a slight effervescence occurs on adding an excess
of diluted hydrochloric acid to a mixture of 2 Gm.
of calcium hydroxide and 50 ml. of water. Arsenic.

— The limit is 5 parts per million. Heavy metals.
— The limit is 40 parts per million. Magnesium. —
When 500 mg. of calcium hydroxide is dissolved
with the aid of hydrochloric acid and treated as
described under the corresponding test for calcium
bromide, not more than 12 mg. of residue is
obtained. U.S.P.

The B.P. includes limit tests for chlorides and
sulfates; the arsenic limit is 4 parts per million,
the lead limit 20 parts per million.

Assay. — A dilute hydrochloric acid solution
representing about 150 mg. of calcium hydroxide
is analyzed according to the reactions summarized
under the assay for calcium bromide. Each ml. of
0.1 iV potassium permanganate represents 3.705
mg. of Ca(OH)2. U.S.P.

The B.P. assay is based on solubilization of the
Ca(OH)2 by a solution of sucrose, in which
calcium carbonate is insoluble, followed by fil-
tration, and titration of an aliquot portion of
the filtrate with 1 N hydrochloric acid.

Uses. — Calcium hydroxide is rarely, if ever,
used as a medicinal agent. It was introduced into
the Pharmacopeia for the purpose of making the
solution, popular under the name of "lime water."
Formerly this solution was made from calcium
oxide, which had to be first hydrated, or slaked,
and the resultant hydroxide dissolved. At present,
however, a relatively pure form of calcium hy-
droxide is commercially available and may be
more conveniently used for the preparation of
this solution.

The lime soaps formed by reaction of calcium
hydroxide and fixed oils have adhesive properties
which sometimes make them of value as ointment
bases and in certain dermatologic lotions (see
Lime Liniment, under Linseed Oil), [v]

Storage. — Preserve "in tight containers."
U.S.P.

CALCIUM HYDROXIDE SOLUTION.
U.S.P. (B.P.)

Lime Water, Liquor Calcis, Liquor Calcii Hydroxidi

"Calcium Hydroxide Solution is a solution
containing, in each 100 ml., at 25°, not less than
140 mg. of Ca(OH)2. The content of calcium
hydroxide varies with the temperature at which
the solution is stored, being about 170 mg. per
100 ml. at 15°, and less at a higher temperature."
U.S.P. The B.P. Solution of Calcium Hydroxide
is required to contain not less than 0.15 per cent
w/v of Ca(OH)2.

B.P. Solution of Calcium Hydroxide. Solution of Lime.
Aqua Calcariae; Solutio Hydroxydi Calcii. Fr. Eau de
chaux; Solute de chaux; Solute d'hydroxyde de calcium.
Ger. Kalkwasser. It. Acqua di calce. Sp. Solucion de
hidroxido de calcio; Aqua de cal; Solucion de Hidrato de
Calcio.

Calcium hydroxide solution may be prepared
by adding 3 Gm. of calcium hydroxide to 1000 ml.
of cool purified water, and agitating the mixture
vigorously and repeatedly during 1 hour. The
excess of calcium hydroxide is allowed to settle,
and only the clear, supernatant liquid is dispensed.
The undissolved portion is not suitable for pre-
paring more calcium hydroxide solution. U.S.P.

The B.P. prepares Solution of Calcium Hydrox-
ide in a similar manner, but using more than

224 Calcium Hydroxide Solution

Part I

three times as much calcium hydroxide as is used
in the U.S.P. This, however, appears to be of
no advantage as water will not dissolve any
more calcium hydroxide in the process and there
is sufficient excess in the U.S.P. formula to
replace any amount which may be precipitated by
carbon dioxide of the air.

The U.S.P. specifies use of cold water in
preparing the solution for the reason that cal-
cium hydroxide is more soluble in cold, than in
hot, water.

The practice of using the undissolved lime
indefinitely, by refilling the bottle with water,
is objectionable, for notwithstanding the apparent
excess of calcium hydroxide it is rapidly con-
verted to carbonate and the resulting lime water
is generally deficient in strength; the U.S.P. for-
bids using the undissolved residue for making a
new quantity of solution. Lime water requires
some time to attain saturation and thus it cannot
be prepared instantly, as is sometimes attempted.
Exposed to air, k absorbs carbon dioxide, and
becomes covered with a pellicle of insoluble cal-
cium carbonate which, subsiding after a time, is
replaced by another, and so on successively until
all the lime is precipitated.

Description. — "Calcium Hydroxide Solution
is a clear, colorless liquid with an alkaline taste.
It is alkaline to litmus." U.S.P.

Standards and Tests. — Identification. — (1)
Calcium hydroxide solution absorbs carbon diox-
ide from the air, forming a film of calcium car-
bonate on the surface of the liquid. (2) On
heating, calcium hydroxide separates and pro-
duces a turbidity. (3 ) Calcium hydroxide solution
responds to tests for calcium. Alkalies and their
carbonates. — On saturating calcium hydroxide
solution with carbon dioxide and then boiling it,
the calcium is precipitated as carbonate and the
liquid is no longer alkaline. U.S.P. The B.P. pro-
vides arsenic and lead limits of 0.2 and 0.5 part
per million, respectively.

Assay. — A 50-ml. portion of the solution,
measured at 25°, is titrated with 0.1 AT hydro-
chloric acid, using phenolphthalein T.S. as indi-
cator. Each ml. of 0.1 N hydrochloric acid repre-
sents 3.705 mg. of Ca(OH)2. U.S.P.

Uses. — Theoretically, lime water should be a
valuable antacid in the treatment of hyperacidity
of the stomach or of the intestines. It has the
advantages of being relatively non-irritating and
of not liberating carbon dioxide. The amount of
calcium hydroxide present, however, is so small
that practically it is of relatively small service;
one tablespoonful of lime water is equivalent in
neutralizing power to about one grain of sodium
bicarbonate. Some believe, however, that it has
an effect in quieting nausea, beyond that which
can be attributed to its antacid action, and it is
not infrequently ordered in digestive disturbances
of infants. It is also used in infants' feeding for-
mulas to decrease the size of the curds formed
from cow's milk. Externally it is frequently em-
ployed in dermatologic formulations, as in the
official calamine lotion. @

Dose, 30 to 120 ml. (approximately 1 to 4
fluid ounces).

Storage. — Preserve "in well-filled, tight con-
tainers." U.S.P.

CALCIUM HYPOPHOSPHITE. N.F.

[Calcii Hypophosphis]

"Calcium Hypophosphite, when dried at 105°
for 1 hour, contains not less than 98 per cent of
Ca(H2P02>2. Caution should be observed in
compounding Calcium Hypophosphite with other
substances, as an explosion may occur if it is
triturated or heated with nitrates, chlorates, or
other oxidizing agents." N.F.

Hypophosphite of Lime. Calcium Hypophospborosum;
Calcaria Hypophosphorosa. Fr. Hypophosphite de calcium;
Hypophosphite de chaux. Ger. Kalzium-hypophosphit ;
Unterphosphorigsaure Kalkerde; L'nterphosphongsaures Cal-
cium. It. Ipofosfito di calcio. Sp. Hipofosfito de calcio.

Calcium hypophosphite may be prepared from
a mixture of finely divided phosphorus and slaked
lime. These materials are mixed with sufficient
water to make a thin suspension, placed under a
hood, and heated to about 50°. The mixture is
kept at this temperature until hydrogen phosphide
is no longer evolved, showing that the reaction
is complete. Calcium hypophosphite is formed
according to the following reaction:

3Ca(OH)2+2P4+6H20-+3Ca(H2P02)2+2PH3

The reaction mixture is now filtered and any
dissolved calcium hydroxide removed from the
filtrate by passing in carbon dioxide and filtering
out the precipitate of calcium carbonate. Calcium
hypophosphite may be obtained from this filtrate
either by concentration and crystallization or by
precipitation with alcohol.

Description. — "Calcium Hypophosphite oc-
curs as colorless, transparent, monoclinic prisms,
as small, lustrous scales, or as a white, crystalline
powder. It is odorless, and has a nauseous, bitter
taste. One Gm. of Calcium Hypophosphite dis-
solves slowly in about 6.5 ml. of water. It is
insoluble in alcohol." N.F.

Standards and Tests. — Identification. — A 1
in 20 solution of calcium hypophosphite responds
to tests for calcium and for hypophosphite.
Acidity. — Not more than 1 ml. of 0.1 N sodium
hydroxide is required to neutralize a solution of
1 Gm. of calcium hypophosphite in 20 ml. of dis-
tilled water, using phenolphthalein T.S. as indi-
cator. Loss on drying. — Not over 3 per cent,
when dried at 105° for 1 hour. Water-insoluble
substances. — Not over 5 mg. from 1 Gm. of cal-
cium hypophosphite dissolved in 20 ml. of water.
Phosphorus compounds. — No offensive odor de-
velops when 5 ml. of a 1 in 10 solution of cal-
cium hypophosphite is heated on a water bath
for 30 minutes with 0.5 ml. of diluted hydro-
chloric acid. Arsenic. — A 5-ml. portion of a
1 in 25 solution of calcium hypophosphite, after
special preliminary treatment, meets the require-
ments of the test for arsenic. Heavy metals. —
The limit is 20 parts per million. N.F.

Assay. — A one-half aliquot of a sample of
about 120 mg. of calcium hypophosphite, previ-
ously dried at 105° for one hour, is treated with
an excess of 0.1 N bromine in acid solution to

Part I

Calcium lodobehenate

225

oxidize the hypophosphite ion to phosphate. The
excess of bromine is estimated by liberation of
an equivalent amount of iodine, which is titrated
with 0.1 N sodium thiosulfate. Each ml. of 0.1 N
sodium thiosulfate represents 2.126 mg. of
Ca(H2P02)2, this equivalent being based on the
reaction of 4 molecules of bromine with each
molecule of calcium hypophosphite. N.F.

Incompatibilities. — Besides having the in-
compatibilities of calcium salts, calcium hypo-
phosphite possesses the pronounced reducing ac-
tivity of hypophosphites, which sometimes may
be so vigorous as to result in an explosion (see
caution notice in the official definition).

Uses. — Calcium hypophosphite was at one time
largely used in tuberculosis, neurasthenia, and
other conditions of impaired nutrition. The hy-
pophosphite ion (see Hypophosphorous Acid) is
probably therapeutically inert.

The usual dose is 500 mg. (approximately 8
grains), three times a day.

Storage. — Preserve "in well-closed containers."
N.F.

Off. Prep. — Compound Hypophosphites
Syrup, N.F.

CALCIUM IODOBEHENATE. N.F.

Calcium Monoiodobehenate, [Calcii Iodobehenas]

"Calcium lodobehenate consists principally of
calcium monoiodobehenate [(C2iH42lCOO)2Ca]
and contains, calculated on the anhydrous basis,
not less than 23.5 per cent of I." N.F.

Sajodia (Winthrop); Calioben. Sp. Yodobehenato de
Calcio.

Behenic acid, CH3(CH2)2oCOOH, is a satu-
rated acid occurring in the glycerides of oil of
ben but this source is not employed for the
preparation of calcium iodobehenate. Instead,
erucic acid, CH3(CH2)7CH=CH(CH2)iiCOOH,
an acid characteristic of glycerides of the fixed
oils from certain seeds, notably the mustards, is
used as the starting compound. When erucic
acid, which differs from behenic in containing a
double bond, is treated with hydriodic acid a
molecule of the latter is added at the double
bond, saturating it and forming monoiodobehenic
acid. The calcium salt of the latter is the official
calcium iodobehenate ; it was introduced in medi-
cine under the trade name sajodin.

Description. — "Calcium Iodobehenate occurs
as a white or yellowish powder, which is unctuous
to the touch. It is odorless or has a slight odor
suggestive of fat. It is affected by light. A mixture
obtained by triturating 1 Gm. of Calcium Iodo-
behenate with 10 ml. of water is neutral to litmus
paper. Calcium Iodobehenate is insoluble in water,
very slightly soluble in alcohol and in ether, and
freely soluble in warm chloroform." N.F.

Standards and Tests. — Identification. — Cal-
cium iodobehenate decomposes on strong heating,
emitting violet vapors of iodine and white vapors
having the odor of burning fat. A solution of
the ash in diluted hydrochloric acid, boiled to
expel carbon dioxide and neutralized with am-
monia T.S., responds to tests for calcium. Loss
on drying. — Not over 2 per cent, when dried at

105° for 1 hour. Water-soluble substances. — A
mixture of 1 Gm. of calcium iodobehenate with
25 ml. of water is filtered and 10 ml. of filtrate
evaporated to dryness and dried at 105° for
1 hour: the residue weighs not more than 1 mg.
Carbonate. — Addition of diluted hydrochloric acid
to calcium iodobehenate produces no efferves-
cence. Chloride. — The limit is 350 parts per mil-
lion. Sulfate. — The limit is 500 parts per million.
Inorganic salts. — 1 Gm. of calcium iodobehenate
dissolves in 10 ml. of warm chloroform with not
more than an opalescence. Magnesium and alkali
salts. — 1 Gm. of calcium iodobehenate is heated
with a dilute hydrochloric acid solution and
the lower aqueous layer is separated from the
fatty acid that is formed; the calcium in the
aqueous solution is precipitated as calcium ox-
alate, the latter filtered off, and the filtrate evap-
orated to dryness and the residue ignited: the
residue should not weigh more than 3 mg. N.F.

Assay. — A sample of about 500 mg. of calcium
iodobehenate is heated with anhydrous potassium
carbonate whereby the iodine is converted to
iodide. The latter is extracted with boiling water,
acidified with nitric acid, and potassium perman-
ganate solution added to form just enough iodine
to produce a blue color with starch T.S. The
iodide is now titrated with 0.1 N silver nitrate,
the end point being the discharge of the blue
color due to depletion of iodide ions essential to
the starch-iodide color reaction. Each ml. of 0.1 N
silver nitrate represents 12.69 mg. of iodine.
U.S.P.

Uses. — The action of calcium iodobehenate
depends on the liberation of iodine and therefore
resembles the alkali iodides in its general action.
Being practically insoluble in the gastric juice, it
is not irritating to the stomach. Its absorption is
slower and less complete than that of the inor-
ganic iodides; Broking (Ztschr. exp. Path. Ther.,
1905, 2, 416) found that after oral administration,
iodine did not appear in the saliva or urine for at
least one hour and that 84 hours were required
for the complete elimination of a single dose. He
further showed that from 7 to 10 per cent of
the drug could be recovered unchanged from the
feces. Evidently the iodine is not liberated from
the compound in the intestinal tract. McLean
(Arch. Int. Med., November, 1912, and January,
1915) observed that after the administration of
potassium iodide, from 30 to 32 per cent of the
iodine is retained in the lipoid portion of internal
organs and from 67 to 70 per cent as a water-
soluble compound, while with an iodized fatty
acid from 50 to 75 per cent of the iodine is in
the tissues in lipoid-soluble form. Because of its
slower absorption, iodism is much less likely to
occur after calcium iodobehenate than after the
iodides. It would appear that it is absorbed either
from the alimentary tract or from the subcuta-
neous tisues in a materially unchanged form —
perhaps in fatty solution — and deposited in the
adipose and lipoid tissues where it is slowly de-
composed, liberting ionic iodine. Whether or not
the organic molecule — in which form the drug
circulates in the blood — has any effect upon the
body functions has not been determined; the

226

Calcium lodobehenate

Part I

compound is used purely for its iodine action.
Where a long-continued mild effect of iodine is
desired, calcium iodobehenate is preferred over
inorganic iodides, not merely because of the com-
parative freedom from gastric disturbances and
the lesser likelihood of producing iodism, but also
because the amount of iodine in the blood is
much more constant. On the other hand, where a
rapid profound effect is required, the inorganic
salts are superior. Calcium iodobehenate has been
recommended in the treatment of goitre, syphilis,
actinomycosis, chronic bronchitis, asthma, arte-
riosclerosis, chronic arthritis and other chronic
conditions in which iodides have been used.

Dose, 500 mg. (approximately lYz grains),
three to six times daily.

Storage. — Preserve "in well-closed, light-re-
sistant containers." N.F.

CALCIUM LACTATE. N.F., B.P., LP.

[Calcii Lactas]

(CH3.CHOH.COO)2Ca.5H20

"Calcium Lactate, dried at 120° for 4 hours,
contains not less than 98 per cent of C6HioCa06."
The B.P. specifies that it contain not less than
97.0 per cent and not more than the equivalent
of 103.0 per cent of the crystallized salt,
CeHioOeCa.SHoO. The LP. reauires not less than
98.0 per cent of (CsHsOs^Ca.SLL-O.

Calcium Lacticum; Lactas Calcicus. Fr. Lactate de
calcium. Ger. Kalziumlaktat ; Milchsaures Kalk. It.
Lattato di calcio. Sp. Lactato de calcio.

Calcium lactate may be prepared, according to
the B.P., by neutralizing diluted lactic acid with
calcium carbonate and evaporating the resulting
solution. Besides this process calcium lactate may
also be obtained directly from lactic acid fermen-
tation of suitable carbohydrate materials (see
under Lactic Acid).

Description. — "Calcium Lactate occurs as
white, almost odorless, granules or powder. It is
somewhat efflorescent and at 120° becomes an-
hydrous. One Gm. of Calcium Lactate dissolves
in 20 ml. of water. It is practically insoluble in
alcohol." N.F.

Standards and Tests. — Identification. — A 1
in 20 solution of calcium lactate responds to tests
for calcium and for lactate. Loss on drying. —
Not less than 25 per cent and not over 30 per
cent, when dried at 120° for 4 hours. Acidity. —
Not over 0.5 ml. of 0.1 N sodium hydroxide is
required to neutralize a solution of 1 Gm. of
calcium lactate in 20 ml. of water, using phenol-
phthalein T.S. as indicator. Heavy metals. — The
limit is 20 parts per million. Magnesium and
alkali salts. — When 1 Gm. of calcium lactate is
treated as described under the corresponding test
for calcium bromide, not more than 5 mg. of
residue is obtained. Volatile fatty acid. — No odor
of volatile fatty acid is emitted on warming a
mixture of 500 mg. of calcium lactate and 1 ml
of sulfuric acid. N.F.

The B.P. additionally provides limit tests for
reducing sugars, sulfate, chloride and iron. The
arsenic limit is 2 parts per million, the lead limit
is 10 parts per million.

Assay. — About 500 mg. of calcium lactate,

previously dried at 120° for 4 hours, is dissolved
in water acidified with hydrochloric acid and
analyzed according to the reactions summarized
under the assay for calcium bromide. Each ml. of
0.1 N potassium permanganate represents 10.91
mg. of CeHioCaOc. N.F.

Uses. — Calcium lactate is an eminently satis-
factory dosage form for obtaining the therapeutic
effects of calcium. It is less likely to disturb the
stomach than is the chloride. Administration of
calcium lactate solutions by stomach tube to
newborn infants is reported to be a safe procedure
(Yale J. Biol. Med., 1946, 18, 135;, whereas
similar uses of calcium chloride solutions caused
ulceration and necrosis of the stomach. It is used
in the treatment of conditions in which calcium
is indicated (see Calcium, Calcium Chloride and
Calcium Gluconate). In tetany Luckhardt and
Goldberg (J.A.M.A., 1923, 80, 79) obtained re-
sults from the lactate which they could not from
other calcium salts. It should be noted that the
official calcium lactate contains less than one-half
the amount of calcium present in an equal weight
of the chloride. Capsules of 650 mg., taken one
to three times daily, of a mixture of approxi-
mately equal parts of calcium lactate and potas-
sium chloride (/. Lab. Clin. Med., 1944, 29, 709)
have been effective in the treatment of migraine.
It has been used, along with nicotinic acid
(/. Allergy, 1944, 15, 141), for urticaria. Ware
(/. M. Assn. Georgia, 1946, 35, 27) treated a
patient with lichen planus refractory to x-ray
and vitamin A and D therapy with about 6 Gm.
(approximately 90 grains) of calcium lactate
daily; improvement was observed in a week and
the eruption disappeared in 30 days. Salvesen
(Acta med. Scandinav. Suppl., 1951, No. 259, 75 )
gave 1 5 Gm. daily, orally, to uremic patients with
advanced renal disease with a marked decrease in
the concentration of blood urea and an increase
in carbon dioxide-combining power. IS

Dose. — The N.F. gives the usual dose as 5 Gm.
(approximately 75 grains); the B.P. gives a range
of 1 to 4 Gm. See above for daily dosages.

Storage. — Preserve "in tight containers." N.F.

CALCIUM LACTATE TABLETS

N.F. (B.P, LP.)

[Tabellae Calcii Lactatis]

"Calcium Lactate Tablets contain not less than
94 per cent and not more than 106 per cent
of the labeled amount of C6HioCa06.5H20."
N.F. The corresponding B.P. limits are 92.0 and
108.0 per cent, while those of the LP. are 94.0
and 106.0 per cent.

B.P., LP. Tablets of Calcium Lactate. LP. Compressi
Calcii Lactatis.

Usual Sizes. — 5 and 10 grains (approximately
300 and 600 mg.).

CALCIUM LEVULINATE. N.F.

[Calcii Levulinas]

[CH3.CO.(CH2)2.COO]2.Ca.2H20

"Calcium Levulinate is a hydrated calcium salt
of levulinic acid and contains not less than 97.5
per cent and not more than 100.5 per cent of

Part

Calcium Mandelate

227

CioHiiCaOe calculated on a dry basis, the loss on
drying being determined on a separate portion by
drying in a vacuum oven at a pressure not ex-
ceeding 5 mm. and a temperature of 60° for
5 hours." N.F.

Levulinic acid, also known as y- or 4-keto-
pentanoic acid, Y- or 4-ketovaleric acid, and aceto-
propionic acid, may be prepared by boiling
sucrose, starch, glucose or other hexose derivatives
with hydrochloric acid. The black solid material
obtained in the process is removed by filtration,
the filtrate is evaporated to dryness, and the
residue extracted with ether or other solvent.
After distilling off the ether the residue is dis-
tilled under vacuum; the fraction boiling between
137° and 139° at 10 mm. pressure is levulinic
acid. The acid may also be prepared by a synthe-
sis utilizing acetoacetic ester and chloroethylace-
tate. The official calcium salt may be prepared
by neutralizing this acid with calcium carbonate
or calcium hydroxide.

Description. — "Calcium Levulinate occurs as
a white, crystalline or amorphous powder, having
a faint odor suggesting burnt sugar and a bitter,
salty taste. Calcium Levulinate is freely soluble
in water, and slightly soluble in alcohol. It is
insoluble in ether and in chloroform. Calcium
Levulinate melts between 119° and 125°, when
the bath is preheated to 100° before introducing
the sample." N.F.

Standards and Tests.— pH.— The pH of a
1 in 10 aqueous solution of calcium levulinate is
between 7.0 and 8.5. Identification. — (1) A 1 in
10 aqueous solution responds to tests for calcium.
(2) To 5 ml. of a 1 in 10 aqueous solution is
added 5 ml. of sodium hydroxide T.S. and the
mixture filtered. The filtrate yields a precipitate
of iodoform on adding 5 ml. of iodine T.S. (3)
The hydrazone which crystallizes when a solution
of 100 mg. of the levulinate in 2 ml. of distilled
water is mixed with 5 ml. of dinitrophenylhydra-
zine T.S. and allowed to stand in an ice bath for

1 hour, then filtered and washed with cold dis-
tilled water, melts between 198° and 206°. Loss
on drying.— Not less than 10.5 per cent and not
more than 12 per cent when dried as specified in
the rubric. Water-insoluble substances. — Not over
5 mg. from 5 Gm. of calcium levulinate. Chloride.
—The limit is 700 parts per million. Sulfate.—
The limit is 500 parts per million. Arsenic— A
solution representing 500 mg. of calcium levuli-
nate meets the requirements of the test for
arsenic. Henvy metals.— -The limit is 20 parts per
million. Readily oxidizable substances. — The pink
color of a mixture of 5 ml. of a 1 in 10 aqueous
solution of calcium levulinate and 1 ml. of 0.1 N
potassium permanganate does not disappear in

2 minutes. Limit of color. — The color of a 1 in
10 aqueous solution of calcium levulinate is not
deeper than that of a solution prepared by mix-
ing 2.5 ml. of ferric chloride C.S. and 0.1 ml. of
cobaltous chloride C.S. with enough distilled water
to make 100 ml. Reducing sugars.— A solution
of 500 mg. of calcium levulinate in 10 ml. of
distilled water and 2 ml. of diluted hydrochloric
acid is boiled 2 minutes, cooled, 5 ml. of 2 N
sodium carbonate added and the mixture allowed
to stand 5 minutes, diluted to 20 ml. with distilled

water and filtered: No red precipitate forms on
adding 2 ml. of alkaline cupric tartrate T.S. to
5 ml. of the filtrate. N.F.

Assay. — A 100-ml. portion of a solution of
3 Gm. of calcium levulinate in 10 ml. of hydro-
chloric acid and sufficient distilled water to make
500 ml. of solution is analyzed in the same man-
ner as calcium bromide. Each ml. of 0.1 N potas-
sium permanganate represents 13.51 mg. of
CioHi4Ca06. N.F.

Uses. — Calcium levulinate is used to obtain
the therapeutic effects of calcium. It has the
advantage over calcium gluconate of being con-
siderably more soluble in water; solutions con-
taining 50 per cent w/v of the salt may be
prepared, though the usual concentration is 10
per cent w/v. A further advantage over calcium
gluconate is that the levulinate contains approxi-
mately 13 per cent of calcium, as compared with
approximately 9 per cent in the gluconate. Cal-
cium levulinate may be administered orally, intra-
venously, intramuscularly, or subcutaneously; it
is practically nonirritant even when given by the
latter two methods.

The dose, by injection, is 1 Gm. (approximately
15 grains) every day or two for adults, and from
0.2 to 0.5 Gm. (approximately 3 to 7j/2 grains)
for children; orally, the dose is 4 to 5 Gm. (ap-
proximately 60 to 75 grains) three times daily
for adults, and 1 to 2 Gm. (approximately 15 to
30 grains) three times daily for children.

Storage. — Preserve "in tight containers." N.F.

CALCIUM LEVULINATE INJECTION
N.F.

Calcium Levulinate Ampuls, [Injectio Calcii Levulinatis]

"Calcium Levulinate Injection is a sterile solu-
tion of calcium levulinate in water for injection,
and yields not less than 95 per cent and not more
than 105 per cent of the labeled amount of
CioHuCa06.2H20." N.F.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." N.F.

Usual Size. — 10 ml. containing 1 Gm. (ap-
proximately 15 grains).

CALCIUM MANDELATE.

[Calcii Mandelas]

U.S.P.

CHCOO"

"Calcium Mandelate, dried at 105°, for 4 hours,
contains not less than 98.5 per cent of CieHu-
CaOe." U.S.P.

Sp. Mandelato de Calcic

Calcium mandelate may be prepared by neu-
tralizing a hot aqueous solution of mandelic acid
with a suspension of calcium carbonate, the re-
sulting precipitate being separated by filtration
and washed to remove the slight excess of man-
delic acid employed. The salt may also be pre-
pared by the reaction of soluble salts of mandelic
acid and of calcium.

Description. — "Calcium Mandelate occurs as

228

Calcium Mandelate

Part I

a white, odorless powder. Calcium Mandelate is
slightly soluble in cold water and insoluble in
alcohol. One Gm. dissolves in about 80 ml. of
boiling water." i .S.P.

Standards and Tests. — Identification. — (1)
Mandelic acid obtained from the salt melts be-
tween 118° and 120°. (2) The odor of benzalde-
hyde is noticeable on adding 3 ml. of potassium
dichromate T.S. and 5 ml. of sulfuric acid to a
solution of 100 mg. of the mandelic acid obtained
in the preceding test in 2 ml. of water. (3) Cal-
cium mandelate responds to tests for calcium.
Loss on drying. — Not over 1 per cent, when dried
at 105° for 4 hours. Completeness and color of
solution. — A solution of 1 Gm. of calcium mande-
late in 100 ml. of boiling water is complete and
colorless. Acidity. — Not more than 0.5 ml. of 0.1
N sodium hydroxide is required to neutralize a
solution of 1 Gm. of calcium mandelate in 100
ml. of boiling water, using phenolphthalein T.S. as
indicator. Chloride. — The limit is 200 parts per
million. Sulfate. — 'The limit is 500 parts per mil-
lion. Heavy metals. — The limit is 20 parts per
million. Magnesium and alkali salts. — When 1
Gm. of calcium mandelate is treated as described
under the corresponding test for calcium bromide,
not more than 10 mg. of residue is obtained.
U.S.P.

Assay. — About 500 mg. of calcium mandelate,
previously dried for 4 hours at 105°, is dissolved
in water acidified with hydrochloric acid and
analyzed according to the reactions summarized
under the assay for calcium bromide. Each ml.
of 0.1. V potassium permanganate represents
17.12 mg. of CieHuCaOe. U.S.P.

Uses. — Calcium mandelate is a urinary anti-
septic with certain advantages over mandelic acid
or ammonium mandelate. In an acid urine
(pH S.5 or less) it is bacteriostatic or bacteri-
cidal against E. coli, A. aerogenes and 5. faecalis;
it is effective against some strains of Proteus,
Pseudomonas, Alcaligenes, Salmonella and Shi-
gella (Burns. South. M. J., 1944. 37, 320V It
has the advantage over mandelic acid in that it is
much less irritant to the stomach; over sodium
mandelate that, inasmuch as calcium is poorly
absorbed from the alimentary tract, it does not
interfere with acidulation of urine, which is so
essential for the action of mandelic acid; over
the ammonium salt it has the advantage of being
comparatively tasteless. Tablets may be less ef-
fective than syrup or elixir of mandelic acid or
its ammonium salt because of poor absorption.
Fluid intake should not exceed 1200 ml. daily;
12 to 14 days of treatment is sufficient since
other measures are needed if cure is not effected
in this period of time. It is contraindicated in
the presence of renal insufficiency. Nausea, diar-
rhea, dysuria and hematuria rarely require
discontinuation of therapy. H

Dose. — The usual dose is 3 Gm. (approxi-
mately 45 grains) 4 times daily, by mouth, with a
range of 0.5 to 3 Gm. The maximum safe dose is
usually 4 Gm. and the total dose during 24
hours seldom exceeds 16 Gm. For a child, the
dose is 0.5 to 3 Gm.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

CALCIUM MANDELATE TABLETS.
U.S.P.

"Calcium Mandelate Tablets contain not less
than 95 per cent and not more than 105 per cent
of the labeled amount of CieHi-iCaOe." U.S.P.

Assay. — A representative portion of the pow-
dered tablets, equivalent to about 2 Gm. of cal-
cium mandelate, is reacted with hydrochloric acid,
which liberates mandelic acid, soluble in the
aqueous reaction medium. After removing insol-
uble matter by filtration, the mandelic acid in an
aliquot portion of the filtrate is extracted with
ether, the ether is evaporated, and the residue
of mandelic acid is titrated with 0.1 N sodium
hydroxide, using phenolphthalein T.S. as indi-
cator. Each ml. of 0.1 N sodium hydroxide repre-
sents 17.12 mg. of CieHuCaOe. U.S.P.

Usual Size. — 500 mg. (approximately lYi
grains).

CALCIUM PANTOTHENATE. U.S.P.

Dextro Calcium Pantothenate

[HOCH2.C(CH3)2.CH(OH).-
CO.XH.CHi-.CH2.COO]2Ca

"Calcium Pantothenate is the calcium salt of
the dextrorotatorv isomer of pantothenic acid."
U.S.P.

In 1933 Williams and his associates separated
from tissues of lower forms of animal and vege-
table life a substance which greatly accelerated
growth of yeast. To this substance they gave
the name of pantothenic acid — to indicate its
universal distribution. Pantothenic acid is
D( + )-N(a,Y-dihyclroxy-P.3-dimethylbutyryl)-
3-alanine; its synthesis from a-hydroxy-P-di-
methyl-Y-butyrolactone and ^-alanine was re-
ported by Williams and Major {Science, 1940,
91, 246). The D-form far exceeds the L-form
in microbiological activity, as measured by
stimulation of growth of Lactobacillus casei. The
commonly available salt of pantothenic acid is
calcium pantothenate.

Description. — "Calcium Pantothenate occurs
as a slightly hygroscopic, white powder. It is
odorless and has a bitter taste. It is stable in
air. Its solutions are neutral or slightly alkaline to
litmus, having a pH of 7 to 9. One Gm. of Cal-
cium Pantothenate dissolves in about 3 ml. of
water. It is soluble in glycerin, but is practically
insoluble in alcohol, in chloroform and in ether."
U.S.P.

Standards and Tests. — Identification. — (1)
A 1 in 20 solution responds to tests for calcium.

(2) A deep blue color develops on adding a
drop of cupric sulfate T.S. to the filtrate sepa-
rated from a mixture of 50 mg. of calcium
pantothenate and 5 ml. of sodium hydroxide T.S.

(3) A strong yellow color is produced on adding
5 ml. of 1 Ar hydrochloric acid and 2 drops of
ferric chloride T.S. to a mixture of 50 mg. of
calcium pantothenate and 5 ml. of 1 N sodium
hydroxide which has been boiled for a minute
and then cooled. Specific rotation. — Not less
than +25° and not more than +2 7°, when deter-
mined in a solution containing 500 mg. of cal-
cium pantothenate in each 10 ml., calculated on

Part I

Calcium Pantothenate

229

the anhydrous basis. Loss on drying. — Not over
5 per cent, when dried at 105° for 3 hours.
Alkaloids. — No turbidity is produced within 1
minute when 2 drops of mercuric-potassium
iodide T.S. are added to a solution of 200 mg.
of calcium pantothenate in 5 ml. of water,
acidified with 1 ml. of diluted hydrochloric
acid. Heavy metals. — The limit is 20 parts per
million. Nitrogen content. — Not less than 5.7
per cent and not more than 6.0 per cent, when
determined by the Kjeldahl method. Calcium con-
tent.— Not less than 8.2 per cent and not more
than 8.6 per cent, when determined by the pro-
cedure described under Calcium Bromide. U.S.P.

Stability. — Calcium pantothenate solutions
have optimum stability at a pH between 5 and
7; under other conditions the solutions undergo
more or less hydrolytic decomposition. Solutions
of calcium pantothenate are not stable when
autoclaved and sterilization by bacteriological fil-
tration is necessary. The alcohol form (see
Pantothenyl Alcohol in this monograph) is under
certain conditions more stable. For further in-
formation concerning stability of calcium pan-
tothenate see Frost and Mclntire, J.A.C.S., 1944,
66, 425.

Uses. — Pantothenic acid, so named because of
its universal distribution in living tissues, plays
an important role in metabolism but no human
deficiency syndrome involving it has been recog-
nized, and its therapeutic use is not clear.

Liver and muscle tissue, and also cereal, milk
and eggs are important sources of the vitamin;
it is also synthesized by intestinal bacteria. In
tissues it is largely bound to protein (Neilands
et al., J. Biol. Chem., 1950, 185, 335), in conse-
quence of which it is sometimes detectable only
after preliminary hydrolysis.

Deficiency. — Symptoms of pantothenic acid
deficiency in the chick include keratitis, derma-
titis, fatty liver, lesions of the spinal cord, and
involution of the thymus. In rats necrotic lesions
of the adrenal cortex have been observed, along
with hypotension, hypoglycemia, hypochloremia,
increased nonprotein nitrogen in the blood, fatty
liver, decreased 11-oxysteroid production, anemia
and leukopenia. Achromotrichia is observed in
black rats maintained on a diet deficient in pan-
tothenic acid. Little is known about the impor-
tance of the vitamin in human nutrition.

Physiologic Function. — Pantothenic acid is a
component of coenzyme A, which is concerned
with many acetylation reactions in tissues (No-
velli, Physiol. Rev., 1953, 33, 525). Coenzyme A
probably consists of pantothenyl diphosphate,
adenosine and glutamic acid, in combination with
a protein. It is concerned with such acetylation
reactions as the conversion of choline to acetyl-
choline, acetate to acetoacetate, oxalacetate to
citrate, as well as with the acetylation of
^-aminobenzoic acid, sulfonamides and of certain
foreign organic compounds. An acetylation
mechanism is also involved in the biosynthesis
of sterols from acetate precursors (Winters
et al, Proc. S. Exp. Biol. Med., 1952, 79, 695).
Moreover, pantothenate deficiency results in
necrosis of the adrenal cortex, which is aggra-
vated by administration of corticotropin. In

carbohydrate and fat metabolism coenzyme A is
involved in the tricarboxylic acid cycle in the
conversion of a-ketoglutaric acid to succinic
acid. It may also be involved in peptide synthesis.
Coenzyme A is concerned in transphosphoryla-
tion (Maas, Fed. Proc, 1954, 13, 256); the oxi-
dative reactions resulting in succinic acid form
phosporylcoenzyme A which can transfer its
phosphoryl group to produce the high energy
compound adenosinetriphosphate.

It has been observed that antibody formation
is impaired in pantothenic acid deficiency (Ludo-
vici and Axelrod, Proc. S. Exp. Biol. Med., 1951,
77, 530).

The analogue w-methylpantothenic acid, which
contains a methyl group in place of a hydrogen
atom in the terminal CH2OH group of panto-
thenic acid, functions as an antimetabolite; it
causes the pantothenic acid deficiency syndrome
in animals and prevents acetylation of sulfona-
mides.

The concentration of pantothenic acid in blood
ranges from 19 to 23 micrograms per 100 ml.
Ingestion of dextrose decreases this level. In the
healthy human the urine (tubular secretion)
contains 1 to 7.5 mg. daily; studies in which the
vitamin has been administered have failed to
show any distinction between normal and defi-
cient patients (Schmidt, Acta med. Scandinav.,
1951, 139, 185).

Therapeutic Uses. — Administration of panto-
thenic acid has produced improvement in some
cases of peripheral neuritis (Vernon, J.A.M.A.,
1950, 143, 799), muscular cramps in the legs
during pregnancy (Dumont, Presse med., 1950,
58, 3), Korsakoff's syndrome, and delirium
tremens (see Elvehjem, J. -Lancet, 1943, 63,
339). Field et al. (Am. J. Digest. Dis., 1945,
12, 245) reported that glossitis which developed
during or persisted following administration of
nicotinic acid and some other members of the
vitamin B complex was relieved after adminis-
tration of calcium pentothenate. Trial of the
vitamin for treatment of gray hair or alopecia
in humans has been unsuccessful (Schmidt,
/. Gerontol., 1951, 6, 369). In post-operative
ileus, marked improvement has been reported
following 1 to 3 doses of 50 mg. intramuscularly
(Jacques, Lancet, 1951, 2, 861) ; it may favorably
influence formation of acetylcholine (q.v.). In dis-
seminated lupus erythematosus combination
therapy with ascorbic acid has been beneficial
(Goldman, /. Invest. Dermat., 1950, 15, 291).
Amelioration of untoward symptoms during thy-
roid therapy of cretins (Barthelmes, Munch,
med. Wchnschr., 1952, 94, 259), and benefit in
acute catarrhal respiratory disorders (Svoboda,
Deutsch. med. Wchnschr., 1951, 76, 644) have
been reported.

Pantothenyl Alcohol. Panthenol (Hoffmann-
La Roche). CH2OH.C(CH3)2.CHOH.CONH.-
CH2.CH2.CH2OH. This substance, a,Y-dihydroxy-
N- (3 -hydroxypropyl)-(3, P-dimethyl-butyramide,
is identical with pantothenic acid except that the
carboxyl group is reduced to a primary alcohol
group. It is a viscous, slightly hygroscopic liquid,
freely soluble in water. Pantothenyl alcohol may
be prepared by addition of propanolamine to

230

Calcium Pantothenate

Part I

optically active a, Y-dihydroxy-P, 3-dimethylbu-
tyrolactone (U.S. Patent 2,413,077—1946). It is
converted in the body to pantothenic acid; only
the D-form of pantothenyl alcohol has vitamin
activity. By virtue of the greater stability of
pantothenyl alcohol, as compared with panto-
thenic acid or its salts, the alcohol form is pref-
erable for some formulations; thus, it is possible
to prepare solutions in the range of pH 3 to 5
with pantothenyl alcohol, and also to sterilize
aqueous solutions by heating, while with panto-
thenic acid or its salts material decomposition
would occur under similar conditions. The alcohol
is, however, hydrolyzed in alkaline and strongly
acid solutions, and long heating causes racemiza-
tion. For additional data see Rubin, J.A.Ph.A.,
1948, 37, 502.

The activity of pantothenyl alcohol in correct-
ing pantothenic acid deficiency in animals is
approximately equal to that of calcium panto-
thenate (Weiss et al., Proc. S. Exp. Biol. Med.,

1950, 73, 292). Following oral or parenteral ad-
ministration of the alcohol to rats or humans it
is converted to pantothenic acid and larger
amounts of the latter are excreted in the urine
than after the same dose of calcium pantothenate
(Combes and Zuckerman, /. Invest. Dermat.,

1951, 16, 379). Pantothenic acid deficiency in
animals can be corrected by the application of
the alcohol to the skin (Burlet, Jubilee Vol.
Emil Barell, 1946, 92).

Following recognition of the essentiality of
pantothenic acid for normal epithelial function
(Jurgens and Pfaltz, Ztschr. Vitaminforsch.,
1943, 14, 243), the percutaneous absorption of
the alcohol suggested its trial in various dermato-
logic disorders. A 5 per cent ointment of Panthe-
nol was used with beneficial effect in severe
burns, infected wounds and decubital ulcers
(Sciclounoff and Naz, Schweiz. Med. Wchnschr.,
1945, 75, 767; Leder, ibid., 1946, 76, 828).
Marked improvement in a variety of infected
ulcers of the skin followed application of a 5
per cent ointment, in either a lanolin or poly-
ethylene glycol vehicle, every day or two, the
treated area being covered with a gauze dressing
(Combes and Zuckerman, loc. cit.). In 25 of 31
patients with eczema, dermatitis venenata or
epidermophytosis good results were obtained with
2 per cent of Panthenol in a water-miscible
cream vehicle {Panthoderm Cream, U. S. Vita-
min Corp.) ; antipruritic and antibacterial ac-
tions, as well as stimulation of epithelizatiun,
were attributed to the pantothenyl alcohol prepa-
ration (see also Welsh and Ede, Arch. Dermat.
Syph., 1954, 69, 732).

Dose. — The usual dose of calcium pantothenate
is 10 mg. (about % grain), with a range of
10 to 50 mg.; the maximum safe dose is probably
larger than 1 Gm. The minimum daily require-
ment is not established; it would appear to be
of the order of 5 mg. Intramuscularly 100 mg.
has been given 1 to 3 times daily. A 2 to 5
per cent concentration of pantothenyl alcohol, in
the form of ointment or cream, is used topically.

Storage. — Preserve "in tight containers."
U.S.P.

RACEMIC CALCIUM PANTO-
THENATE. U.S.P.

"Racemic Calcium Pantothenate is a mixture
of the calcium salts of the dextrorotatory and
levorotatory isomers of pantothenic acid. It con-
tains the equivalent of not less than 45 per cent
of the dextrorotatory calcium pantothenate, cal-
culated on the dried basis." U.S.P.

"Note. — The physiological activity of Racemic
Calcium Pantothenate is approximately one-half
that of Calcium Pantothenate." U.S.P.

Chemical synthesis of calcium pantothenate
yields a racemic mixture of isomers, separation
of which is troublesome and costly. As with sev-
eral other substances, it is an economic advantage
not to separate the optical isomers and, in order
to compensate for the physiologic inactivity of
the levorotatory isomer, to use twice the dose
of the racemic variety.

Description. — "Racemic Calcium Pantothe-
nate occurs as a white, slightly hygroscopic pow-
der. It is odorless, has a bitter taste, and is stable
in air. Its solutions are neutral or alkaline to
litmus, having a pH of 7 to 9. It is optically in-
active. Racemic Calcium Pantothenate is freely
soluble in water. It is soluble in glycerin, and is
practically insoluble in alcohol, in chloroform and
in ether." U.S.P.

The standards and tests for the racemic salt
are identical with those for Calcium Pantothenate,
except for omission of the test for alkaloid
(which may be present in the dextrorotatory
isomer if it has been separated from the levorota-
tory isomer by precipitation with, for example,
quinine) and the stipulation that the racemic salt
is optically inactive. Since the racemic salt is
assayed microbiologically the assay for nitrogen
has been omitted.

Racemic calcium pantothenate is used in doses
twice those of calcium pantothenate since the
levorotatory component of the racemic mixture
is biologically inactive. The usual dose is given as
20 mg. (equivalent to 10 mg. of the dextrorota-
tory component).

Labeling. — "Label preparations containing
Racemic Calcium Pantothenate in terms of the
equivalent amount of dextrorotatory Calcium
Pantothenate." UJS.P.

Storage. — Preserve "in tight containers."
U.S.P.

DIBASIC CALCIUM PHOSPHATE.
U.S.P.

Dicalcium Orthophosphate. [Calcii Phosphas Dibasicus]
CaHP04.2H.20.

"Dibasic Calcium Phosphate contains not less
than 98 per cent of CaHP04.2H20 calculated on
the anhydrous basis." US.P.

Dicalcium Phosphate; Secondary Calcium Phosphate.
Calphate (Merrell); D.C.P. (.Parke, Davis). Calcium Phos-
phoricum; Calcium Phosphoricum Bibasicum. Fr. Phos-
phate mono-acide de calcium; Phosphate monocalcique
mono-acide; Phosphate bicalcique officinal. Ger. Kalzium-
phosphat; Calciumphosphat; Dicalciumphosphat; Sekun-
dares Calciumphosphat; Zweibasisches Calciumphosphat;
Phosphorsaures Calcium. It. Fosfato bicalcico; Fosfato
di calcio; Fosfato bibasico di calcic Sp. Fosfato de calcio,

Part I

Calcium Phosphate, Tribasic 231

monoacido; Fosfato Dibdsico de Calcio; Fosfato de cal
bibasico; Ortofosfato bicalcico.

Dibasic calcium phosphate is prepared by the
interaction of a secondary phosphate, as
Na2HP04, and calcium chloride in aqueous solu-
tions; the calcium phosphate, being almost in-
soluble in water, precipitates.

Description. — "Dibasic Calcium Phosphate
occurs as a white, odorless, and tasteless powder.
It is stable in air. Dibasic Calcium Phosphate is
almost insoluble in water, but is readily soluble
in diluted hydrochloric and nitric acids. It is
insoluble in alcohol." U.S.P.

Standards and Tests. — Identification. — (1)
A white precipitate forms on adding 5 ml. of
ammonium oxalate T.S. to a warm solution of
100 mg. of dibasic calcium phosphate in a mix-
ture of 5 ml. of diluted hydrochloric acid and
5 ml. of water. (2) A yellow precipitate of
ammonium phosphomolybdate forms on adding
ammonium molybdate T.S. to a warm solution
of dibasic calcium phosphate in a slight excess
of nitric acid. Loss on ignition. — Not less than
24.5 per cent and not more than 26.5 per cent.
Hydrochloric acid-insoluble matter. — 5 Gm. of
dibasic calcium phosphate yields not more than
5 mg. of matter insoluble in a dilute hydrochloric
acid solution. Carbonate. — No effervescence oc-
curs on adding 2 ml. of hydrochloric acid to a
mixture of 1 Gm. of dibasic calcium phosphate
and 5 ml. of water. Chloride. — The limit is 0.25
per cent. Fluorine. — The test and the limit are
as described under the corresponding test for
Tribasic Calcium Phosphate. Sulfate. — The limit
is 0.5 per cent. Arsenic. — The limit is 10 parts
per million. Barium. — No turbidity develops
within 10 minutes following addition of potas-
sium sulfate T.S. to a filtered solution of 500 mg.
of dibasic calcium phosphate in dilute hydro-
chloric acid. Heavy metals. — The limit is 30 parts
per million. U.S.P.

Assay. — About 300 mg. of dibasic calcium
phosphate is dissolved in diluted hydrochloric
acid, the calcium precipitated as oxalate and the
latter estimated by titration with 0.1 N potas-
sium permanganate. Each ml. of 0.1 N potassium
permanganate represents 8.605 mg. of CaHP04.-
2H20. U.S.P.

Uses. — This salt has come into common use
as a supplementary source of calcium and phos-
phate in connection with diets in which milk and
milk products are restricted or for conditions,
such as pregnancy, lactation, osteoporosis, etc.,
in which the demand for calcium and phosphate
is increased. Like tribasic calcium phosphate, this
salt is insoluble and there seems to be no evidence
that it is better absorbed from the gastrointes-
tinal tract. Where calcium alone is important,
calcium gluconate or lactate is to be preferred,
but as a dietary supplement both calcium and
phosphate are essential. It is claimed that a
ratio of calcium to phosphorus in the diet of
about 1 or 2 to 1 is best utilized (Bethke et al.,
J. Biol. Chem., 1932, 98, 389; Stearns and Jeans,
Proc. S. Exp. Biol. Med., 1934, 32, 428). Roche
and Mourgue (Compt. rend. soc. biol., 1943, 137,
451) reported that the first bone salt to be de-

posited in the sheep embryo was a mixture of
dibasic and tribasic calcium phosphate. It is used
in the form of powder, capsules, tablets and
flavored wafers. To several preparations vita-
min D2, in a proportion of about 600 U.S.P. units
per 1 Gm. of dicalcium phosphate, has been
added, since most patients requiring supplemen-
tal calcium and phosphorus need additional
vitamin D and the absorption is improved by
adequate amounts of the vitamin. E

The usual dose is 1 Gm. (approximately 15
grains), by mouth, three times a day between
meals, with a range of 1 to 5 Gm. The maximum
safe dose is usually 5 Gm. and a total dose of
15 Gm. in 24 hours is seldom exceeded.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

TRIBASIC CALCIUM PHOSPHATE.
N.F. (B.P.)

Precipitated Calcium Phosphate, [Calcii Phosphas
Tribasicus]

"Tribasic Calcium Phosphate consists of a vari-
able mixture of calcium phosphates having the
approximate composition Caio(OH)2(P04)6.
After ignition at about 800° for 30 minutes, it
contains an amount of phosphate (PO4) equiva-
lent to not less than 90 per cent of tribasic cal-
cium phosphate, Ca3(P04)2." N.F. The B.P., in
which this chemical is official as Calcium Phos-
phate, states that it is a variable mixture of
calcium phosphates. Its calcium content is re-
quired to be equivalent to not less than 85.0 per
cent of Ca3(P04)2.

B.P. Calcium Phosphate; Calcii Phosphas. Calcium
Orthophosphate; Tricalcic Phosphate; Tricalcium Phos-
phate; Tertiary Calcium Phosphate; Precipitated Phosphate
of Lime. Calcii Phosphas Prsecipitatus, N.F. VI; Calcium
Phosphoricum Tribasicum; Calcium Phosphoricum Basicum;
Phosphas Calcicus Praecipitatus; Phosphas Tricalcicus. Fr.
Phosphate neutre de calcium; Diphosphate tricalcique;
Phosphate tricalcique officinal. Ger. Tertiares Kalzium-
phosphat; Dreibasisches Calciumphosphat. It. Fosfato
tricalcico. Sp. Fosfato de calcio, neutro; Fosfato de
calcio tribasico.

Tribasic calcium phosphate is found abun-
dantly in nature; so-called phosphate rock, which
is found in the southern parts of the United
States, sometimes contains as much as 90 per cent
of the compound. It is found also in other
minerals, and is a normal constituent of bones
and teeth. The U.S.P. V and the B.P. 1885 de-
scribed a method for preparing calcium phosphate
from bone ash. In this process carefully calcined
bones were treated with hydrochloric acid, which
dissolved the calcium phosphate of the bones,
and the basic phosphate was precipitated from
this solution, in a state of minute subdivision,
by addition of ammonia. The precipitate was
washed free of ammonium chloride. The salt
thus or similarly obtained is called bone calcium
phosphate.

The official tribasic calcium phosphate is made
by interaction between solutions of calcium chlo-
ride, sodium phosphate, and ammonium hydroxide
at boiling temperature. From an analytical study
of commercial samples of tribasic calcium phos-
phate. Millar (/. A. Ph. A., 1941, 30, 139)
concluded that Ca3(P04)2 is not the correct

232 Calcium Phosphate, Tribasic

Part I

formula for the official phosphate; the formula
[Ca3(P04)2]3.Ca(OH)2 would appear to agree
more closely with the true composition of the
salt.

Description. — "Tribasic Calcium Phosphate
occurs as a white, odorless, and tasteless powder,
which is permanent in air. Tribasic Calcium
Phosphate dissolves readily in diluted hydrochloric
and nitric acids. It is insoluble in alcohol and
almost insoluble in water. N.F.

Standards and Tests. — Identification. — Tri-
basic calcium phosphate responds to the identi-
fication tests under Dibasic Calcium Phosphate
and in addition gives the flame test characteristic
of calcium. Loss on ignition. — Not over 8 per
cent. Acid-insoluble substances. — 2 Gm. of tri-
basic calcium phosphate yields not more than
4 mg. of matter insoluble in a dilute hydrochloric
acid solution. Water-soluble substances. — A one-
half aliquot portion of the 100 ml. of water
used to extract 2 Gm. of tribasic calcium
phosphate yields 'not more than 5 mg. of resi-
due. Carbonate. — No effervescence occurs on
adding diluted hydrochloric acid, dropwise,
to a suspension of 2 Gm. of tribasic calcium
phosphate in 20 ml. of water. Chloride. — The
limit is 0.14 per cent. Nitrate. — The blue color
of a mixture of 200 mg. of tribasic calcium
phosphate, in distilled water with sufficient hydro-
chloric acid to effect solution, 0.1 ml. of indigo
carmine T.S., and sulfuric acid, persists for at
least 5 minutes. Sulfate. — The limit is 0.8 per
cent. Arsenic. — A 5 ml. portion of 1 in 25 solution
of tribasic calcium phosphate in diluted hydro-
chloric acid meets the requirements of the test
for arsenic. Barium. — No turbidity develops
within 15 minutes on adding potassium sulfate
T.S. to a filtered solution of 500 mg. of tribasic
calcium phosphate in dilute hydrochloric acid.
Dibasic salt and calcium oxide. — A solution of
2 Gm. of tribasic calcium phosphate in 50 ml.
of 1 N hydrochloric acid requires not less than
12.5 ml. and not more than 13.8 ml. of the acid
for each Gm. of salt (calculated on a water-free
basis) when the excess of acid is titrated with
1 N sodium hydroxide, using methyl orange T.S.
as indicator. Fluorine. — The test depends on the
fact that fluorides bleach the pink color of a
lake prepared from sodium alizarinsulfonate T.S.
and a thorium nitrate solution; the concentration
of fluorine in the tribasic calcium phosphate is
determined by observing the volume of a standard
solution of sodium fluoride required to produce
the same degree of bleaching in a control test
as that produced in a distillate containing the
fluorine from tribasic calcium phosphate. The
limit corresponds to 50 parts per million of
fluorine. Heavy metals. — The limit is 30 parts
per million. N.F. The B.P. specifies an arsenic
limit of 4 parts per million and a lead limit of
20 parts per million.

Assay. — About 200 mg. of tribasic calcium
phosphate, previously ignited to constant weight,
is dissolved in a dilute nitric acid solution and
the phosphate precipitated as ammonium phos-
phomolybdate. After washing, the precipitate is
dissolved in a measured excess of 1 ^V sodium
hydroxide and titrated with 1 N sulfuric acid.

using phenolphthalein T.S. as indicator. Each ml.
of 1 N sodium hydroxide represents 6.743 mg. of
Ca.3(P04)2. The equivalent weight of tribasic
calcium phosphate in this assay is Vm of its
molecular weight, since each of the two molecules
of ammonium phosphomolybdate produced re-
quires 23 molecules of sodium hydroxide in the
reaction (see assay of Aluminum Phosphate Gel
for explanation of reaction). N.F.

In the B.P. assay calcium phosphate is dis-
solved in an aqueous hydrochloric acid solution,
the calcium precipitated as oxalate, and finally
titrated with 0.1 N potassium permanganate.

Uses. — Despite the insolubility of tribasic
calcium phosphate it is slowly absorbed from the
intestines. It is not of value in acute calcium
deficiency, but is effective during rapid growth,
pregnancy, etc.

It is used as an antacid in the treatment of
gastric hyperacidity. The mechanism of its action
as an antacid appears to involve replacement of
the extensively ionized hydrochloric acid by phos-
phoric acid, or primary or secondary phosphate,
all of which produce a considerably lower hydro-
gen ion concentration (or higher pH) than
hydrochloric acid. It has the advantage over so-
dium phosphates in that there is no danger of
systemic alkalosis or secondary hypersecretion of
gastric acid and over the carbonates in that there
is no effervescence of gas. Tribasic calcium phos-
phate is a little less efficient than calcium
carbonate (Clin. J., 1931, 60, 97, 109). In the
treatment of peptic ulcer a mixture of calcium
and magnesium phosphates has been used. 0

Dose, 1 Gm. (approximately 15 grains) three
times daily or, as a gastric antacid, six or more
times daily.

Off. Prep. — Dry Extract of Nux Vomica, B.P.

CAMPHOR. U.S.P., B.P., LP.

[Camphora]

CH,

H.C — C-

C(CH3)2

•CH„

HX — C-
2 H

"Camphor is a ketone obtained from Cinna-
momum Camphora (Linne) Nees et Ebermaier
(Fam. Lauracece) (Natural Camphor) or pro-
duced synthetically (Synthetic Camphor)."
U.S.P. The B.P. definition is essentially identical;
a content of not less than 96.0 per cent of
CioHieO is required. The LP. does not indicate
the source of camphor; it specifies only a purity
rubric of not less than 96.0 per cent of CioHieO.

Gum Camphor; Laurel Camphor; Camphanone-2. Cam-
phora Officinarum. Fr. Camphre du Japon; Camphre
artificiel; Camphre droit; Camphre synthetique. Ger.
Kampfer; Japancampher; Campher; Laurineenkampfer;
Laurazeenkampfer; Synthetischer Kampfer. It. Canfora.
Sp. Alcanfor.

The term camphor was originally applied to
two products which came from China into Europe
about the 13th century. The two substances were
the products respectively of Dryobalanops Cam-

Part I

Camphor 233

phora (Borneol, see Part II), which was probably
the more ancient, and of Cinnamomum Catn-
phora, the official camphor. Subsequently the
term was also applied to various solid, oxygen-
ated principles from volatile oils which bear no
close chemical or medical relation.

The supply of natural camphor is far from
adequate to meet the commercial demand. Since
the introduction of synthetic camphor this prod-
uct has achieved great commercial importance,
although only in recent years has it come into
use medicinally. As turpentine is used as the
starting point in the synthesis of camphor the
price of the artificial product cannot fall low
enough to entirely displace the natural camphor.

The camphor tree {Cinnamomum C amphora)
is an evergreen which sometimes attains great
size, having the aspect of the linden, with a
trunk straight below, but divided above into
many branches, which are covered with a smooth,
greenish bark. Its leaves, which stand alternately
upon long foot-stalks, are ovate-lanceolate,
entire, smooth and shining, ribbed, of a bright
yellowish-green color on their upper surface,
paler on the under, and two or three inches in
length. The flowers are small, white, pediceled,
and borne in clusters, which are supported by
long axillary peduncles. The fruit is a purple, one-
seeded drupe, resembling that of the cinnamon.
The camphor tree is a native of China, Japan,
and adjacent portions of eastern Asia, but is
capable of cultivation in most sub-tropical
countries, where the minimum winter temperature
is not below — 6.6°, and the summers are warm.
The chief obstacle to its cultivation seems to be
the extreme slowness of growth of the tree, and
the corresponding slowness of returns from the
investment. For an account of cultivation in
Florida see True and Hood, Proc. A. Ph. A., 1909,
p. 719.

Before World War II, about 80 per cent of the
world's supply of natural camphor came from
the island of Formosa and most of the rest from
Japan and China. The amounts produced in India
and in Florida were too small to be of commercial
significance. During 1952 there were imported
over 6,500,400 pounds of crude and refined cam-
phor from Japan, Taiwan, and China. Large quan-
tities have been made synthetically in the United
States since 1933.

In Japan and Formosa the drug is obtained
chiefly from the root, trunk and branches by the
process of sublimation, but in the American
plantations the leaves and small twigs are utilized,
thus avoiding injury to the trees. Only the older
trees are employed; indeed, it is said that a tree
must be fifty years old before it should be con-
sidered available. In the province of Tosa, in
Japan, the method of obtaining camphor, as
reported by Dewey (Circular 12, U. S. Dept. of
Agric, Div. of Botany), is to pass a current
of steam through chips of the camphor tree, the
volatilized camphor being conducted through a
bamboo tube into a condensing chamber which
is kept cool by water falling on the top and run-
ning down over the sides. The upper part of the
air chamber is sometimes filled with clean rice
straw, on which the camphor crystallizes, while

the oil drips down and collects on the surface of
the water. In some cases, the camphor and oil
are allowed to collect together on the surface of
the water, and are afterward separated by filtra-
tion through rice straw or by pressure. By this
method 20 to 40 pounds of chips are required for
1 pound of crude camphor. In China the com-
minuted plant is said to be first boiled with
water until the camphor adheres to the stick used
in stirring, when the strained liquor is allowed
to cool, and the camphor which concretes, being
alternated with layers of earth, is submitted to
sublimation. In Formosa, a current of steam is
passed through the chips and the volatilized cam-
phor condensed on earthenware pots. The crude
camphor is taken to the towns in baskets and
then put into large vats, with holes in the bottom,
through which a volatile oil, called camphor oil,
escapes; it is much used by the Chinese for
medicinal purposes. The oil may also be removed
by expression.

Crude camphor is of a pinkish color and of a
softer consistency than the refined. It is purified
by mixing it with about one-fiftieth of its weight
of quicklime and heating in an iron vessel, first
to a temperature of about 100° which drives off
the water and volatile oil. Afterward the vessel
is connected with a suitable receiver and heated
to a temperature of 175° to 200° which causes
the camphor to sublime, the vapors condensing
in the receiver. It is refined in Taiwan, China,
Japan, and in the United States.

Synthetic Camphor. — Camphor is chemically
related to pinene, the principal constituent of
turpentine, and it is with this natural substance
that the synthesis of camphor begins. Pinene is
prepared by fractionally distilling turpentine.
This, after drying, is converted into bornyl chlo-
ride (also called pinene hydrochloride, and tech-
nically known as "artificial camphor") by treat-
ment with dry hydrochloric acid gas. This solid
is then converted into camphene by treatment
with alkali which removes hydrochloric acid and
rearranges the molecule. The camphene can be
oxidized directly to camphor by chromic acid,
but a better yield is obtained by the following
process. Beginning with camphene, glacial acetic
acid is used to convert this substance to iso-
bornyl acetate, which is then saponified to iso-
borneol. After purification the latter compound, a
secondary alcohol, is oxidized by chromic acid
or other oxidant to camphor.

Synthetic camphor possesses the chemical
properties of natural camphor but differs in op-
tical activity; the former occurs almost always
as the racemic variety, while the latter is dextro-
rotatory.

Description. — "Camphor occurs as colorless
or white crystals, granules, or crystalline masses;
or as colorless to white, translucent, tough masses.
It has a penetrating, characteristic odor, a
pungent, aromatic taste, and is readily pulveriz-
able in the presence of a little alcohol, ether, or
chloroform. Its specific gravity is about 0.99. It
slowly volatilizes at ordinary temperatures. One
Gm. of Camphor dissolves in about 800 ml. of
water, in 1 ml. of alcohol, in about 0.5 ml. of
chloroform, and in 1 ml. of ether. It is freely

234 Camphor

Part I

soluble in carbon disulfide, in petroleum benzin,
and in fixed and volatile oils. Camphor melts be-
tween 174° and 179°, when tested as directed
under Class I, using a capillary glass tube having
an internal diameter between 2 and 2.5 mm. The
specific rotation of Natural Camphor, deter-
mined in a solution in alcohol containing 1 Gm.
of Camphor in each 10 ml., is not less than +41°
and not more than +43°." U.S.P.

When small fragments of camphor are thrown
upon water, the solid performs singular circula-
tory movements, which cease upon the addition
of a drop of oil; this property has been applied
to the detection of grease in liquids, a very small
proportion of which is sufficient to prevent the
movements. Camphor boils at 204°. It is not
changed by air and light, but readily takes fire.

Leo and Rimbach found that the solubility of
camphor in pure water decreases with rise of
temperature. (/. Soc. Chem. Ind., 1919, 38,
738 A.) Carbon dioxide increases the solubility
in water. /

Standards and Tests. — Water. — A 1 in 10
petroleum benzin solution of camphor is clear.
Non-volatile matter. — On gently heating 2 Gm. of
camphor it sublimes without carbonization and
without leaving over 1 mg. of residue. Halogens.
— The limit is 350 parts per million. U.S.P.

Assay. — The U.S.P. does not require camphor
to be assayed, but the B.P. and LP. do, the same
assay being employed by both compendia. The
camphor is dissolved in aldehyde-free alcohol, a
solution of dinitrophenylhydrazine is added to
precipitate camphor dinitrophenylhydrazone, the
mixture heated on a water bath under a reflux
condenser for 4 hours and allowed to stand for
24 hours to complete the precipitation, following
which the precipitate is filtered into a Gooch
crucible or sintered glass crucible, washed with
water, and dried to constant weight at 80°. Each
Gm. of precipitate is equivalent to 0.4580 Gm. of
CioHieO.

Oil of Camphor. — Under the title Oleum
Camphors the U.S.P. V recognized a volatile
oil obtained from the camphor tree. This is a
colorless fluid or of a light yellowish-brown
color, having a strong odor like that of camphor,
a bitterish camphorous taste and a specific grav-
ity, at 20°, of 0.875 to 0.900. It is strongly dextro-
rotatory. In addition to camphor, the following
substances have been reported in this oil: Ter-
pineol, phellandrene, dipentene, cadinene, eu-
genol, cineol, d-pinene, safrol and acetaldehyde.
The oil is said to be used in Japan for the prepa-
ration of Chinese ink and varnishes, and for
burning. As a diluent for artists' colors it is
useful because its ability to dissolve resins is
greater than that of oil of turpentine and similar
liquids.

Oil of camphor is no longer employed as an
internal remedy but is occasionally used as a
rubefacient and anodyne liniment, diluted with
soap liniment or olive oil, in local rheumatism
and neuralgic pains, bruises, sprains, etc.

Uses. — The therapeutic uses of camphor seem
to depend chiefly on its topical irritant
action and on its strong odor and taste.

Locally camphor is irritant, with probably
a benumbing influence upon the peripheral
sensory nerves, and somewhat antiseptic. It is
absorbed through mucous membranes and from
subcutaneous tissue. It combines in the body with
glucuronic acid and is eliminated in this inactive
combination by the kidneys. The systemic action
of camphor is not well understood. In frogs it is
depressant to the spinal cord and causes increas-
ing paralysis of the central nervous system. In
the higher mammals, however, it produces active
convulsions. After toxic doses there is secondary
depression and death is usually due to respiratory
failure. Experiments with camphor on the circu-
lation have been quite voluminous, with extraor-
dinary divergence of results. The conclusions of
Heathcote (/. Pharmacol., 1923, 21, 177), that
there is "no convincing pharmacological evidence
that camphor possesses any value as a cardiac
or circulatory stimulant," seems justified. When
camphor is thus employed it is rather with the
hope than with the expectation of benefit.
Whether the effects in hysteria and neuralgia
are attributable to any action other than a psychic
influence from the strong taste of the drug is
open to question (Friedman, /. Nerv. Ment. Dis.,
1943, 98, 229).

Intramuscular injections of 100 mg. (approxi-
mately Wi grains) twice the first day, then
daily for three days, have been employed for
engorgement of the breasts when it is desired to
inhibit lactation but Greene and Ivy (J.A.M.A.,
1938, 110, 641) questioned the efficacy of the
procedure.

Camphor is sometimes used for its carmina-
tive action, and its slight expectorant action is
also utilized on occasion.

Probably the most frequent use of camphor
in this country is as a local remedy. It is of value
as a mild counterirritant in muscular strains, in
rheumatic conditions, and many similar inflam-
mations. It is frequently used, especially in con-
junction with menthol or phenol, for its local
anesthetic effect to relieve itching of the skin
and in treatment of acute rhinitis or conjuncti-
vitis. It has been used in conjunction with phenol
as a local remedy for epidermophytosis; it is
thought that camphor diminishes absorption of
phenol. However, instances of ulceration from
a single application of this mixture have been
reported (Hubler, J.A.M.A., 1943, 123, 990).
In any event, such applications are not curative
and may be harmful in the vesicular type of lesion
(Glenn and Hailey, Arch. Dermat. Syph., 1943,
47, 239). N\

Toxicology. — Cases of camphor poisoning,
chiefly from accidental ingestion of camphor
liniment, have been reported. Benz (J.A.M.A.,
1919, 72, 1217) recorded 20 such cases, and
Craig (Archives of Disease in Childhood, 1953,
28, 475) stated that 12 children died in Great
Britain from poisoning by camphor, while many
others were made ill, in a period of 20 years.
One fluidrachm of camphor liniment caused the
death of a child of 16 months; the same dose
caused marked symptoms in a 6-year-old boy.
The most constant symptom observed has been

Part I

Camphor and Soap Liniment 235

clonic convulsions, usually accompanied with
vertigo, more or less mental confusion often
amounting to active delirium, and sometimes
followed with coma; vomiting may occur. Craig
emphasized the need for quickly inducing emesis ;
gastric lavage is also indicated. While sedation
must be undertaken with care, because of the
risk of eventual respiratory failure, Craig states
that the short-acting barbiturates, given intra-
venously, or paraldehyde given intramuscularly,
seem to be the most rational form of treatment.
A case of poisoning in a 2 ^-year-old child from
application of camphor liniment to the chest for
a cold was recorded by Summers (Brit. M. J.,
Dec. 20, 1947).

The dose of camphor varies from 120 to 300
mg. (approximately 2 to 5 grains). For subcu-
taneous injection from 100 to 300 mg. may be
dissolved in 1 or 2 ml. of a sterile fixed oil, such
as olive oil; solutions in liquid petrolatum are
not to be used subcutaneously since the camphor
seems not to be absorbed and often causes se-
rious inflammatory changes.

Storage. — Preserve "in tight containers, and
avoid exposure to excessive heat." U.S.P.

Off. Prep. — Camphorated Opium Tincture,
U.S.P., B.P.; Flexible Collodion, U.S. P.; Cam-
phor and Soap Liniment; Camphor Liniment;
Camphor Water, N.F., B.P.; Camphor Spirit;
Compound Ephedrine Spray; Camphorated Para-
chlorophenol, N.F.; Ammoniated Liniment of
Camphor; Liniment of Turpentine, B.P.

CAMPHOR LINIMENT. N.F. (B.P.)

Camphorated Oil, [Linimentum Camphorae]

"Camphor Liniment contains not less than
19 per cent and not more than 21 per cent of
camphor. Caution. — This preparation is not in-
tended for parenteral use." N.F. The B.P. re-
quires Liniment of Camphor to contain 20.0
per cent w/w (limits 19.0 to 21.0) of camphor.

B.P. Liniment of Camphor. Oleum Camphoratum Forte.
Ger. Starkes Kampferol. Sp. Linimento de Alcanfor.

Place 800 Gm. of cottonseed oil into a suit-
able dry flask or bottle, heat it on a water bath,
add 200 Gm. of coarsely powdered camphor,
stopper the container securely and dissolve the
camphor by agitation without further applica-
tion of heat. N.F.

The B.P. preparation contains the same pro-
portion of camphor but arachis oil is used in
place of cottonseed oil as the vehicle.

Assay. — Approximately 5 ml. of camphor
liniment is weighed into an Erlenmeyer flask,
placed in an oven at 110°, and the camphor vola-
tilized from the liniment while passing carbon
dioxide gas over it; after displacing the carbon
dioxide with dry air, the loss of weight of the
sample is determined, this being assumed to be
equivalent to the weight of camphor in the
original sample. The use of carbon dioxide gas
is for the purpose of hastening the volatilization
of camphor, while at the same time preventing
any oxidative changes in the cottonseed oil,
which would occur if air were used similarly.
N.F. The B.P. assay consists of heating a sample

of the liniment in a dish on a water bath until
the odor of camphor is no longer discernible,
the loss in weight being calculated as camphor.
For a discussion of volatilization methods for
estimating camphor in oil solutions see Berman
(/. A. Ph. A., 1940, 29, 120).

Uses. — Camphor liniment is used as a counter-
irritant in sprains, bruises, rheumatism, acute
bronchitis, and various other inflammatory states.
Its oily base invites rubbing, which is often bene-
ficial.

Many cases of poisoning, a considerable num-
ber of them terminating fatally, have resulted
from accidental ingestion of this liniment by
children; even its application has resulted in
poisoning of a child (for discussion see Toxi-
cology, under Camphor).

The term "camphorated oil" is sometimes
applied to a solution of camphor in oil intended
for hypodermic use; camphor liniment should
under no circumstances be used for this pur-
pose. !y|

Storage. — Preserve "in tight containers."
N.F.

AMMONIATED LINIMENT OF
CAMPHOR. B.P.

Linimentum Camphorae Ammoniatum

Compound Liniment of Camphor. Linimentum Am-
moniato-camphoratum; Linimentum Camphoratum cum
Ammonia; Linimentum Ammoniatum Camphoratum. Fr.
Liniment ammoniacal camphre. Ger. Fluchtiges Kampfer-
liniment. It. Linimento ammoniacale canforato.

Camphor (12.5 per cent w/v), lavender oil,
stronger ammonia water and alcohol are mixed
together in preparing this liniment, the final
product having an alcohol content of 54 to 58
per cent.

This liniment or a variant of it is popular in
England and many countries in Europe.

CAMPHOR AND SOAP LINIMENT.
N.F. (B.P.)

Soap Liniment, [Linimentum Camphorae et Saponis]

B.P. Liniment of Soap ; Linimentum Saponis. Camphor-
ated Tincture of Soap; Liquid Opodeldoc. Linimentum
Saponis Camphoratum Liquidium ; Spiritus Saponato-caru-
phoratus. Fr. Liniment savonneux camphre. Ger. Flussiger
Opodeldok. Sp. Linimento de jabon alcanforado, liquido;
Balsamo opodeldoch, liquido; Linimento de Alcanfor y
Jabon.

Dissolve 45 Gm. of camphor, in small pieces,
and 10 ml. of rosemary oil in 700 ml. of alcohol,
add 60 Gm. of hard soap, dried and granulated
or powdered, and enough purified water to make
1000 ml. Agitate the mixture until the soap has
dissolved, set aside in a cool place for 24 hours,
and filter.

The B.P. Liniment of Soap is made similarly,
though it contains soft soap instead of hard soap.

Alcohol Content. — From 62 to 66 per cent,
by volume, of C2H5OH. N.F.

Uses. — Soap liniment is used as a gentle
rubefacient in sprains, bruises, and rheumatic or
gouty pains. It is useful also as a vehicle for more
active counterirritants.

Storage. — Preserve "in well-closed contain-
ers." N.F.

Off. Prep. — Chloroform Liniment, N.F.

236 Camphor Spirit

Part I

CAMPHOR SPIRIT. N.F.

[Spiritus Camphors; ]

"Camphor Spirit is an alcohol solution con-
taining, in each 100 ml., not less than 9.0 Gm.
and not more than 11.0 Gm. of CioHioO.'' X.F.

Spiritus Camphoratus; Solutio Alcoholica Camphors. Fr.
Teinture de camphre concentree; Alcool camphre; Esprit
de camphre. Gcr. Kampferspiritus. It. Spirito canforato.
Sp Solucion de alcanfor, alcoholica; Alcohol alcanforado;
Kspintu de alcanfor.

Dissolve 100 Gm. of camphor in sufficient alco-
hol to make 1000 ml. Filter, if necessary. X.F.

Tests. — Specific gravity. — Not less than 0.824
and not more than 0.826. Added water. — On add-
ing 50 mg. of potassium carbonate to 5 ml. of
camphor spirit the solid does not liquefy nor
does it adhere to the bottom of the container.
X.F.

Assay. — The camphor in 2 ml. of spirit is
heated during 4 hours with freshly prepared
dinitrophenylhydrazine T.S. whereby the cam-
phor, a ketone, forms a dinitrophenylhydrazone
which is quantitatively precipitated. After
standing overnight following acidification of the
mixture the precipitate is filtered on a crucible,
washed with distilled water, and dried to constant
weight at 80°. Each Gm. of the camphor dini-
trophenvlhvdrazone represents 458.0 mg. of
CioHinO. X.F.

Alcohol Content. — From 80 to 87 per cent,
by volume, of C2H5OH. X.F.

Uses. — Camphor spirit was once widely used
in the treatment of diarrhea, and in hysteria and
other forms of nervous excitement; it is today
used relatively infrequently. To minimize pre-
cipitation of camphor on dilution with water it
may be dropped on sugar and then mixed with
water. It is more frequently used, especially by
the layman, as an application for various local
ailments. H

Dose, from 0.6 to 1.25 ml. (approximately 10
to 20 minims).

Storage. — Preserve "in tight containers." N.F.

CAMPHOR WATER. N.F.. B.P.

[Aqua Camphorae]

"Camphor Water is a saturated solution of
camphor in purified water, prepared by solution
of the camphor as described under Waters." X.F.

Aqua Camphorata. Fr. Eau camphree. Gcr. Campher-
wasser. Sp. Agua de Alcanfor.

The B.P. Camphor Water is made by dissolving
1 Gm. of camphor in 2 ml. of 90 per cent
alcohol and adding this gradually to 1000 ml.
of distilled water.

Uses. — Camphor water is used as an euphoric
in states of nervous excitement, but whether its
effects are physiologic or psychologic is open to
question. It is often employed as a vehicle for
the administration of more active substances and
is an astringent ingredient of liquid preparations
for application to the eye.

Dose, 15 to 30 ml. (approximately l/2 to 1
fiuidounce), repeated every one or two hours.

MONOBROMATED CAMPHOR. N.F.

[Camphora Monobromata]

CioHisOBr

Camphor Bromate; Bromocamphor; Brominated Camphor.
Camphor* Monobromidum. Fr. Camphre monobrome. Ger.
Bromkampfer; Bromcampher. It. Canfora monobromata.
Sp. Alcanfor monobromado.

This substance may be made by heating to-
gether bromine and camphor, whereby a hydrogen
atom of the — CH2 group adjacent to the ketone
group of camphor is replaced by bromine.

Description. — "Monobromated Camphor oc-
curs as colorless, prismatic needles or scales, or
as a powder. It has a mild, but characteristic,
camphoraceous odor and taste. It is stable in
the air, but is decomposed by prolonged exposure
to sunlight. One Gm. of Monobromated Cam-
phor dissolves in about 6.5 ml. of alcohol, in
about 0.5 ml. of chloroform, and in about 1.6 ml.
of ether. It is almost insoluble in water. Mono-
bromated Camphor melts between 74° and 77"."
X.F.

Standards and Tests. — Identification. — A
yellow precipitate of silver bromide forms on
heating together 100 mg. each of monobromated
camphor and silver nitrate and 2 ml. each of
nitric acid and sulfuric acid until nitrous vapors
are no longer evolved. Residue on ignition. — Not
over 0.05 per cent. Bromide. — The filtrate from
500 mg. of powdered monobromated camphor
shaken with 10 ml. of distilled water is neutral,
and is not rendered more than slightly opalescent
by several drops of silver nitrate T.S. X.F.

Uses. — Monobromated camphor was intro-
duced into medicine with the expectation that
it would combine the sedative effect of the bro-
mide ion with that of camphor. As it represents
only about 35 per cent of bromine it is obvious
that it cannot, in the doses in which it is employed,
exert any perceptible degree of bromide effect.
That its action is chiefly that of the camphor
in it is shown by the fact that the use of large
doses has led to the occurrence of convulsions.
It has been employed for the treatment of head-
aches in combination with various coal tar anal-
gesics and for sundry chronic neurologic con-
ditions.

The dose is from 120 to 300 mg. (approxi-
mately 2 to 5 grains).

Storage. — Keep "in well-closed, light-resistant
containers."' X.F.

CANTHARIDES. N.F.

Spanish Flies, Russian Flies, Cantharis

"Cantharides consists of the dried insect.
Cantharis vesicatoria (Linne) De Geer (Fam.
Meloidece). Cantharides yields not less than 0.6
per cent of cantharidin. Caution. — Cantharides
having an ammoniacal odor must not be used."
N.F.

Blistering Flies; Blistering Beetle. Muses Hispanicse. Fr.
Cantharide; Insectes coleopteres heteromeres; Meloides.
Ger. Spanische Fliegen; Kanthariden; Blasenkafer; Pflas-
terkafer. It. Cantaride. Sp. Cantarida.

The term Cantharis was employed by the an-
cient Greek writers to designate many coleopter-

Part I

Cantharides

237

ous insects or beetles. Linnaeus gave the title
to a genus not including the official blistering
insects, placing the latter in the genus, Meloe,
which, however, has been since divided into sev-
eral genera. Geoffrey made the Spanish fly
(beetle) the prototype of a new genus, Can-
tharis, substituting Cincindela as the title of the
Linnaean genus. Fabricius altered the arrange-
ment of Geoffrey, and substituted Lytta for Can-
tharis as the generic name. The former was
adopted by the London College, and at one
time was in extensive use; but, the latter, having
been restored by Latreille, is now universally em-
ployed. By this naturalist the vesicating beetles
were grouped in a small tribe, corresponding very
nearly with the Linnaean genus Meloe, and dis-
tinguished by the title Cantharides. This tribe he
divided into eleven genera, among which is
Cantharis.

Cantharis vesicatoria is a beetle from 15 to 25
mm. long, and of a shining, golden-green color.
The head is large and heart-shaped, bearing a pair
of stout mandibles and filiform antennae; the
thorax short and quadrilateral; the wing-sheaths
long and flexible, covering brownish membranous
wings. They attach themselves preferably to
certain trees and shrubs, such as the white pop-
lar, privet, ash, elder, and lilac, upon the leaves
of which they feed. They are most abundant in
Spain, Italy, and southern France, but are found
also in all the temperate parts of Europe and in
western Asia. According to the researches of
Lichtenstein, the eggs are laid by the female in
the latter part of June in small cylindrical holes
made in the ground. A week later the larvae
hatch out. They are a millimeter long, with two
long caudal threads, and of a brown color. After
many efforts, Lichtenstein succeeded in getting
them to feed on the honey contained in the
stomach of bees. In a few days they changed into
milk-white larvae, and about a month after this
buried themselves in the ground, to assume the
chrysalis stage and to hatch out the following
spring as perfected beetles. In the wild state the
larvae are said to crawl up flowers and attach
themselves to bees or other hymenopterous
insects; carried by the bee to the hive, the larvae
feed upon the young bees and the honey and bee-
bread stored up for use. The beetles usually
make their appearance in swarms upon the trees
in May and June, when they are collected.

The time preferred for collection is in the
morning, at sunrise, when they are torpid from
the cold of the night, and easily let go their
hold. Persons with their faces protected by masks,
and their hands with gloves, shake the trees, or
beat them with poles ; and the insects are received
as they fall upon linen cloths spread underneath.
They are then plunged into vinegar diluted with
water, or exposed in sieves to the fumes of
ammonia, vinegar, chloroform, burning sulfur or
carbon bisulfide, after which they are dried in the
sun or by other means of heating. This mode of
killing the flies by the vapor of vinegar is as
ancient as the times of Dioscorides and Pliny.
When perfectly dry, they are introduced into
casks or boxes fined with paper and carefully

closed, so as to exclude as much as possible the
atmospheric moisture.

Cantharides comes chiefly from Spain, southern
Russia and Hungary, and other parts of southern
Europe, as Sicily, Poland, and Roumania. The
Russian flies are most esteemed. They may be
distinguished by their greater size, and their
color approaching to that of copper.

In the United States are several species of
Cantharis, which have been formerly employed as
substitutes for C. vesicatoria and found equally
efficient. For description of unofficial blistering
beetles, see U.S.D., 19th ed., p. 284. Various
other allied insects have been used at one time
or another as a substitute for the Spanish beetle.

Cantharis vittata Latreille, or potato fly, was
recognized by the U.S. P. 1850. It is rather
smaller than C. vesicatoria, which it resembles in
shape. Its length is about six lines (J^ inch). The
head is light red, with dark spots upon the top;
the feelers are black; the elytra or wing-cases are
black, with a yellow longitudinal stripe in the
center, and with a yellow margin; the thorax is
also black, with three yellow lines; and the
abdomen and legs, which have the same color,
are covered with a cinerous down. It inhabits
chiefly the potato vine, and appears about the
end of July or beginning of August, in some
seasons very abundantly. This insect must not be
confused with the "potato bug," or Colorado
potato beetle (Doryphora decemlineata), which
has proved so destructive to potato plants, and
which contains no cantharidin.

Mylabris cichorii Fabr. is thought to be one of
the insects described by Pliny and Dioscorides
under the name of cantharides, and is to this day
employed in Italy, Greece, the Levant, Egypt,
and China. It, as well as the related species,
M. sidtz Fabr., is imported to some extent from
Shanghai and Singapore under the name of Chi-
nese blistering fly for the extraction of canthari-
din. They are black with 2 brownish-yellow to
orange transverse bands on their elytra, with the
powder blackish gray and free from shining
particles; they yield 1.25 per cent of cantharidin.

The B.P. Add. 1900, under the name of Myla-
bris, recognized not only the dried beetle Mylabris
phalerata Pallas (M . sidce Fabr.), but also al-
lowed the use in the Colonies of other species
of the genus, provided that they yield a similar
proportion of cantharidin. Mylabris was charac-
terized as "usually an inch (twenty-five milli-
metres) or rather more long, and three-eighths
of an inch (nine millimetres) broad; with two
long elytra, each three times as long as broad,
black with two broad wavy transverse orange-
colored bands and a large orange-colored spot
at the base of each; one pair of brown membra-
nous wings."

Among other beetles that have occasionally
found their way into commerce may be men-
tioned: Cantharis quadrimaculattis {Mexican
Cantharides), Mylabris lunata, M. pustulata
(from India), M. bifasciata (from South Africa),
Epicauta gorhami (from Japan), Lytta aspersa
(from Argentina), etc.

Description. — "Unground Cantharides are

238

Cantharides

Part

beetles from 15 to 25 mm. in length and 5 to
8 mm. in breadth, oblong, somewhat compressed
above, externally iridescent, and having a brown
through olive-brown, green, blue to bluish pur-
ple color. The head is triangular, separated into
two lateral lobes by a faint median line. The
mandibles are stout and partly concealed; the
antennae filiform, of 11 joints, the basal clavate,
the second globular, and the remaining somewhat
conical. The eyes are comparatively small; the
prothorax angulate; the first and second pairs of
legs have 5 tarsal joints, the hind pair has 4
tarsal joints, and all legs have 2 distal claws.
The posterior wings are membranous and yel-
lowish brown or yellowish orange. The elytra or
wing sheaths has 2 parallel fines and are finely
wrinkled. Cantharides has a strong, disagreeable
odor, and a slight, acrid taste.

"Powdered Cantharides is moderate yellowish
brown to moderate olive-brown, often containing
iridescent particles. It shows long, pointed
spicules about 500 n in length and 20 n in width
at the base; fragments of striated muscles, of
chitinous body wall, and of wings and frequently
fragments of mites and their eggs." N.F.

Dried Spanish flies preserve the form and color
of the living insect. If kept perfectly dry, in well-
stoppered glass bottles, they retain their activity
for a great length of time, but exposed to a damp
air they quickly undergo putrefaction, and this
change takes place more speedily in the powder.
Hence the insects should either be kept whole,
and powdered as they are wanted for use. or, if
kept in powder, should be well dried immediately
after pulverization, and preserved in air-tight
vessels.

Cantharides are subject to attack by mites,
which feed on the interior soft parts of the body,
reducing them to powder, while the hard exterior
parts are not affected. An idea was at one time
prevalent that the vesicating property of the in-
sect was not injured by the worm, which was
supposed to devour only the inactive portion.
But this has been proved to be a mistake. Chloro-
form and carbon tetrachloride are among the
simplest, safest and best preservatives to prevent
the development of insects in drugs. Cantharides
will bear a very considerable heat without losing
the brilliant color of their elytra; nor is this
color extracted by water, alcohol, ether, or the
oils, so that the powder might be deprived of
all its active principle and yet retain the exterior
characters unaltered. The wing cases resist putre-
faction for a long time, and the shining particles
have been detected in the human stomach,
months after interment.

Standards and Tests. — Mylabris beetles. —
Unground cantharides should show no insects
with black and yellowish orange striped elytra.
Moisture. — Not over 10 per cent. N.F.

Assay. — The cantharidin from 15 Gm. of can-
tharides is extracted with a mixture of 2 volumes
of benzene and 1 volume of petroleum benzin. in
the presence of hydrochloric acid. A two-thirds
aliquot portion of the extract is concentrated by
evaporation and the cantharidin in it permitted
to crystallize. The crystals are washed with a
mixture of dehydrated alcohol and petroleum

benzin, saturated with cantharidin, until free of
fat and coloring matter; finally the cantharidin is
dried at 60° and weighed. N.F.

Constituents. — The activity of cantharides is
due to cantharidin, which was isolated by Robi-
quet in 1810. Cantharidin, C10H12O4, is hexa-
hydro-3a, 7a-dimethyl-4, 7-epoxyisobenzofuran-l,
3-dione, an anhydride (lactone) of cantharidic
acid, which latter is a derivative of cyclo-
hexanedicarboxylic acid. It has been com-
mercially extracted by several methods, and
was official in the B.P. 1932. Cantharidin
has been synthesized (see Ziegler et al.,
Ann. Chem., 1942, 551, 1; Paranjape et al.,
Proc. Indian Acad. Sci., 1944. 19A, 385; Stork
et al., J.A.C.S., 1953, 75, 384). There is present
also about 12 per cent of a fixed oil and. accord-
ing to Orfila, a volatile principle, upon which the
fetid odor of the beetle depends. Formic acid has
been reported to be present as well. The green
color of the wing cases is probably due to light
interference of their translucent films of tissue.

Adulterants. — These are not common. Occa-
sionally other insects, or even beads, are added,
purposely or through carelessness. These may be
readily distinguished by their appearance. Flies
exhausted of their cantharidin have been substi-
tuted for the genuine drug. These may be dis-
tinguished by their lack of substance and their
yielding a nearly colorless ethereal tincture. The
percentage of cantharidin found in cantharides
furnishes the best test of its activity.

Uses. — Internally administered, cantharides is
a powerful irritant. Genitourinary irritation is
ordinarily the first symptom produced by small
doses of cantharides, and, if the dose has been
large enough, it may cause violent strangury,
attended with excruciating pain, and the dis-
charge of bloody urine. Cantharides or some
similar vesicating insect appears to have been
used as far back as the time of Hippocrates in
the treatment of dropsy and amenorrhea. By its
local irritant effect, cantharides will increase the
quantity of urine, but it has been abandoned
in favor of less harmful diuretics. Because of
the priapism seen in cantharides poisoning the
drug has been used in sexual impotence but it is
capable of such serious injury that its employ-
ment is not advisable. As an internal remedy,
cantharides is of little practical value.

Externally applied, cantharides excites inflam-
mation in the skin, which terminates in a copious
secretion of serum under the cuticle. It has been
used both as a rubefacient and as a blistering
agent. In the former capacity it has no particular
merit, but as an epispastic it was preferred to all
other substances. When blistering agents are
allowed to stay on only long enough to irritate the
skin, but not to blister, they are sometimes of
service in neuralgias, applied directly over the
seat of pain. The chief use of cantharides, how-
ever, was to produce true blisters for the relief
of various internal inflammations. For this pur-
pose Cantharides Cerate was officially recog-
nized as recently as in N.F. VIII and was pre-
pared as follows: Moisten 350 Gm. of cantharides
(in very fine powder) with a mixture of 150 ml.
of turpentine oil and 25 ml. of glacial acetic acid.

Part I

Capsicum 239

and macerate in a well-covered container in a
warm place during 48 hours. Melt together 175
Gm. of rosin, 175 Gm. of yellow wax, and
200 Gm. of benzoinated lard, strain the mixture
through muslin, add the macerated cantharides,
and maintain the mixture in liquid condition by
heating on a water bath, stirring occasionally,
until reduced to a weight of 1000 Gm. Discon-
tinue heating, and stir the cerate until it becomes
firm. N.F. VIII. The B.P. recognized Plaster of
Cantharidin containing 0.2 per cent of cantharidin
in a mixture of castor oil, beeswax and wool-fat,
which was used similarly. These preparations were
applied to the skin as a plaster, which was made
by spreading an amount equivalent to 100 mg. per
square centimeter on a backing material such as
muslin or adhesive plaster. Such a plaster was left
on the part for 4 to 6 or at the most 8 hours,
depending on the sensitivity of the skin and the
degree of blistering desired. Even though the
plaster was removed in 4 to 6 hours, when the
skin was red but not blistered, a blister would
form. The serum was drained out of the blister
by incising its dependent portion and the lesion
was covered with an antiseptic powder. This form
of counterirritation has largely gone out of use.
It was employed in pneumonia, pleurisy, arthritis,
etc. It is possible for enough cantharidin to be
absorbed by the raw surface of a blister to cause
marked irritation of the genitourinary tract, [v]

Toxicology. — Toxic doses of Spanish fly pro-
duce obstinate and painful priapism, vomiting,
bloody stools, severe pains in the whole abdomi-
nal region, excessive salivation with a fetid
breath, hurried respiration, a hard and frequent
pulse, burning thirst, exceeding difficulty of de-
glutition, sometimes a dread of liquids, convul-
sions, tetany, delirium, and death. About 1.5 Gm.
of the powder has proved fatal. Dissection reveals
severe and acute inflammatory changes in the
kidney, the intestines and sometimes the spleen
(see J. AM. A., 1921, 76, 50). The drug has
been reported by Gordon {Clin. Proc, 1943, 2,
293) to be the most common poison in South
Africa.

The poisonous effects may be counteracted by
the use of emetics, cathartics, and opiates by the
stomach and rectum. Oils accelerate the poisonous
action, probably by dissolving the cantharidin. It
would seem probable that activated charcoal
might be useful as an antidote.

The dose of cantharides may be stated as 4 to
30 mg. (approximately %5 to ty grain), but it is
probably no longer prescribed.

Storage. — Preserve "in tight containers." N.F.

CANTHARIDES TINCTURE. N.F.

[Tinctura Cantharidis]

Tincture of Spanish Flies. Tinctura Cantharidum. Fr.
Teinture de cantharide. Ger. Spanischfliegentinktur. It.
Tintura di cantaride. Sp. Tintura de cantaridas.

Mix 100 Gm. of cantharides, in fine powder,
with 100 ml. of glacial acetic acid and 100 ml.
of alcohol, and macerate the mixture in a suitable
closed vessel during 4 days in a warm place.
Then transfer the mixture to a percolator; per-
colate slowly, using alcohol as additional men-

struum until the tincture measures 1000 ml. Mix
the product thoroughly. N.F.

Alcohol Content. — From 78 to 84 per cent,
by volume, of C2H5OH. N.F.

For a report on the efficiency of methods of
extraction of cantharides see Ohmart and Morgan
(/. A. Ph. A., 1939, 28, 385). The tincture is
the form in which cantharides was used (see
Cantharides) when it was prescribed internally.
It is still occasionally used as a rubefacient; the
likelihood of producing vesication should be kept
in mind.

Cantharides tincture has been given in doses
of 0.06 to 0.2 ml. (approximately 1 to 3 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

CAPSICUM. N.F.

Cayenne Pepper, [Capsicum]

"Capsicum is the dried ripe fruit of Capsicum
frutescens Linne, known in commerce as African
Chillies, or of Capsicum annuum Linne var.
conoides Irish, known in commerce as Tabasco
Pepper, or of Capsicum annuum var. longum
Sendt, known in commerce as Louisiana Long
Pepper, or of a hybrid between the Honka variety
of Japanese Capsicum and the Old Louisiana
Sport Capsicum known in commerce as Louisiana
Sport Pepper (Fam. Solanaceae.) . Capsicum must
be labeled to indicate which of the above varieties
is contained in the package. Capsicum yields not
less than 12 per cent of a non- volatile ether-
soluble extractive." N.F.

Red, African, Guinea, Bird, Spur, Zanzibar, Mombasa
or Nyassaland Pepper; African Cayenne; Capsicum Fruit;
Chillies. Capsici Fructus; Piper HisDanicum; Fructus
Capsici; Piper Indicum. Fr. Poivre d'Espagne; Capsique.
Ger. Spanischer Pfeffer ; Brasilianischer (Indischer; Un-
garischer; Tiirkischer) Pfeffer; Schotenpfeffer; Taschen-
pfeffer. It. Peperone.

Probably as a result of its widespread culti-
vation, the genus Capsicum contains a large
number of plant forms whose specific relations
afford a very difficult problem to the systematic
botanist. The probability is that the entire genus
was originally confined to the American tropics,
although it has been cultivated since the time
of Columbus in the temperate and tropical zones
of almost the whole world. Its first appearance
in literature seems to be in a writing of Peter
Martyn, dated September, 1493, referring to
its having been brought by Columbus. Neither in
ancient Sanskrit, Chinese, Greek, Latin, or
Hebrew is there a name for it. In 1887 Asa Gray
expressed his belief that there are only two species
in the genus, although in the last previous revi-
sion of the genus, in 1852, Dunal had recorded
fifty species. After a very thorough and careful
study of the subject, including the cultivation of
every procurable variety and species for four
years in the Missouri Botanical Garden, H. C.
Irish reached the conclusion that the dictum of
Gray was correct, and that there are really only
two species of the genus, one of which is herba-
ceous and annual or biennal, the other shrubby
and perennial, a conclusion which seems to be ac-
cepted by the great majority of taxonomists.

240 Capsicum

Part I

L. W. Bailey, however, believes the annual her-
baceous Capsicums to have descended from the
perennial, shrubby, C. frittescens and that these,
therefore, represent varieties or forms of that
species (see Bailey, Gentes Herbarum, 1923,
128-29).

The first of these species is the one most ex-
tensively cultivated in Europe and in this coun-
try; it is the C. annuum, L. The second is, in its
varieties, very largely grown in the tropical and
subtropical latitudes, its fruit not ripening at all
or only to a slight degree in the temperate zone.
It is the species which was described under the
name of C. frittescens, by Linnaeus, in 1737. By
Irish it is divided into two varieties — C. frutescens
proper which is characterized by its fruit being
oblong, acuminate, and usually embraced by the
calyx, and C. frutescens baccatum (C. baccatum
L.) which is characterized by its ovate or sub-
round fruit, usually seated on the calyx. In the
first of these perennial varieties are included the
C. fastigiatum of Blume and the C. minimum of
Miller, which yield most of the cayenne pepper
produced in the tropics, although, especially in
the West Indies and South America, C. baccatum
is largely cultivated.

Capsicum frutescens, the shrubby capsicum, is
cultivated in the southern United States, Mexico,
India, Japan, and British East Africa. The fruits
are collected when fully mature, deprived of
their calyxes, and carefully dried. Most of the
African chillies used in this country comes from
Zanzibar, Mombasa, Nyasal or Sierra Leone.
During 1952 importations of unground capsicum,
from Mexico, Japan. Sudan, Turkey, British East
Africa, Nigeria, Ethiopia, and Union of S. Africa,
amounted to 5,730,710 pounds. For an account of
the culture and the structure of capsicum grown
in Louisiana see Youngken (J. A. Ph. A., 1938,
27, 323).

The following are the characteristics of the
plant as given by Irish: "Plants shrubby, peren-
nial, two and a half to six feet high. Branches
angular, often channelled, puberulent or pubes-
cent, especially on the younger portions; usually
greatly enlarged and slightly purple at the nodes,
green or sometimes purplish striate. Leaves
broadly ovate, acuminate, 7.5 to 15 cm. long,
usually puffed or wrinkled, more or less pubes-
cent, especially around the veins. Petioles me-
dium, usually subciliate; peduncles slender, 2.5
to 5 cm. long, often in pairs, usually longer than
the fruit. Calyx usually cup-shaped, embracing
base of the fruit; teeth short, corolla white or
greenish white, spreading 10 to 20 mm. long,
often with ocherous markings in the throat. Fruit
red, ovate, obtuse or oblong acuminate, 20 to 30
mm. long and 6 to 18 mm. in diameter."

Capsicum annuum, the common green pepper,
while not used as a medicine, is of such impor-
tance as a condiment and food that some descrip-
tion of it seems justified. It is an annual herb
largely cultivated both in the United States and
in Europe, flowering in the early or middle sum-
mer, and ripening its fruit in the early autumn.
There are numerous varieties of it differing in
the shape of their fruit. That which is chiefly

cultivated in the United States for market, to be
used in the green state in pickling, or cooked for
the table, is the variety grossum; it has a large
irregularly ovate or conical berry depressed or
horned at the extremity, and when ripe varying
in color from yellowish to scarlet. A variety
with a long, conical, pointed and recurved fruit.
which is usually not thicker than the finger (var.
longum), is especially used in the making of red
pepper and is extensively used in the seasoning
of sausages. In another variety, var. cerasiforme
Irish, the cherry or oxheart pepper, the berries
are not more than an inch in diameter, spherical
and slightly compressed.

The fruit of the Capsicum annuum constitutes
paprika, or as it is sometimes called, sweet pep-
per; it has scarcely more than one-sixth the
pungency of real Cayenne pepper, so that the
addition of it to powdered chillies may be con-
sidered an adulteration.

The varieties of capsicums which occur on the
American market may be distinguished by the
size and color of their fruits as follows: The
pods of the East African pepper are about 12 mm.
in length, flattened, almost cylindrical, although
showing distinctly the conical form. The pods
of the Madagascar pepper reach the length of 6 to
7 cm. and a breadth of about 20 mm. The Bom-
bay, or cherry, peppers are very dark in color,
3.5 to 5 cm. in length, and 12 mm. or more in
breadth at the base; they are strictly conical and
less likely to be flat than those of the other vari-
eties. Zanzibar pepper is smaller than the East
African pepper but otherwise similar to it. Japa-
nese capsicum, whose botanical source is not
positively known, occurs in the market in two
forms, one in which the pods are large, reaching
the length of about 6 cm.; the other in which
the small pods are not 2.5 cm. in length. The
larger pods are scarcely to be distinguished from
Madras chillies; the smaller resemble, but are
nearly twice the size of, the East African pepper.
Sudan chillies from Africa, which is derived from
C. frutescens, consist of small, corneal red to
reddish brown or yellowish red fruits up to 2 cm.
in length and up to 5.5 mm. in breadth. The
color of the pods varies from light yellowish-
brown to deep red.

Description. — "Unground Capsicum occurs
as oblong-conical, often curved (Louisiana Long
Pepper), usually laterally compressed, from 10
to 25 mm. in length and from 4 to 8 mm. in
diameter (African Chillies), or up to 15 cm. in
length and 2.5 cm. in diameter (Louisiana Long
Pepper), or up to 5.5 cm. in length and up to
13 mm. in diameter (Louisiana Sport Pepper),
or up to 4 cm. in length and up to 9 mm. in
diameter (Tabasco Pepper). The fruit is 2-3-
locular, the dissepiments being united to a coni-
cal, central placenta at the base. The pericarp is
thin and membranous, its outer surface dark red-
dish brown to dusky yellowish orange, glabrous,
shrivelled, its inner surface striate with 2 to 3
distinct longitudinal ridges representing the pari-
etal placentae; the seeds are light brown to weak
yellowish orange, suborbicular or irregular, flat-
tened, from 2 to 4 mm. in diameter, with a

Part I

Capsicum 241

thickened edge and a prominent, pointed
micropyle. The calyx is moderate brown to
dusky yellowish orange, gamosepalous, inferior,
S-toothed, and sometimes attached to a long,
straight peduncle. Capsicum has a characteristic
odor, an intensely pungent taste and is sternu-
tatory." N.F. For histology see N.F.X.

"Powdered Capsicum is dark orange or dark
reddish orange to strong yellowish brown. It
shows numerous fragments of thin-walled paren-
chyma containing oil globules and orange, red, or
yellow chromoplasts; fragments of epicarp
with either striated, rectangular cells arranged in
parallel series (African Chillies), or with polyg-
onal, triangular, or irregular cells, with or without
beaded walls. The endocarp contains stone cells
with slightly wavy, lignified walls and broad
lumina. Numerous fragments of spermoderm
composed of stone cells are present, showing in
surface view, deeply sinuate, greatly thickened
and lignified vertical walls containing numerous
pore canals. Fragments of small-celled paren-
chyma of the endosperm containing fixed oil and
aleurone grains, the latter up to 5.5 u- in diameter,
are also present as well as occasional fibro-
vascular elements and calyx tissues." N.F.

Standards and Tests. — Stems and calyxes. —
Not over 3 per cent. Foreign organic matter. —
Not over 1 per cent. Acid-insoluble ash. — Not
over 1.25 per cent. N.F.

Assay. — This consists in determining the pro-
portion of non-volatile ether-soluble extractive.
As evidence of the potency of the drug this test
is of little if any value. The organoleptic test of
Munch (/. A. Ph. A., 1934, 23, 25) and the
colorimetric method proposed by Tice {Am. J.
Pharm., 1933, 105, 320) are more specific. The
latter assay involves comparison of the blue color
produced by capsaicin and vanadium oxytrichlo-
ride, VOCI3, with standard solutions containing
known amounts of capsaicin to which the same
reagent has been added. Hayden and Jordan
(/. A. Ph. A., 1941, 30, 107) called attention
to the fading of color in the standards and pro-
posed the use of permanent standards in which
the color is simulated by mixing cupric sulfate
and ferric chloride solutions. They also showed
that a number of substances containing phenolic
compounds, which might be present as adul-
terants, gave color reactions which nullify the
value of the test in such cases.

Constituents. — Although Braconnot described
a resinous, fatty mixture, named capsicin, as a
principle of capsicum, it was the work of Thresh
which led to the isolation, in 1876, of the prin-
ciple capsaicin, which is the most important
constituent of capsicum. The structure of this
substance was established, largely through the
work of E. K. Nelson, as a vanillylamide of iso-
decenoic acid, the formula being:

CH3O.OH.CeH3.CH2.NH.-

CO(CH2)4.CH :CH.CH(CH3)2

Capsaicin may also be described as 8-methyl-
N-vanillyl-6-nonenamide. It has been synthe-
sized from vanillylamine and isodecenoic acid.

Dodge (Drug and Cosmetic Industry, 1941, 49,
516) called attention to the fact that the pungent
principles of ginger also contain the vanillyl
group.

The capsaicin content of commercial red pep-
pers varies from 0.1 to 1 per cent. Isolation of
capsaicin may be readily carried out by the
method of Tice (loc. cit.) in which capsicum
oleoresin is mixed with mineral oil, the capsaicin
extracted with 57 per cent alcohol, purified by
solution in lithium hydroxide (or other hydroxide
according to Dodge) and precipitation with carbon
dioxide, and finally crystallized from petroleum
ether. Pure capsaicin is a white, crystalline sub-
stance, almost insoluble in water, but freely sol-
uble in alcohol, in ether and in alkalies. It melts
between 64° and 65°. The vapors of capsaicin
are extremely acrid, and handling of the substance
requires much precaution.

The principal coloring matter of capsicum is
the carotenoid pigment capsanthin, C-ioHssO;
other pigments include capsorubin, zeaxanthin,
cryptoxanthin, lutein and carotene. Ascorbic acid
has been reported to be present in quantities
ranging from 0.106 per cent to 0.572 per cent
(Dodge, loc. cit.).

Uses. — Capsicum is a powerful local stimulant,
producing, when swallowed, a sensation of heat in
the stomach, and a general glow over the body
without any narcotic effect. It is much employed
as a condiment, especially in hot climates, and
may be useful in cases of atony of the stomach
or intestines. It is contraindicated in cases of
gastric inflammation, though in chronically in-
flamed stomachs of persons of intemperate habits
it frequently appears to do good. It may also be
of value in certain cases of serous diarrhea not
dependent on true inflammation of the intestines.

When applied to the skin in proper concen-
tration solutions of capsicum produce at first a
sensation of warmth and, with more concentrated
solutions, later an almost intolerable burning.
It differs from other local irritants in that there
is practically no reddening of the skin even when
there is very severe subjective sensation. In other
words, while it exerts a strongly irritating effect
upon the endings of the sensory nerves, it has
very little action upon the capillary or other
blood vessels. Therefore, it does not cause blister-
ing even in strong solution. It is not proper to
call capsicum a rubefacient because it does not
produce reddening of the skin. It is, however, fre-
quently added to counterirritant applications. It
is also used in plasters. The sensation of warmth
which it produces is often very acceptable to the
patient, but it is doubtful whether it exerts the
same therapeutic effect as the rubefacients. The
burning sensation may be alleviated by applica-
tion of petrolatum. In the form of lozenges,
capsicum has been used for the treatment of
relaxed uvula and other similar conditions of the
pharynx. The tincture has been employed exter-
nally in the treatment of chilblains, [v]

Dose, of the powder, 60 mg. (approximately
1 grain) one to three times daily.

Storage. — Preserve "in well-closed containers,
adding a few drops of chloroform or carbon tetra-

242 Capsicum

Part I

chloride from time to time to prevent attack by
insects." N.F.

CAPSICUM OLEORESIN. N.F.

[Oleoresina Capsici]

Prepare the oleoresin from capsicum, in coarse
powder, by percolating it with either acetone or
ether. Recover the greater part of the solvent
from the percolate by distillation, transfer the
residue to a dish, and allow the remainder of the
volatile solvent to evaporate spontaneously in a
warm place remote from flame. Separate the
liquid oleoresin from the fatty matter by decan-
tation, or by draining it in a funnel containing a
pledget of absorbent cotton; reject the fatty
matter. N.F.

The active principles of capsicum appear to
be completely extracted by this process. It has
been suggested that an improvement in the
method of separating the fatty matter may be
effected by chilling the product, piercing the
solidified fatty layer and pouring off the liquid
oleoresin. The oleoresin is a very thick liquid
having a dark reddish-brown color ; though it does
not have much of the odor of capsicum, it is
intensely pungent to the taste.

Uses. — Capsicum oleoresin may be used for
any of the purposes discussed under Capsicum.
When taken internally in overdose the oleoresin
may cause strangury.

Capsicum Ointment, N.F.IX, was made by
incorporating SO Gm. of the oleoresin into a
melted mixture of 100 Gm. of paraffin and 850
Gm. of petrolatum; the preparation was used as
a counterirritant.

Dose, from 15 to 30 mg. (approximately % to
l/2 grain).

Storage. — Preserve "in tight containers." N.F.

CAPSICUM TINCTURE. N.F.

[Tinctura Capsici]

Tincture of Cayenne Pepper. Fr. Teinture de poivre
d'Espagne. Ger. Spanischpfeffertinktur. It. Tintura di
capsico annuo.

Prepare the tincture, by Process P (see under
Tinctures), from 100 Gm. of capsicum, in mod-
erately coarse powder, using a menstruum of
9 volumes of alcohol and 1 volume of water.
Macerate the drug during 3 hours, then percolate
rapidly, preparing 1000 ml. of tincture. N.F.

Alcohol Content. — From 80 to 85 per cent,
by volume, of C2H5OH. N.F.

Uses. — Capsicum tincture has been used in
atonic conditions of the stomach, especially in
alcoholic gastritis. It was also employed locally in
various sluggish conditions of the throat and for
other purposes for which capsicum is applicable.
Applied by means of a camel's-hair pencil to the
relaxed uvula, it sometimes produces contraction
and relieves prolapsus of that part. E

Dose, of the N.F. tincture, 0.3 to 0.6 ml.
(approximately 5 to 10 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

CARAMEL. N.F.

Burnt Sugar Coloring, [Caramel]

"Caramel is a concentrated aqueous solution of
the product obtained by heating sugar or glucose
until the sweet taste is destroyed and a uniform
dark brown mass results, a small amount of
alkali, alkaline carbonate or a trace of mineral
acid being added while heating." N.F.

Sugar Coloring. Saccharum Ustura. Fr. Caramel. Get.
Karamel.

When sucrose is heated above its melting
point, but short of a charring temperature, it
develops a deep brown color, and is finally trans-
formed to a brown, sticky mass which is called
caramel. Glucose, when treated similarly, yields
a like product. It is usually found in commerce
as a thick liquid which is a concentrated solution
of the solid mass which results when anhydrous
sugar is used. Solid caramel is an amorphous,
reddish-brown, brittle mass, quite porous and
highly deliquescent. Caramel made from cane
sugar is more soluble in hydro-alcoholic liquids
than that made from glucose, on account of the
dextrins present in glucose, which yield deriva-
tives not readily soluble in alcohol. For methods
of preparing caramel see U.S.D., 22nd ed., p. 286.

Description. — "Caramel is a thick, dark
brown liquid with the characteristic odor of
burnt sugar, and a pleasant, bitter taste. One
part of Caramel dissolved in 1000 parts of dis-
stilled water yields a clear solution having a dis-
tinct yellowish orange color. The color of this
solution is not changed, and no precipitate is
formed after exposure to sunlight for 6 hours.
Caramel spread in a thin layer on a glass plate
appears homogeneous, reddish brown,. and trans-
parent. Caramel is miscible with water in all
proportions, and is miscible with dilute alcohol
up to 55 per cent by volume. It is immiscible
with ether, chloroform, acetone, benzene, petro-
leum benzin, or turpentine oil. The specific
gravity of Caramel is not less than 1.30°." N.F.

Standards and Tests. — Purity. — No precipi-
tate forms on adding 0.5 ml. of phosphoric acid to
20 ml. of a 1 in 20 aqueous solution of caramel.
Residue on ignition. — When incinerated, caramel
swells and forms a coke-like charcoal which burns
only on prolonged heating at a high temperature;
not more than 8 per cent of residue results. N.F.

Constituents. — The substances caramelan,
caramelen, and caramelin have been described in
the literature as the true constituents of caramel.
The work of von Elbe (J.A.C.S., 1936, 58, 600),
however, indicates these substances to be mixtures
and that sucrose caramel in reality consists of a
mixture of two colorless compounds, as yet un-
characterized but apparently closely related to
the original sucrose, and a dark-brown infusible
substance which shows the properties of a lyo-
phobic colloid. The latter compound is kept in
dispersion by the former substances and, on sepa-
ration, is coagulated irreversibly. Von Elbe de-
scribes the isolation and certain properties of
these substances in bis report. For references to
earlier work on the composition of caramel see
U.S.D., 22nd ed., p. 287.

Part I

Caraway Oil 243

Uses. — Caramel is used in medicine only as a
coloring agent.

Storage. — Preserve "in tight containers." N.F.
Off. Prep.— Pentobarbital Elixir, N.F.

CARAWAY. N.F., B.P.

Caraway Fruit, Caraway Seed, Carum

"Caraway is the dried ripe fruit of Carum
Carvi Linne (Fam. Umbelliferce)." N.F. The
B.P. definition is identical.

Carui Fructus; Fructus Carvi; Semen Carvi; Semen
Cumini Pratensis. Fr. Carvi; Cumin des pres. Ger. Kiim-
mel; Brotkiimmel; Garbe; Karbensamen; Kummich. Sp.
Alcaravea.

The caraway plant is a biennial herb with a
spindle-shaped, fleshy, whitish root from which
arises, during the first year, a cluster of bi- to
tripinnate leaves. During the second year there
arises a slender stem bearing alternate, pinnate
to bipinnate leaves, the terminal segments of
which are very narrow and pointed. The in-
florescence is a long-stalked, compound umbel
bearing small white flowers with five minute calyx
teeth, five ovate and notched petals, five stamens
and a conical stylopod. The fruits are oblong,
laterally compressed, dark-brown cremocarps.

It is a native of Europe and Asia, growing
wild in meadows and pastures, and cultivated
in many places. The flowers appear in May and
June, and the seeds, which are not perfected
until the second year, ripen in August. The root,
when improved by culture, resembles the parsnip,
and is used as food in Northern Europe.

Caraway has been cultivated in several Euro-
pean countries, in India and to a lesser extent
in the northern part of the United States. The
plant thrives well in clay soil containing some
humus. The plants are mowed down when the
oldest fruits are ripe, dried in the field or in the
barn loft until they have lost most of their mois-
ture, after which the fruits are thrashed out,
cleaned and stored in bags. During 1952 there
were imported into this country 6,536,889 pounds
of caraway seed from Netherlands, Belgium,
French Morocco and Indonesia.

Description. — "Unground Caraway occurs
chiefly as separated mericarps from about 4 up
to about 7 mm. in length and from 1 to 2 mm.
in diameter. The mericarp is oblong, curved, and
tapers toward base and apex to which half of
the stylopod is attached. Externally, it is dark
brown to weak brown and shows 5 lighter col-
ored, filiform primary ribs, between each pair of
which, on the dorsal surface, occurs a secondary
rib. The odor and taste are characteristically
aromatic." N.F. For histology see N.F.X.

"Powdered Caraway is moderate yellowish
brown to light olive brown. It shows fragments
of the epicarp with striped cuticle; numerous
polyhedral endosperm cells containing aleurone
grains with embedded rosette aggregate crystals
of calcium oxalate; few fragments of slightly
lignified fibers and spiral vessels; fragments of
cross cells of endocarp; orange to yellow frag-
ments of vittae; no reticulate parenchyma." N.F.

Standards and Tests. — Foreign organic mat-
ter.— Not over 3 per cent of other fruits, seeds,

or other foreign organic matter. Acid-insoluble
ash. — Not over 1.5 per cent. N.F. The B.P. re-
quires not less than 3.5 per cent v/w of volatile
oil.

The characteristic aromatic odor and taste of
caraway depend on an essential oil, which may be
removed by distillation (see Caraway Oil).

Adulterants. — "Drawn caraway seeds," a
term applied to such as have been recovered
from the still residue after obtaining the volatile
oil, are used to adulterate caraway; the ex-
hausted "seeds" are much darker in color than
are the genuine and are less odorous. Other adul-
terants have been ergotized caraway seed, which
may be detected by the bluish-black sclerotia,
cumin, and the fruits of Aegopodium podagraria,
L. While these are the principal forms of adul-
teration, the drug may contain large amounts of
stems, gravel, sand, dust, weed seeds and other
impurities.

Uses. — Caraway is a mild stomachic and car-
minative, occasionally used in flatulent colic, and
as an adjuvant or corrective of other medicines.
The volatile oil, however, is more often employed
(see Caraway Oil).

Dose, 1 to 2 Gm. (approximately 15 to 30
grains).

Storage. — Preserve "in well-closed containers.
Caraway is susceptible to attack by insects." N.F.

Off. Prep. — Compound Cardamom Tincture,
N.F., B.P.; Caraway Oil, N.F.

CARAWAY OIL. N.F.

[Oleum Cari]

"Caraway Oil is a volatile oil distilled from the
dried, ripe fruit of Carum Carvi Linne (Fam. Um-
bellijercz). Caraway Oil yields not less than 50
per cent, by volume, of carvone (CioHuO)." N.F.

Oleum Carvi; Oleum Carui. Fr. Essence de carvi. Ger.
Kummelol. It. Essenza di comino.

This oil is prepared to a considerable extent
by distillers in this country but it has also been
largely imported, especially from Holland.

Description. — "Caraway Oil is a colorless to
pale yellow liquid, with the characteristic odor
and taste of caraway. One volume of Caraway
Oil is soluble in 8 volumes of 80 per cent alcohol.
The specific gravity of Caraway Oil is not less
than 0.900 and not more than 0.910. The optical
rotation of Caraway Oil is not less than +70°
and not more than +80° when determined in a
100-mm. tube, at 25°. The refractive index of
Caraway Oil at 20° is not less than 1.4840 and
not more than 1.4880." N.F.

Assay. — A 10-ml. portion of caraway oil is
heated, in a cassia flask, with saturated solution
of sodium sulfite which has been neutralized to
phenolphthalein by addition of saturated sodium
bisulfite solution; as a pink color develops on
heating, the mixture is neutralized with the
sodium bisulfite solution. When no coloration
appears on adding more phenolphthalein T.S.
and heating for 15 minutes, the oily layer is
brought into the calibrated neck of the flask by
adding sodium sulfite solution. The volume of
the oily layer should not exceed 5 ml., indicating
the oil to contain at least 50 per cent, by volume,

244 Caraway Oil

Part I

of carvone. This assay is based on the fact that
the carvone (C10H14O) component of the oil,
being a ketone, forms a water-soluble sodium
bisulfite addition product, the non-ketonic frac-
tion remaining insoluble; the latter constitutes
the oily layer measured at the end of the assay.

Constituents. — Caraway oil is essentially a
mixture of the ketone carvone — of which it con-
tains from 50 to 60 per cent — with a terpene
formerly called carvene but now recognized to be
(//-limonene. Traces of carvacrol also have been
reported. The carvone can be isolated from the
oil and prepared in a pure state by taking ad-
vantage of the formation of a crystalline com-
pound of carvone and hydrogen sulfide, which can
then be decomposed by treatment with alcoholic
potassium hydroxide.

Uses. — Caraway oil is used to impart flavor to
medicines, and to correct their nauseating
and griping effects. Gmeiner (Berl. tierdrztl.
Wchnschr., 1909, p. 695) recommended the use
of caraway oil in the treatment of scabies. He
employed a solution containing 5 volumes each of
alcohol and oil of caraway in 75 volumes of
castor oil.

Dose, from 0.06 to 0.3 ml. (approximately 1 to
5 minims).

Storage. — Preserve "in tight, light-resistant
containers." X.F.

Off. Prep. — Compound Cardamom Spirit,
N.F.

CARBACHOL. U.S.P., B.P., LP.

Carbamylcholine Chloride, [Carbacholum]

[XH2CO.O.CH2CH2.N(CH3)3.]Cl

The B.P. requires not less than 99.5 per cent
of C6H15O2N2CI, calculated with reference to
the substance dried to constant weight at 105° ;
the LP. rubric is not less than 97.0 per cent of
the same component, calculated with reference
to the substance dried at 110°. While the U.S. P.
provides no such rubric, its quantitative test for
nitrogen is equivalent to a requirement of not
less than approximately 97.8 per cent of the
active component, the test sample being dried
at 105° for 2 hours.

Choline Chloride Carbamate; Carbaminoylcholine Chlo-
ride, Doryl (Merck); Carcholin (Merck — for ophthalmic use
only); Moryl; Choryl. Sp. Carbacol.

Choline, HOCH2.CH2.N(CH3)3.OH, is a qua-
ternary ammonium base containing also a primary
alcohol group which may be esterified to form
choline esters. The most important of these esters
is acetylcholine (see under this title in Part I).
If, instead of the acetyl group being introduced
into the choline molecule, esterification results in
the introduction of the carbaminoyl (XH2CO — )
group of the hypothetical carbamic acid there is
produced carbaminoylcholine. the hydrochloric
acid salt of which is carbachol. Synthesis of car-
bachol is achieved through the interaction of
2-chloroethyl carbamate and trimethylamine.

Description. — "Carbachol occurs as white or
faintly yellow crystals or as a crystalline powder.
It is odorless and hygroscopic. Its solutions are
neutral to litmus. One Gm. of Carbachol dis-

solves in about 1 ml. of water and in 50 ml. of
alcohol. It is practically insoluble in chloroform
and in ether. Carbachol melts between 201° and
205°." US. P. The B.P. gives the melting point
as 210°, with decomposition, while the LP. gives
a range of 207° to 211°, also with decomposition.

Standards and Tests. — Identification. — (1)
A red precipitate, soluble in acetone, is produced
when 5 ml. of a 1 in 30 solution of ammonium
reineckate is added to a solution of 5 mg. of
carbachol in 5 ml. of water, the mixture being
shaken vigorously for a minute. (2) A white pre-
cipitate is produced on boiling 500 mg. of carba-
chol with 10 ml. of alcoholic potassium hydroxide
T.S.; on cooling an amine odor is perceptible. If
the supernatant liquid is decanted and 3 ml. of
diluted hydrochloric acid added to the precipi-
tate effervescence results. (3) A 1 in 20 solution of
carbachol responds to tests for chloride. (4)
Yellow crystals of aurichloride compound are
produced on adding 3 ml. of a 1 in 10 solution of
gold chloride to a solution of 100 mg. of carba-
chol in 1 ml. of water; the precipitate, after re-
crystallization from about 5 ml. of hot water,
separates in glistening scale-like crystals which
melt between 183° and 185° after preliminary
drying at 105°. Loss on drying. — Not over 2
per cent, when dried at 105° for 2 hours. Residue
on ignition. — Not over 0.1 per cent. Heavy metals.
— The limit is 30 parts per million. Xitrogen
content. — Not less than 15.0 per cent and not
more than 15.5 per cent, when determined by the
Kjeldahl method. U.S.P.

The B.P. and LP. also specify that a cream-
colored precipitate shall be produced on adding
potassio-mercuric iodide solution to a 1 per cent
w/v solution of carbachol. It is indicated that
on boiling carbachol with fixed alkali ammonia
is first evolved (from hydrolysis of the carba-
minoyl group), then trimethylamine (from the
choline group).

Assay. — The U.S.P. specifies limits for nitro-
gen content (see above), but the B.P. directs
titration of a solution of 500 mg. of carbachol
in 25 ml. of water with 0.1 -V silver nitrate,
using potassium chromate solution as indicator.
Each ml. of 0.1 A' silver nitrate represents 18.2 7
mg. of C6H15O2X2CI. The LP. assays for both
nitrogen and chloride.

Uses. — The most important use of carbachol
is that of a miotic in ophthalmology, particularly
in glaucoma.

Action. — As discussed under Parasympatho-
mimetic Drugs, in Part II, certain esters of
choline produce physiological effects which are
the same as those caused by stimulating the
parasympathetic nerves. Among these actions
may be mentioned especially: slowing of the
heart from vagal stimulation: general vasodilata-
tion with lowering of the blood pressure;
increased secretion of sweat, bronchial mucus
and saliva; increased intestinal, uterine and uri-
nary bladder peristalsis; and contraction of the
pupil.

The effects of carbachol are more prolonged
than those of acetylcholine because the former
is unaffected by the cholinesterase of the body

Part I

Carbachol, Injection of 245

(hence it is also not affected by simultaneous
administration of such anti-esterase drugs as
neostigmine and eserine). Compared with acetyl-
p-methylcholine (methacholine), its action is
much greater on the intestinal and urinary tracts
and much less on the circulation. Doses which
cause little, if any, other effects cause marked
stimulation of both acid and pepsin secretion in
the gastric juice (Goodman, /. Pharmacol., 1938,
63, 11). It also differs in having nicotine-like
action (affecting preganglionic and somatic motor
nerves), in addition to the muscarine-like action
(affecting postganglionic cholinergic nerves to
smooth muscle and gland cells) of acetylcholine
and its methyl derivative (Molitor, /. Pharmacol.,
1936, 58, 337).

In a study on normal persons, Starr (Am. J.
Med. Sc, 1937, 193, 393) reported that the
effects come on slowly; after subcutaneous doses
of 0.5 mg. warmth and flushing of the face was
the first sign. Sweating, salivation and lachri-
mation came later but were less marked than
after methacholine chloride. Audible peristalsis
occurred in about 15 minutes, and some persons
experienced a desire to urinate. Only a very slight
increase in heart rate and decrease in diastolic
blood pressure were found. Doses of 1 mg. pro-
duced similar effects except that abdominal
cramps were so severe as to require the adminis-
tration of atropine. Oral doses of 0.6 mg. showed,
after 1 to 2 hours, similar but milder effects.
Response to oral administration varied greatly
with different individuals; some showed evidence
of cumulative action. Most subjects tolerated
oral doses of 0.2 to 0.4 mg. twice daily. Atropine
abolishes the muscarine-like action of carbachol
but the antidotal action is much slower, and larger
doses of atropine are required as compared with
methacholine chloride.

Therapeutic Uses. — Carbachol has been em-
ployed in the treatment of peripheral vascular
disease of vasospastic type. Saland et al. (Ann.
Int. Med., 1945, 23, 48) reported, however, that
relief of pain was the only benefit derived from
biweekly injections. The drug has been used
effectively for urinary retention following opera-
tion, delivery, etc., and for abdominal distention
due to intestinal stasis (see Officer and Stewart,
Lancet, 1937, 2, 850). It produced only tempo-
rary decrease in the blood pressure of hyperten-
sive patients (Starr, loc. cit.). For paroxysmal
tachycardia methacholine chloride is preferred.
For myasthenia gravis neostigmine is a better
drug. James (Brit. M. J., 1945, 1, 663) reported
effective prophylaxis of migraine attacks from
oral administration. Ekbom (Acta med. Scandi-
nav., 1945, Suppl. 158) described relief of the
noctural syndrome "irritable legs" following use
of carbachol.

Ophthalmology. — Carbachol reduces intraocular
tension, is a powerful miotic and produces loss
of accommodation through muscle spasm. In the
treatment of glaucoma simplex one drop of a
1.5 per cent solution of carbachol, preferably in
a 1:3,000 solution of benzalkonium chloride,
may be instilled at intervals of 8 to 12 hours.
An ointment containing 1.5 per cent carbachol

may be similarly used. Carcholin (Merck) is the
powder commercially available for such use; it
must not be employed orally or by injection. A
0.1 per cent solution has been applied locally in
the nose for treatment of ozena.

Toxicology. — Carbachol should never be
given intravenously or intramuscularly. A hypo-
dermic syringe containing 0.6 mg. O/ioo grain) of
atropine should be available when carbachol is
administered, to be injected at the first evidence
of excessive fall in blood pressure, syncope,
marked irregularity of the cardiac rhythm or
pulse (see Burn, Brit. M. J., 1945, 1, 781). A
dose of 100 mg., given by mistake, caused death
in less than 3 hours (Lancet, 1946, 250, 713).

Contraindications. — Patients with bronchial
asthma or peptic ulcer should not be given
carbachol. S

In the U.S.P. carbachol is official for topical
use only, as a miotic, in 0.75 to 1.5 per cent con-
centration in ophthalmic solution or ointment.
By mouth carbachol is given in doses of from
0.2 to 0.8 mg. (approximately %oo to Yso grain),
two or three times daily. The B.P. gives the dose
as 1 to 4 mg. If given subcutaneously the dose is
0.25 to 0.5 mg.

Storage. — Preserve "in tight containers."
U.S.P.

INJECTION OF CARBACHOL.

B.P., LP.

Injectio Carbacholi

The B.P. Injection of Carbachol is a sterile
solution of carbachol in water for injection, with
the addition of 5 per cent w/v of dextrose. It
contains not less than 90.0 per cent and not more
than 110.0 per cent of the labeled content of
C6H15O2N2CI. The solution is sterilized by heat-
ing in an autoclave, maintaining it at 115° to
116° for 30 minutes, or by filtration through a
bacteria-proof filter. The LP. does not specify
use of dextrose in preparing the injection; the
assay rubric is the same as that of the B.P.

Assay. — A volume of injection equivalent to
8 mg. of carbachol is refluxed with sodium hydrox-
ide solution, which effects hydrolysis of carbachol
to choline. The solution is made slightly acid
with acetic acid, and the choline precipitated as
reineckate by addition of ammonium reineckate
T.S. The precipitate is filtered off, washed with
ice-cold water, dissolved in acetone, and the
percentage of light transmission of the solution
determined in a suitable photoelectric colorimeter
with a filter having a maximum transmission at
about 520 millimicrons. By comparison with a
reference transmission curve prepared from
aliquot portions of a solution of U.S.P. Choline
Chloride Reference Standard, treated in the same
manner as the carbachol solution, the weight of
choline chloride equivalent to the carbachol in
the solution under test is determined. This weight
is multiplied by 1.308 to obtain the weight of
C6H15CIN2O2 in the assay sample. U.S.P.XIV.
The B.P. and LP. assays are based on the same
reactions.

246 Carbachol, Injection of

Part I

Storage. — Preserve "in hermetic or other
suitable containers." U.S.P.XIV.

TABLETS OF CARBACHOL.

Compressi Carbacholi

LP.

The LP. requires that the average weight of
carbachol, C0H15O2N2CI, in the tablets shall be
not less than 90.0 per cent, and not more than
110.0 per cent, of the prescribed or stated
amount of carbachol.

For identification test and assay see U.S.P.XIV,
which procedures are employed by the LP.

Storage.— "Tablets of Carbachol should be
kept in a tightly-closed container." I.P.

Usual Size. — 2 mg. (approximately ^0 grain).

CARBARSONE. U.S.P., B.P., I.P.

p-Ureidobenzenearsonic Acid, [Carbarsonum]

0As(0H)2

hN-CO-NH5

"Carbarsone, dried at 80° for 6 hours, contains
an amount of As equivalent to not less than
97.5 per cent and not more than 101 per cent
of C7H9ASN2O4." U.S.P. The B.P. defines it as
/>-ureidophenylarsonic acid, and requires it to
contain not less than 28.1 per cent and not more
than 28.8 per cent of As, calculated with refer-
ence to the substance dried to constant weight at
105°. The I.P. limits for As are 28.0 to 28.8
per cent, referred to the substance dried at 80°
for six hours.

N-Carbaraylarsanilic Acid; />-Carbaminophenylarsonic
Acid; p-Carbaminobenzenearsonic Acid. Aminarsone. Sp.
Carbarson.

Carbarsone may be prepared by reacting an
aqueous sodium hydroxide solution of arsanilic
acid with a freshly prepared suspension of cyano-
gen bromide in water (see Stickings, /. Chem. S.,
1928, 3131) or by the interaction of arsanilic
acid and urea.

Description. — "Carbarsone occurs as a white,
almost odorless powder, having a slightly acid
taste. Its saturated solution is acid to litmus.
Carbarsone is slightly soluble in water and in
alcohol, and is nearly insoluble in chloroform and
in ether. It is soluble in solutions of alkali hy-
droxides and carbonates." U.S.P.

Standards and Tests. — Identification. — (1)
Moistened red litmus paper turns blue when
held over the mouth of a test tube in which
500 mg. of carbarsone is being gently heated
with 5 ml. of a 1 in 5 solution of sodium hydrox-
ide. (2) A light yellow precipitate, insoluble in
excess sodium hydroxide T.S., forms on adding
2 Gm. of sodium hydrosulfite to a solution of
1 Gm. of carbarsone in a mixture of 10 ml. of
sodium hydroxide T.S. and 10 ml. of water, and
warming to 50°. (3) A yellow precipitate of
arsenic sulfide, soluble in ammonium carbonate
T.S., is produced when hydrogen sulfide is passed
through a portion of the solution resulting from

the assay. Loss on drying. — Not over 1.5 per cent,
when dried for 6 hours at 80°. Arsenate. — No pre-
cipitate forms within 30 minutes on adding 3 ml.
of magnesia mixture T.S. to a solution of 500 mg.
of carbarsone in 2 ml. of ammonia T.S. diluted
to 5 ml. with water. U.S.P.

Assay. — About 250 mg. of dried carbarsone is
decomposed by heating with sulfuric acid in the
presence of potassium sulfate. The resulting solu-
tion is made alkaline with sodium hydroxide, then
acidified slightly with diluted sulfuric acid and,
after adding an excess of sodium bicarbonate, the
trivalent arsenic is titrated with 0.1 TV iodine.
Each ml. of 0.1 N iodine represents 13.00 mg. of
C7H0ASN2O4. U.S.P. The B.P. and I.P. assays are
identical with the procedure utilized for Try-
parsamide.

Uses. — In 1930 the efficacy of carbarsone in
the treatment of intestinal amebiasis was reported
(Leake et al., Proc. S. Exp. Biol. Med., 1931,
29, 125). In a concentration of 1 :600 it is amebi-
cidal, but not trypanocidal (Nakamura and
Anderson, /. Parasitol., 1951, 37, 421). It is
absorbed from the gastrointestinal tract but
arsenic is excreted only slowly in the urine and
interrupted therapy is necessary to avoid cumu-
lative poisoning. Carbarsone is active against
the encysted as well as the vegetative forms of
the parasite and Arnett {Am. J. Med. Sc, 1947,
213, 608) reported it to be the most effective
drug, although not in all cases, in the manage-
ment of asymptomatic carriers.

Cure of 90 per cent of cases of amebic dysen-
tery with one course of treatment was reported
by Anderson and Reed {Am. J. Trop. Med., 1934,
14, 269); Craig has confirmed this efficacy.
However, Wilmot et al. {J. Trop. Med. Hyg.,
1951, 54, 161) compared the results with ten
different compounds used singly in fifty cases
each and found that only 20 per cent were cured
in twenty days with carbarsone; chiniofon or
diiodohydroxyquinoline was superior. In pointing
out the superiority of combination therapy of
amebiasis, Martin {J. A.M. A., 1953, 151, 1055)
reported cure of only 4 out of 22 cases in six
weeks with carbarsone alone, whereas combina-
tion therapy with emetine, chiniofon and carbar-
sone produced good initial results in all of 23
cases and relapse in only 4 cases. Zavola and
Hamilton {Ann. Int. Med., 1952, 36, 110) also
emphasized the superiority of combination ther-
apy; they preferred diiodohydroxyquinoline with
emetine or chloroquine. Conn and Feldman
{Postgrad. Med., 1951, 9, 137) reported cure in
86.8 per cent of 497 cases with combined diiodo-
hydroxyquinoline and carbarsone therapy, Martin
(loc. cit.) recommended oxytetracycline plus
carbarsone or one of the other drugs, such as
emetine, chiniofon, chloroquine or bismuth gly-
coarsanilate and chloroquine. Radke {Ann. Int.
Med., 1951, 34, 1433) used carbarsone with
quinacrine to destroy cysts and observed relapse
in only 12 per cent of 25 cases.

For balantidiasis, it has been used effectively
in the same doses as for amebiasis (Young and
Burrows, Pub. Health Rep., 1943, 58, 1272).
Combes and Canizares {Arch. Dermat. Syph.,
1950, 62, 786) alleviated 8 of 15 cases of pem-

Part I

Carbol-Fuchsin Solution

247

phigus; a dose of 250 mg. daily was used for
seven days and then increased 250 mg. per day
at weekly intervals until a dose of 1 Gm. daily
was reached. If 100 mg. of sodium />-aminoben-
zoate was administered every 2 or 3 hours, the
large dose of carbarsone was tolerated. One of
the cases had used carbarsone for almost 10
years. For Trichomonas vaginalis vaginitis sup-
positories containing 130 mg. in a glycerin-
gelatin vehicle have been used nightly for two
weeks with success (Gospe, Calif. & West. Med.,
1934, 41, 172).

Intolerance to the drug was observed in only
1 patient in 330 by Anderson and Reed (loc. cit.) ;
the symptoms disappeared as soon as treatment
was discontinued. No deleterious effects on the
optic nerve have been reported. A case of
hepatic degeneration following the use of 5 Gm.
in a period of 10 days has been reported by
Epstein {J. A.M. A., 1936, 106, 769). It should
not be given to patients with severe kidney dis-
ease or liver disease; this includes cases of amebic
hepatitis or amebic abscess of the liver. Treat-
ment should be discontinued should vomiting,
increased diarrhea, pulmonary congestion, neu-
ritis, pruritus, dermatitis, hepatomegaly, spleno-
megaly or albuminuria appear. Sandground and
Hamilton (/. Pharmacol, 1943, 78, 109, 203,
209) observed that ^-aminobenzoic acid was
capable of protecting rats against toxic doses of
this and other pentavalent organic arsenical
compounds without interfering with their trypano-
cidal action.

Dose. — For carriers (cyst passers) without
diarrhea or for cases of amebic dysentery, after
acute symptoms have been controlled with eme-
tine if necessary, carbarsone is given in doses of
250 mg. (4 grains) twice daily for 10 days. The
patient should have a light diet and be at rest,
although mild activity is safe, if necessary and
desired. If amebic cysts persist in the feces, or re-
appear, the course of carbarsone may be repeated
after an interval of 10 days, although it is current
custom in resistant cases to alternate courses of
carbarsone with chiniofon or diiodohydroxy-
quinoline (War Med., 1941, 1, 539). If deep
ulcers persist in the lower colon, retention enemas
of 2 Gm. (30 grains) of carbarsone dissolved in
200 ml. of 2 per cent sodium bicarbonate solution
are often effective. These should be administered
on alternate nights following a cleansing enema
of sodium bicarbonate solution for a total of 5
doses; oral carbarsone should be discontinued
during the use of retention enemas. The adminis-
tration of a hypnotic, such as 100 mg. of pheno-
barbital, about 1 to 2 hours before the enema
may facilitate its retention. The dose of carbar-
sone for children is 30 mg. per 20 pounds of body
weight twice daily.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

CARBARSONE CAPSULES. U.S.P.

[Capsulae Carbarsoni]

"Carbarsone Capsules contain not less than
93 per cent and not more than 107 per cent of
the labeled amount of C7H9ASN2O4." U.S.P.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Usual Size. — 250 mg. (approximately 4
grains).

CARBARSONE SUPPOSITORIES.
U.S.P.

[Suppositoria Carbarsoni]

"Carbarsone Suppositories contain not less
than 90 per cent and not more than 1 10 per cent
of the labeled amount of C7H9ASN2O4." U.S.P.

The commercially available carbarsone sup-
positories are made with a glycerogelatin base
and are intended for vaginal insertion.

Uses. — Carbarsone suppositories are intended
for local use in the treatment of vaginitis caused
by the protozoan Trichomonas vaginalis. Gospe 's
(Calif. & West. Med., 1934, 41, 172) method of
treatment is to have the patient insert a sup-
pository nightly, on retiring, for 2 weeks; a so-
dium bicarbonate douche is permitted once each
week. After this course of treatment the ma-
jority of patients show normal vaginal smears
and clinical improvement; patients with a posi-
tive smear are given a second, and in some cases
a third, course of treatment. Recurrences are
frequent, but these respond to further treatment.
Another method of treatment consists in the in-
sertion of 2 suppositories, after cleansing the
vagina, twice weekly. Opinion is divided as to
whether treatment should be continued during
the menstrual period. Drabkin (Am. J. Obst.
Gyn., 1937, 33, 846) employed carbarsone sup-
positories both in the rectum and in the vagina.

The U.S.P. gives the usual vaginal dose as 130
mg.

Storage. — Preserve "in a cool place." U.S.P.

Usual Size. — 130 mg. (approximately 2
grains) of carbarsone.

CARBARSONE TABLETS.
U.S.P. (LP.)

[Tabellae Carbarsoni]

"Carbarsone Tablets contain not less than 93
per cent and not more than 107 per cent of the
labeled amount of C7H9ASN2O4." U.S.P. The
LP. provides the same limits.

Usual Sizes. — 50 mg. and 250 mg. (approxi-
mately }i and 4 grains).

CARBOL-FUCHSIN SOLUTION. N.F.

Castellani's Paint

Dissolve 3 Gm. of basic fuchsin in a mixture of
50 ml. of acetone and 100 ml. of alcohol; add to
this a solution of 10 Gm. of boric acid, 45 Gm.
of phenol and 100 Gm. of resorcinol in 725 ml.
of purified water; finally add purified water to
make the volume of the product measure 1000
ml., and mix thoroughly. N.F.

Carbol-Fuchsin Paint. Carfusin (Rorer).

Description. — "Carbol-Fuchsin Solution is a
dark purple liquid which appears purplish red
when spread in a thin film. The specific gravity of
Carbol-Fuchsin Solution is not less than 0.990 and
not more than 1.050." N.F.

Uses. — Carbol-fuchsin solution is a stabilized

248

Carbol-Fuchsin Solution

Part I

preparation of the original fuchsin formulation
known as Castellani's paint, and is widely em-
ployed for topical application to superficial fun-
gous infections of the skin. It is used in the
subacute and chronic stages of dermatophytosis
of the feet, in tinea corporis and cruris, and may
be of some value in other cutaneous diseases
with an intertriginous component, such as psori-
asis and seborrheic dermatitis; it has also been
used in the subacute and chronic phases of num-
mular eczema. In the dry, scaling type of der-
matophytosis the paint may be alternated with
ointments containing suitable antifungal and kera-
tolytic agents. Initial test applications of carbol-
fuchsin solution diluted with one or two volumes
of water may be advisable before treatment is
begun with the undiluted paint. The solution may
be applied once or twice daily.

Carbol-fuchsin solution shares with other tri-
phenylmethane (rosaniline) dyes the disadvantage
of staining clothing. It should not be applied to
large areas of the body, particularly to those that
are eroded. Contact sensitivity may occur.

For further information concerning uses of
basic fuchsin see under this title, in Part I.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

CARBON.

C (12.011)

Fr. Carbone. Ger. KoMenstoff. It. Carbone. Sp. Carbon.

Carbon, both free and combined, is widely
distributed in nature. At least 300,000 compounds
of it are known, compared to about 25,000 of all
other compounds. It exists in large quantity in
the mineral kingdom as carbonates and as coal,
and is the most abundant constituent of animal
and vegetable matter. In crystalline form it con-
stitutes the diamond and, more or less pure, it
forms the substances called graphite (black lead
or plumbago), anthracite and bituminous coal,
coke, lampblack, animal charcoal, and vegetable
charcoal (for a discussion of charcoal, see under
Activated Charcoal). Combined with oxygen it
forms carbon dioxide, which is a constituent of
the atmosphere, and is present in many natural
waters. With oxygen and a base it forms the
carbonates, among others calcium carbonate,
which is one of the most abundant of minerals.
There are at least two allotropic forms of car-
bon, represented by diamond and by graphite;
both are crystalline, the former belonging to the
isometric system, the latter to the hexagonal.
Amorphous carbon, represented by charcoal, coke
and carbon black, is considered by some to be a
third allotropic modification while others state
that these substances are composed of very small
crystals which have the crystalline structure of
graphite.

The diamond has been found in quantity in
India, in Brazil, and in South Africa, but at the
present time is obtained almost exclusively from
the last-named source. Several diamonds have
been found in the gold regions of Georgia and
North Carolina. This gem is perfectly transpar-
ent, and the hardest and most brilliant substance
in nature. Its density is about 3.5. In air or

oxygen it is combustible, the product being the
same as when charcoal is burned namely, carbon
dioxide. It has been made artificially at the tem-
perature of the electric arc (2500° to 3000°).

Next to diamond, graphite or plumbago is the
purest natural form of carbon. Graphite is the
substance of which "black-lead" crucibles and
so-called lead-pencils are made. Important de-
posits of graphite are found in Ceylon, Siberia,
Madagascar, Korea, Germany, Canada, Mexico
and the United States. In physical characters
it is entirely different from the diamond; it
crystallizes in hexagonal plates, is very soft and
unctuous, has a density of 2 to 2.5, and generally
contains some mineral matter. In connection
with the production of silicon carbide (carborun-
dum) in the electric furnace, Acheson produced
a very pure artificial graphite by increasing the
heat until the silicon was volatilized. This arti-
ficial graphite has a density of 2.5, is soft and of
high metallic luster. It is extensively used for
the manufacture of electrodes in electrochemical
manufacturing processes, and in making graphite
paint. Graphite is also extensively used for lubri-
cating purposes, especially in the colloidal form
known as deflocculated graphite.

Anthracite, the purest variety of natural coal,
occurs in different parts of the world, but particu-
larly in the State of Pennsylvania. The best
variety contains from 90 to 95 per cent of carbon,
and only several per cent of ash. Ordinary
anthracite for domestic heating purposes con-
tains from 10 to 25 per cent of ash. Bituminous
coal is another variety containing, besides the
fixed or free carbon, some 10 to 15 per cent of
volatile hydrocarbons or gas-making material.
When this is driven off by heating the coal in
the absence of air, as in the manufacture of coal-
gas, coke is obtained. Large quantities of coke
are employed in the manufacture of water gas
(an important fuel and source of hydrogen), in
the metallurgy of iron for its ability to reduce
iron oxides to metal, and as a household fuel.

Carbon black is a finely divided carbon obtained
by burning natural gas in a limited supply of air;
the carbon similarly obtained from oil or tar is
called lampblack. Carbon black, the better of
these two forms, is extensively used in the manu-
facture of rubber articles, especially tires, to
which it gives strength, resiliency and resistance
to wear. Other uses for these carbons are as
components of printer's ink, certain paints and
polishes, carbon paper and typewriter ribbons.

Colloidal carbon may be prepared by gradually-
adding sugar to sulfuric acid with continuous agi-
tation, then pouring the mixture into water and
filtering. The sulfuric acid may be removed by
dialysis and a clear black solution of colloidal
carbon remains. Other substances such as acetyl-
ene, for example, may be used in place of sugar.

Amorphous carbon, by which is meant the
forms of carbon other than graphite and
diamond, varies in color, density and hardness,
but all forms of it, when pure, are identical
chemically. Carbon is not affected by boiling with
dilute acids and alkalies but concentrated nitric
and sulfuric acids oxidize it slowly when heated.
At high temperatures carbon unites directly with

Part I

Carbon Dioxide

249

oxygen, with most metals, and with many non-
metals.

Isotopes. — Carbon exists in several isotopic
forms. One of these has an atomic weight of
13, and is referred to as carbon-13; it is a
stable isotope, i.e., not radioactive. It is present,
in very small amounts, in compounds contain-
ing predominantly ordinary carbon and is ob-
tained by a concentration process involving
thermal diffusion of gaseous forms of carbon
compounds. Its presence is readily detected, and
it may be quantitatively measured, by means of
the mass spectrometer. Compounds containing
carbon-13 are indistinguishable from identical
compounds containing ordinary carbon (carbon-
12) and they undergo the same reactions, includ-
ing those of metabolic processes, as do the
compounds containing carbon-12. But while the
compounds containing ordinary carbon cannot be
traced as they participate in the intricate reac-
tions of plant and animal life, corresponding
compounds containing carbon-13 may be de-
tected with the mass spectrometer; as a result,
much has been learned about the mechanisms of
chemical reactions in plants and animals.

Even more useful than carbon-13 as a tracer
element is the radioactive isotope carbon-14, ob-
tained by neutron bombardment of nitrogen-
containing compounds; this radioisotope has a
half-life of about 5000 years. It may be detected
by any of the methods employed for the detec-
tion and measurement of radioisotopes (see
article on Radium and Radioactivity), such
methods requiring less complicated apparatus
than is necessary for compounds containing
carbon-13. Carbon-14, in the form of carbon
dioxide and other compounds, is providing the
answers to many questions concerning the mecha-
nism of biochemical reactions; it has been a
particularly useful tool in extending our knowl-
edge of the nature of photosynthesis.

CARBON DIOXIDE. U.S.P., B.P., LP.

Carbonic Acid Gas, [Carbonei Dioxidum]

"Carbon Dioxide contains not less than 99 per
cent by volume of CO2." U.S.P. The B.P. and
LP. have the same rubric.

LP. Carbonei Dioxydum Sp. Bioxido de Carbono.

Carbon dioxide was first prepared in the early
part of the seventeenth century by Van Helmont,
who obtained it by the action of acids on chalk
and called it spiritus sylvestris. Occurring in
small proportions in the atmosphere, it is found
in somewhat higher concentrations in caves and
mines (constituting choke-damp) and, in solution,
in many spring waters. In aqueous solution a
portion of it combines with water to form H2CO3,
called carbonic acid.

In the laboratory it may be prepared by the
reaction of an acid with a carbonate. Commer-
cially it is made by separating it from gases
obtained in the combustion of coal or coke
by absorption in potassium carbonate solution;
the latter is subsequently heated under reduced
pressure to release the carbon dioxide. It is also
obtained as a by-product of industrial alcoholic

fermentations, and from the calcination of cal-
cium carbonate in lime kilns. A cheap source of
the gas is in the natural wells yielding carbon
dioxide, one well being reported to yield a gas of
98.5 per cent purity, the other constituents being
nitrogen and helium. In some wells hydrocarbons,
costly to remove, occur as impurities.

Carbon dioxide is usually supplied in com-
pressed form in metallic cylinders, in which it
exists largely as liquid, but for many purposes
the solid form, known as dry ice, is preferable.
This may be obtained by subjecting the gas to
high pressure and low temperature. Dry ice is
especially useful as a refrigerant; when it absorbs
heat from its surroundings the solid reverts to
gas without going through the liquid state.

Description. — "Carbon Dioxide is an odor-
less, colorless gas. Its solutions are acid to litmus.
One liter of Carbon Dioxide at 0° and at a pres-
sure of 760 mm. weighs 1.977 Gm. One volume
of Carbon Dioxide dissolves in about 1 volume
of water." U.S.P.

The solubility of carbon dioxide in water
diminishes with increasing temperature. At 0°,
760 mm. pressure, it dissolves in 0.56 volume of
water, and at 25° in 1.3 volumes. At constant
temperature the solubility of the gas increases
about one volume for each atmosphere of pres-
sure; in other words, at a pressure of about 30
pounds to the square inch it is approximately
twice as soluble as at one atmosphere. It is more
easily soluble in alcohol than in water. Its specific
gravity, compared with air, is 1.53 at 15°. It
liquefies at a pressure of 35 atmospheres and a
temperature of 0°, forming a colorless liquid
which boils at — 78.2° at atmospheric pressure.
When liquefied carbon dioxide is suddenly re-
leased from pressure a portion of it volatilizes
so rapidly as to absorb enough heat to solidify
the remainder, forming what is known as carbon
dioxide snow which, when compressed, forms dry
ice.

Standards and Tests. — Identification. — (1)
Carbon dioxide extinguishes a flame. (2) On
passing carbon dioxide into barium hydroxide T.S.
a white precipitate, dissolving in acetic acid with
effervescence, is produced. Acid and sulfur diox-
ide.— When 1000 ml. of carbon dioxide is passed
through 50 ml. of recently boiled and cooled
water it imparts at most an acidity corresponding
to 1 ml. of 0.01 N hydrochloric acid, as observed
in a control test, methyl orange T.S. being em-
ployed as indicator. Phosphine, hydrogen sulfide,
and organic reducing substances. — When 1000 ml.
of carbon dioxide is passed through a mixture of
silver ammonium nitrate T.S. and ammonia T.S.
no turbidity or darkening is produced. Carbon
monoxide. — 1000 ml. of the carbon dioxide to be
tested and 1000 ml. of carbon dioxide prepared
by treating sodium bicarbonate with hydrochloric
acid are separately shaken with a dilution of
blood, then with a mixture of pyrogallol and tan-
nic acid. The solution from the carbon dioxide
being tested should show no pink color and match
the gray color produced in the blank test. This
test depends on the fact that carboxyhemoglobin
possesses a characteristic bright red color which
does not react with pyrogallol and tannic acid to

250

Carbon Dioxide

Part I

produce the gray color shown by hemoglobin.
U.S.P.

The description and identity tests of the B.P.
and I. P. are much the same as those of the U.S.P.
In the B.P. test for the limit of acid and sulfur
dioxide, however, 500 ml. of carbon dioxide is
passed, successively, through a solution of sodium
bicarbonate and then through water containing
methyl orange indicator. Through one-half of the
latter is then passed 500 ml. more of carbon
dioxide and it is required that the color of this
portion of the solution not differ from that of
the other half of the methyl orange solution.

Assay. — A sample of 100 ml. of carbon diox-
ide, measured in a nitrometer, is passed through
a 50 per cent potassium hydroxide solution until
all of the CO2 has been absorbed, forming potas-
sium carbonate. The non-absorbed gas, if any,
should measure not more than 1 ml. U.S.P.

Uses. — Carbon dioxide is an essential sub-
stance in the body and has important uses both
systemically and' topically. Carbon dioxide and
water are end-products of the metabolism of fat
and carbohydrate, and even of protein, in the
animal organism. Carbon dioxide is excreted by
the lungs and, in the form of bicarbonate ion, by
the kidney, intestine and skin. On the other hand,
when sodium bicarbonate labeled with carbon-11
was administered to rats the labeled carbon was
found in glycogen in the liver (Vennesland et al,
J. Biol. Chem., 1942, 142, 379). Ochoa {Physiol.
Rev., 1951, 31, 56) reviewed the evidence which
indicates that carbon dioxide is not only released
in the citric acid cycle of metabolite degradation
in animal cells but may enter into the synthesis
of dicarboxylic acids, such as malic acid, and even
citric acid, in a reversal of this cycle. This is
perhaps the predominant process in plants in the
course of utilizing carbon dioxide from the air.

Inhalations of carbon dioxide, mixed with air
or oxygen, are employed clinically to stimulate
respiration in asphyxia with arrested respiration,
to hasten the excretion of poisonous or other
gases, such as carbon monoxide, and to produce
full expansion of the lungs in the treatment or
prevention of atelectasis (Barach, Inhalations
Therapy, J. B. Lippincott Co., 1944). Carbon
dioxide is also used for hiccough, the hyper-
ventilation syndrome in hysteria, air sickness, etc.,
for cough, and for narcosis therapy in certain
cases of psychoneurosis. Solid carbon dioxide is
used in cryotherapy. As carbonated water, it is
used both as a flavoring vehicle and as a bath in
asthenic conditions.

Action. Respiration. — Haldane demonstrated
that the rate and depth of respiration was cor-
related with the tension of carbon dioxide in the
alveolar air of the lungs. The responsiveness of
the respiratory center in the central nervous sys-
tem alters the effect of carbon dioxide. The ca-
rotid body and the aortic body play a role in
the regulation of respiration; these chromaffin
bodies are affected by a deficiency of oxygen and
by other stimuli such as an excess of carbon
dioxide, although a change of at least 0.1 pH unit
in the blood is needed to stimulate them. Reflex
stimuli from the extremities and other portions
of the body also alter respiration (Schmidt, Ann.

Rev. Physiol, 1945, 7, 231). Mills (/. Physiol,
1953, 122, 66) studied alveolar carbon dioxide
tension in humans during the day and night and
found a higher tension at night, although there
was no definite effect of sleep. The responsiveness
of the respiratory center to stimulation by carbon
dioxide (probably an associated increase in the
hydrogen ion concentration of the blood) is de-
pressed by anoxia and various drugs such as ether,
alcohol, chloroform, morphine, barbital, etc. In a
normal person, the inhalation of 1.6 per cent
carbon dioxide in air approximately doubles the
respiratory minute volume and 5 per cent almost
trebles the respiratory volume (Padget, Am. J.
Physiol, 1928, 83, 384); a concentration of 10
per cent produces unbearable dyspnea after a few
minutes and continued use results in vomiting,
disorientation and hypertension; inhalation of 25
per cent carbon dioxide produces only transient
hypernea followed by twitching, clonic convul-
sions, coma and respiratory failure due to acidosis.
Even 7 per cent may be distinctly depressing in
the presence of preanesthetic medication.

Circulation. — The circulation is also affected
by carbon dioxide. A local increase in carbon
dioxide tension in the blood results in increased
acidity and vasodilatation, but an increased con-
centration in the blood reaching the vasomotor
center in the brain results in generalized vaso-
constriction. An increased concentration in the
blood due to exercise is rapidly excreted by the
lungs and stimulation of the vasomotor center
does not result. When carbon dioxide is inhaled
this pulmonary excretion is prevented and pe-
ripheral vasoconstriction with a rise in blood
pressure occurs. In contrast to the rest of the
body, cerebral blood flow is increased and as
already noted an increase in respiratory minute
volume occurs unless the responsiveness of the
respiratory center is depressed by anoxia or drugs.
An increase in cardiac output also occurs although
the heart rate and the conduction of the nervous
impulse in the heart are depressed. Henderson
and his associates {Am. J. Physiol, 1936, 114,
261) called attention to an increase in muscular
tone which resulted in an increased rate of the
return of venous blood to the heart. High con-
centrations of carbon dioxide via pulmonary ar-
terial blood (equilibrated with 8 to 15 per cent
of CO2 and 30 per cent of O2, in nitrogen) de-
crease blood flow through the ventilated and non-
ventilated lung (Bean et al, Amer. J. Physiol,
1951, 166, 723). There are important differences
in the response of various regions of the pulmo-
nary vascular bed and the assumption of gen-
eralized vasoconstriction is unjustified. The de-
creased flow is accompanied by pooling of blood
in the lungs, which may indicate an active vaso-
dilation or a passive reservoir function conse-
quent upon a constriction of efferent vessels by
vascular or parenchymal muscle. These data
should qualify the significant statement that the
vasoconstriction of pulmonary vessels produced
by carbon dioxide serves as a local method of
shunting blood from poorly aerated to more ade-
quately ventilated regions of the lung. Carbon
dioxide in the lung may act directly on vessels
or facilitate their nervous regulation in the intact

Part I

Carbon Dioxide

251

animal by its local anticholinesterase action
(Gesell et al., Univ. Hosp. Bull. Ann Arbor, 1941,
7, 94).

A deficiency of carbon dioxide in the blood —
acapnia — results in peripheral vasodilatation with
a fall in blood pressure, tachycardia with de-
creased cardiac output, and a diminished stimulus
for respiration. Voluntary hyperventilation pro-
duces these changes but, during the period of
apnea or of diminished respiration which follows
the overbreathing, carbon dioxide accumulates
and again stimulates respiration. When, however,
anoxia, due to high altitudes, the induction of
ether anesthesia, etc., causes hyperventilation,
there is not only a loss of carbon dioxide but also
a depression in the responsiveness of the respira-
tory center; if respiration ceases, both carbon
dioxide and oxygen may be required to start
breathing again. Carbon dioxide in the blood is
in equilibrium with the carbon dioxide in alveolar
air and with the bicarbonate ion in the blood
which is related to the avalable base (sodium,
calcium, etc.) in the blood. A decrease in the
carbon dioxide in the blood (carbon dioxide con-
tent) may occur without a comparable decrease
in the bases of the blood (carbon dioxide com-
bining power) and result in alkalosis but the bases
are often also decreased (carbon dioxide combin-
ing power) due to an associated acidosis, as in
anesthesia. The enzyme carbonic anhydrase is
concerned in the release of carbon dioxide from
the blood to the lungs (see Evans, Harvey Lec-
tures, 1944, 39, 96 and 273), as it is also in the
absorption of carbon dioxide from tissues by
blood.

Therapeutic Uses. — Mixtures of oxygen and
carbon dioxide are preferable to oxygen alone for
maintenance of acid-base equilibrium under re-
duced barometric pressure, such as is encountered
during flights at high altitude (Garasenko, Am.
Rev. Soviet Med., 1944, 2, 119); this conclusion
was based on measurement of the urinary changes
characteristic of hypocapnia. When acapnia is due
to anoxia, the inhalation of oxygen to correct the
anoxia, and the loss of carbon dioxide which re-
sults from the hyperventilation, is the best treat-
ment (Ausherman, Anesth. & Analg., 1948, 27,
172). Administration of carbon dioxide to indi-
viduals who are dyspneic because of the anoxia
of high altitudes or of cardiac or respiratory
disease is seldom indicated.

In 1920 Henderson and his co-workers (see
J. A.M. A., 1921, 77, 1065) recommended inhala-
tion of carbon dioxide as a stimulant in the treat-
ment of shock and respiratory depression, espe-
cially as caused by poisons such as carbon
monoxide which diminish the oxidizing power of
the blood. Although recovery from carbon mon-
oxide poisoning is almost as rapid with oxygen
inhalations alone, a mixture containing 5 to 10
per cent of carbon dioxide is preferable because
it speeds the dissociation of the carbon monoxide
hemoglobin combination and allows more oxygen
to reach the tissue cells (Stadie and Martin,
/. Clin. Inv., 1925, 2, 77). Henderson also sug-
gested use of such mixtures in the management of
asphyxiation of newborn infants but Eastman
{Am. J. Obst. Gyn., 1938, 36, 571) and Kane and

Kreiselman called attention to the high carbon
dioxide content of the blood of the newborn and
reported that oxygen without carbon dioxide is
preferable. It must be remembered that, in poi-
soning by respiratory depressants such as mor-
phine, the sensitivity of the respiratory center is
depressed; there is ample, in fact excessive, car-
bon dioxide in the blood but the respiratory fail-
ure is due to inability of the nervous system to
respond to the stimulation. In poisoning by hydro-
cyanic acid and carbon monoxide, the reduction
in breathing is due to diminished formation of
carbon dioxide because of inability of blood to
transport oxygen and, in the case of cyanide, to
interference with respiratory enzymes in the
tissue cells.

Caution must be exercised in the use of carbon
dioxide inhalations in the treatment of respiratory
depression, especially if the apnea has existed for
some time and the carbon dioxide tension in the
blood is already high. Further administration of
carbon dioxide at this time may lead to further
depression of respiration. When pulmonary func-
tion is impaired an increase in blood carbon
dioxide exists, as well as a decrease in oxygen.
Oxygen inhalation increases oxygen absorption
but does not facilitate carbon dioxide excretion.
In the presence of a high concentration of carbon
dioxide in the blood, the respiratory center be-
comes insensitive to carbon dioxide and when the
low oxygen saturation of the blood is corrected
the respiration may decrease in both frequency
and volume; as a result the concentration of
carbon dioxide may increase to a level causing
coma. Hickam et al. {North Carolina M. J., 1952,
13, 35) reported four such cases during prolonged
oxygen therapy. In bulbar poliomyelitis, loss of
sensitivity to carbon dioxide by the respiratory
center may arise as a result of the disease. Cor-
rection of the anoxia in these cases with oxygen
inhalations alone may result in complete failure
of respiration (Sarnoff et al., J.A.M.A., 1951,
147, 30). Artificial respiration with air is prefer-
able in such patients if the venous plasma carbon
dioxide combining power exceeds 60 volumes per
cent or if the oxyhemoglobin in arterial blood is
less than 94 per cent of saturation (Plum and
Wolff, J.A.M.A., 1951, 146, 442).

Inhalation of carbon dioxide has been recom-
mended in the symptomatic management of cough
(Banyai, J.A.M.A., 1952, 148, 501), for the relief
of the paroxysm of whooping cough {J. A.M. A.,
1932, 99, 654) and for hastening recovery from
ether anesthesia. King {J. A.M. A., 1933, 100, 21)
found that carbon dioxide lessens the postopera-
tive complications, such as pulmonary atelectasis,
pneumonitis and phlebothrombosis, after abdomi-
nal surgery, but that the results are not greatly
superior to those induced by frequent change of
position of the patient. In prolonged narcosis of
poisoning with depressants (such as the barbitu-
rates, morphine, etc.) or that induced in the
treatment of status asthmaticus, intractable epi-
lepsy (Putnam and Rothenberg, J. A.M. A., 1953,
152, 1400), etc., a few inhalations of a mixture
of 10 per cent of carbon dioxide and 90 per cent
of oxygen are used every hour to cause hyper-
ventilation to minimize the pulmonary complica-

252

Carbon Dioxide

Part I

tions of the prolonged coma. Holinger et al.
(J. AM. A.. 1941, 117, 675) found carbon dioxide
to be an extremely efficient expectorant; on in-
halation it reaches the smaller bronchioles, causes
deeper respiration, liquefies sputum and stimu-
lates coughing. Carbon dioxide was more efficient
than the drugs usually prescribed for this purpose
and was somewhat more effective than steam
inhalations. They recommended carbon dioxide
in both acute tracheobronchial infections and in
bronchiectasis. Banyai and Cadden (Brit. J.
Tuberc, 1944, 38, 111) advocated use of car-
bon dioxide as an expectorant in pulmonary
tuberculosis.

The acapnia syndrome frequently observed in
nervous persons or passengers in airplanes as a
result of hyperventilation is corrected rapidly by
the inhalation of carbon dioxide, which may be
accomplished simply by having the patient re-
breathe from a paper bag held closely over the
nose and mouth. The breathing of 7 to 10 per
cent carbon dioxide in oxygen is the most effective
remedy for persistent hiccough; the gravity of
this syndrome justifies the production of the
mild toxic effects of carbon dioxide, if necessary
(Sheldon. J. AM. A., 1927, 89, 1118). A rapid di-
agnostic test for the presence of sickle cell anemia,
developed by Winsor and Burch (J. A.M. A., 1945,
129, 703), involves the comparison of the eryth-
rocyte sedimentation rate of well-aerated blood
with that of blood exposed to carbon dioxide.

Inhalations of carbon dioxide may produce
mental clarity in individuals stuporous due to
excessive use of alcoholic beverages (Barach.
Am. J. Physiol, 1934, 107, 610). Loevenhart
et al. (J.A.M.A., 1929, 92, 880) reported that
such inhalations induced mental clarity in patients
with dementia praecox.

Kindwall (Am. J. Psychiat., 1949, 105, 682)
utilized inhalations of a mixture of 30 per cent of
carbon dioxide and 70 per cent of oxygen to
induce narcosis for psychotherapeutic discussions.
Such inhalations, administered three times weekly,
relieved 11 of S3 cases of stuttering (Meduna,
Carbon Dioxide Therapy, 1950) ; patients whose
stuttering appeared after normal speech had been
established were usually relieved by a treatment
and eventually recovered. Silver (South. M. J.,
1953, 46, 283) employed 8 to 9 inhalations of
nitrous oxide, followed by 15 to 25 inhalations
of the carbon dioxide— oxygen mixture to induce
transient (about 1 minute) coma with benefit in
45 per cent of 250 cases of mild psychoneurotic
depressions and anxiety states. Without the nitrous
oxide the hyperpnea induced aggravated the anxi-
ety in some cases. With 25 to 40 inhalations of the
carbon dioxide-oxygen mixture alone, Moriartv
(/. Clin. Exp. Psychopath., 1952, 13, 181) ob-
tained benefit in 39 per cent of 66 psychoneu-
rotics. Fay (J.A.M.A., 1953, 152, 1623) reported
on the relaxing value of inhalations of 20 per cent
carbon dioxide-80 per cent oxygen mixtures for
1 to 3 minutes for the muscular rigidity of certain
cases of cerebral palsy of the athetotic type.
Leavitt (ibid., 1953, 153, 509), however, asserted
that this was just another form of nonspecific
psychotherapy with unjustifiable toxic potenti-
alities. In 17 young adult men. MacDonald and

Simonson (/. Applied Physiol., 1953, 6, 304) ob-
served electrocardiographic abnormalities in 12
during inhalation of 30 per cent carbon dioxide;
these included various arrhythmias and changes
in the voltage of the P and the T waves.

In the Rubin test for patency of the Fallopian
tubes (oviducts), which is frequently employed
in the evaluation of sterility in the human female,
carbon dioxide is the preferred gas for injection
into the canal of the cervix of the uterus. Patency
is demonstrated by the sudden decrease in the
pressure of the gas and a gurgling sound on
auscultation of the abdomen. Carbon dioxide,
being rapidly dissolved in the body, is preferred
to air. which has caused fatal air embolism in
several cases.

Administration. — Best results from the use of
carbon dioxide as a stimulant require the employ-
ment of an apparatus consisting of a face mask
or a funnel, a tank of carbon dioxide and oxygen
mixture, a valve and tubing. Brown (U. S. Nav.
M. Bull., 1930. 28, 525) found that maximal
stimulation of respiration is brought about in
normal man by 10.4 per cent of carbon dioxide,
but that there is considerable individual variation
and that it is impossible to inhale such high per-
centages for more than a few minutes without loss
of consciousness. Ordinarily mixtures containing
5 to 7 per cent of carbon dioxide may be used.
While in most cases the clinical response is a
satisfactory guide to the dosage of carbon dioxide,
where there is a reduction in the cardiac efficiency
great caution must be observed against the de-
pressant effects of too large doses (Waters,
J. A.M. A., 1933, 100, 1275). Except under special
circumstances, and then only under competent
observation, inhalations of 5 per cent carbon
dioxide in oxygen should not be continued for
over 30 minutes, the 10 per cent not over 10 min-
utes. Particular caution is required in patients
with obstruction of the tracheo-bronchial tree or
those with pulmonary edema; the increased nega-
tive pressure within the chest produced by the
stimulated respiratory movements aggravates any
tendency of the blood plasma to transfer across
the thin membrane into the alveoli of the lungs.

Stimulant Baths. — McClellan and his asso-
ciates (Am. Heart J., 1945. 29, 44) studied the
physiologic effects of baths in carbon dioxide-
charged waters; they reported a decrease in pulse
rate and diastolic blood pressure, better return
of venous blood to the heart, hyperemia of the
skin, a slight increase in cardiac output, an in-
crease in respiratory minute volume, and an
increase of 5 to 10 per cent in the pulmonary
excretion of carbon dioxide; these findings sug-
gest absorption through the skin.

Cryotherapy. — Carbon dioxide is also useful
as an escharotic (see Arch. Phys. Med., 1945, 26,
270). Its destructive action depends on the in-
tense cold produced by the evaporation of the
solidified gas commonly called carbonic acid snow
or dry ice. This may be prepared extemporane-
ously by allowing the compressed gas to escape
from a cylinder into a cone-shaped felt or woolen
receptacle. The rapid expansion of the gas when
released from pressure causes it to solidify in the
form of snow which may be pressed into molds.

Part I

Carbon Tetrachloride

253

The temperature of solid carbon dioxide is
— 109° F. It is widely used as a refrigerant for
food and in certain industrial processes. Its evapo-
ration, when applied to the skin, absorbs an im-
mense amount of heat and almost immediately
freezes the area to which it has been applied, the
depth and permanency of the effect depending on
the duration of the application. Superficial freez-
ing of the skin causes complete cessation of all
functions, thus providing local anesthesia as well
as arrest of blood flow. After thorough freezing
with carbonic acid snow, thrombi are formed in
the superficial capillaries and lead to a permanent
obstruction of the circulation and consequent
death of the part. For application to lesions the
solid or a "slush" has been employed. This "slush"
is prepared by pulverizing the "dry ice" in a mor-
tar and pestle, then adding a little precipitated
sulfur and acetone until a smooth "slush" is pro-
duced, which may be applied on a cotton applica-
tor encased in cotton gauze. Carbonic acid snow is
used for the destruction of various types of neo-
plasms, as warts, hairy moles, and vascular nevi.
It is also of service in the treatment of epithelio-
mata. It has not proved to be useful in the
destruction of scars following acne vulgaris.
Hedge (J.A.M.A., 1928, 90, 1367) used it to
destroy the lesions of blastomycosis. The duration
of a single application is from thirty seconds to
one or two minutes, according to the depth of
action which is desired. Severe "burns" of the skin
following improper industrial use of "dry ice"
have occurred.

Flavoring Agent. — Carbon dioxide serves as
a flavoring agent in carbonated beverages and in
effervescent preparations of several drugs. A solu-
tion which is supersaturated with carbon dioxide
has a pleasant, slightly acid taste and produces a
mildly prickling sensation in the mouth which
effectively masks the taste of salty drugs.

Application. — By inhalation, the usual con-
centration is from 5 to 7.5 per cent, in oxygen.

Storage. — Preserve "in tight containers."
U.S.P.

CARBON TETRACHLORIDE.
N.F., B.P., LP.

[Carbonei Tetrachloridum]

ecu

None of the official compendia provides the
conventional purity rubric statement for this
substance.

Perchloromethane; Chlorocarbon. Carbo Tetrachloratus;
Carboneum Tetrachloratum; Carbonei Chlorurum. Fr.
Tetrachlorure de carbone. Ger. Tetrachlorkohlenstoff;
Chlorokohlenstoff ; Kohlenstofftetrachlorid. Sp. Cloruro de
carbono; Tetracloruro de carbono.

Carbon tetrachloride was discovered by Reg-
nault in 1839. It may be prepared by the inter-
action of the vapor of carbon disulfide with dry
chlorine in the presence of iron as a catalyst, or
by the action of chlorine on methane, but the
usual commercial process involves chlorination of
carbon disulfide by means of sulfur monochloride,
S2CI2, using iron as the catalyst.

Description. — "Carbon Tetrachloride is a
clear, colorless, mobile liquid. It has a charac-

teristic odor, resembling that of chloroform. Car-
bon Tetrachloride is nonflammable, but is slowly
decomposed by light and by various metals if
moisture is present. Carbon Tetrachloride dis-
solves in about 2000 times its volume of water,
and is miscible with alcohol, with chloroform, and
with ether. It dissolves most of the fixed and
volatile oils. The specific gravity of carbon tetra-
chloride is not less than 1.588 and not more than
1.590. Carbon Tetrachloride distils completely
between 76° and 78°." N.F.

Standards and Tests. — Non-volatile residue.
— The residue, if any, from 50 ml. of carbon
tetrachloride evaporated on a water bath is odor-
less; when dried at 105° for 1 hour its weight
does not exceed 1 mg. Readily carbonizable sub-
stances.— The acid layer separating from a mix-
ture of 40 ml. of carbon tetrachloride and 5 ml.
of sulfuric acid which has been shaken vigorously
for 5 minutes has no more color than matching
fluid A. Acid, chloride ion, and free chlorine. —
The aqueous layer separating from a mixture of
15 ml. of carbon tetrachloride and 25 ml. of re-
cently boiled and cooled distilled water which has
been shaken for 5 minutes is neutral to litmus
paper, does not produce a turbidity with silver
nitrate T.S., and is not colored blue on addition
of potassium iodide T.S. and starch T.S. Carbon
disulfide. — No yellow precipitate develops in a
mixture of 10 ml. of carbon tetrachloride in 10 ml.
of a 10 per cent solution of potassium hydroxide
in alcohol to which has been added, after stand-
ing an hour, 5 ml. of acetic acid and then 1 ml.
of cupric sulfate T.S., the mixture being allowed
to stand 2 hours. N.F.

The following B.P. tests are significantly dif-
ferent from those of the N.F. : A test for limit of
free chlorine depending upon the liberation of
iodine from cadmium iodide; a test for the limit
of sulfur compounds in which a portion of carbon
tetrachloride is heated, under a reflux condenser,
with a mixture of dehydrated alcohol and a solu-
tion of potassium plumbite, and set aside for five
minutes at the end of which period the aqueous
layer should be colorless ; a test for limit of oxidiz-
able impurities based upon the treatment of a
portion of carbon tetrachloride with a mixture of
sulfuric acid and 0.1 N potassium dichromate, the
excess of the latter being determined by adding
potassium iodide and titrating the liberated iodine
with 0.1 N sodium thiosulfate.

Khalil (Lancet, 1926, 210, 547) stated that the
toxicity of certain specimens of carbon tetra-
chloride cannot be attributed to carbon disulfide.
He believes that it is due to other sulfur com-
pounds which distil at a lower temperature than
the tetrachloride and recommends that for medici-
nal use the first portion of the distillate be
rejected.

Uses. — Although carbon tetrachloride is a pow-
erful narcotic, surpassing even chloroform in the
strength of its action (Freymuth, Berl. klin.
Wchnschr., 1921, 58, 1330), it is too toxic to be
useful as an anesthetic.

In 1918 Foster called attention to its valuable
insecticide properties, and later Lake (Pub. Health
Rep., May 12, 1922) reported its use as a remedy
against the hookworm. Since then it has been ex-

254

Carbon Tetrachloride

Part I

tensively employed as an anthelmintic. Against
the American hookworm (Necator americanus)
it is probably the most efficient remedy that we
possess. It is also useful, but somewhat less effec-
tive, against the Ancylostoma duodenale. McVail
(Indian Med. Gaz., August, 1922) found it valu-
able in the treatment of threadworms (Oxyuris
vermicularis) . Sandground (New Eng. J. Med.,
1938, 218, 298) treated 13 cases of tapeworm
with carbon tetrachloride; one was unable to
retain it but the other 12 were completely cured.
Its value against ascaris is apparently much less
than against other intestinal parasites. Some au-
thorities say that it is a dangerous drug when
these latter parasites are present in the intestines.
It is commonly used in combination with 1 ml.
(approximately 15 minims) of chenopodium oil.

Although in the great majority of cases it pro-
duces no more unpleasant symptoms than a slight
giddiness or drowsiness — evidences of its narcotic
action — occasionally it produces serious poison-
ing and a number of deaths have been reported
following its use — most likely due to improper
selection and preparation of the patient. Lamson,
Minot. and Robbins (J.A.M.A., 1928, 90, 345)
pointed out that carbon tetrachloride was a dan-
gerous remedy for alcoholics and for persons with
a low calcium balance and that its absorption is
greatly hastened by the presence of either alcohol
or fats in the intestines. Lambert (J. A.M. A., 1933,
100, 247) reported 100,000 successive cases in
which he used the drug without a single death
and with very few untoward symptoms. The fol-
lowing precautions should be observed in the use
of carbon tetrachloride as an anthelmintic: it
should not be used in alcoholics; poorly nourished
patients should have their reserve built up for a
few days previously; while taking the drug the
diet should be rich in calcium and carbohydrates
but low in fats, and all oily substances should be
avoided; the dose should not exceed 3 ml. (ap-
proximately 45 minims) for normal adults and
should be followed by a saline laxative such as
magnesium sulfate.

Carbon tetrachloride is extensively used as a
solvent for fats and resins, as a degreasing appli-
cation to metals, and for removing grease from
garments, replacing petroleum benzin to advan-
tage because of its non-inflammability ; most
proprietary non-inflammable cleaning fluids use it
as the base. Not only is it incapable of burning
but is also valuable to extinguish fires and forms
the basis of the fluid called pyrene. When used,
however, to extinguish fires, it forms considerable
hydrochloric acid gas and possibly more or less
phosgene as well, the latter being dangerously
toxic; the vapor of carbon tetrachloride adds to
the potential toxicity. It is a good solvent for
caoutchouc; and such a solution was at one time
suggested for the purpose of coating the hands of
the surgeon with a sterile and impermeable cover-
ing. Carbon tetrachloride is also employed as a
solvent in various manufacturing processes. M

Toxicology. — Many cases of industrial poi-
soning from inhalation of carbon tetrachloride
vapor have been reported (Maguire, J. A.M. A.,
1932, 99, 988; Allebach and McPhee, Missouri
Med., 1953, 50, 106). Symptoms include head-

ache, vertigo, stupor, anorexia, nausea, vomiting
and diarrhea, intestinal cramps, and in severe
cases, marked evidence of hepatic and renal dam-
age, such as enlargement of the liver attended by
jaundice and tendency to hemorrhage, albumi-
nuria, microscopic hematuria, and azotemia with
hypertension. There may be pulmonary edema
and convulsions.

Straus (J.A.M.A., 1954, 155, 737) reported ob-
servations of 3 cases of aplastic anemia occurring
after chronic exposure to carbon tetrachloride;
all terminated fatally. He suggests that chronic
exposure to the solvent may result in irreversible
bone marrow damage. Carbon tetrachloride poi-
soning should be considered as a possible etiologi-
cal factor in cases of aplastic or refractory anemia.

Most instances of poisoning occurred where
ventilation was inadequate. Bowditch (Ind. Med.,
1943, 12, 440) reported that in one factory, where
workers had symptoms of intoxication, they had
been exposed to air containing only 35 parts per
million, though until then the limit of safety was
believed to be 100 parts per million. It has been
noted that alcoholism predisposes to carbon tetra-
chloride poisoning. Numerous instances of in-
toxication developed in the same way in the mili-
tary service (Bull. U. S. Army M. Dept., 1945,
87, 31; U. S. Armed Forces Med. J., 1952, 3,
1023), and especially among men on submarines,
as reported bv Dillenberg and Thompson (Mil.
Surg., 1945, 97, 39).

In the necropsy findings of a fatal case reported
by Martin et al. (Ann. Int. Med., 1946, 25, 488),
there were marked changes in the liver and kid-
neys. Throughout the liver, areas of necrosis ap-
peared, chiefly near the center of the lobules and
autolysis of supporting structures also permitted
dilatation of hepatic sinusoids which were packed
with erythrocytes. Lipoid droplets were seen
within the cytoplasm of fiver cells at the periphery
of necrotic foci. The fiver was grossly enlarged.
Renal enlargement was also found and on micros-
copy there was marked degeneration of epithelial
cells in the convoluted tubules and loops of Henle.
Lipoid degeneration was demonstrated here also.
Renal complications from carbon tetrachloride
poisoning have been described by Morgan et al.
(Can. Med. Assoc. J., 1949, 60, 145) and by
Partenheimer et al. (New Eng. J. Med., 1952,
246, 325). Myatt and Salmons (Arch. Indust.
Hyg., 1952, 6, 74), suspecting that many cases of
carbon tetrachloride poisoning are not recognized,
suggest that in every case of jaundice, nephritis,
or congestive heart failure in which no previous
occurrence of such disease has been known, the
patient be specifically asked about his use of
solvents and cleaning compositions.

Treatment in poisoning by inhalation consists
in supplying fresh air, and possibly artificial res-
piration and oxygen; caffeine may be given as a
stimulant. In poisoning by ingestion copious
lavage of the stomach with plain water is indi-
cated; no milk or other fatty liquids, or alcohol,
should be administered; magnesium sulfate is
given orally. The patient should be watched for
signs of fiver or kidney disease; a low- fat, high-
calorie diet should be started. If nausea and
vomiting occur the patient should be hospitalized.

Part I

Cardamom Seed

255

If jaundice alone occurs, the patient should rest
in bed and receive a low-fat diet, choline, meth-
ionine, calcium preparations, and vitamin K. If
food cannot be retained by mouth, glucose in
water, with just enough saline solution to replace
that lost by vomiting, should be given intra-
venously. If oliguria occurs, lower nephron ne-
phrosis is probable; restricted fluid intake is the
most important step in maintaining life (Myatt
and Salmons, loc. cit.).

Dose. — Caution: The usual dose, as an anthel-
mintic for adults, is a single dose of 3 ml. (ap-
proximately 40 minims), preferably taken before
breakfast with water or milk and always followed
in 2 hours by a saline cathartic. The B.P. gives
the dose as 2 to 4 ml.

Storage. — Preserve "in tight light-resistant
containers." N.F.

CARBROMAL. N.F.

Bromdiethylacetylurea, [Carbromalum]

(C2H5)2.CBr.CO.NH.CONH2

Adalin (Winthrop); Uradal; Planadalin; Bromadal. Ger.
Adalin. Sp. Bromodietilacetilurea ; Nyctal.

Carbromal, originally introduced under the pro-
prietary name Adalin, may be prepared by the fol-
lowing method: Diethylmalonic ester is hydro-
lyzed, in the presence of sodium hydroxide, to the
sodium salt of diethylmalonic acid; this is pre-
cipitated as the calcium salt, converted to the
free acid by treatment with hydrochloric acid, and
extracted with ether. The diethylmalonic acid is
heated to about 190° whereupon it loses carbon
dioxide and is converted to diethylacetic acid
(also known as a-ethylbutyric acid). This upon
bromination in the presence of red phosphorus
yields a-bromo-diethylacetyl bromide, also known
as a-bromo-a-ethylbutyryl bromide, which is
finally reacted with urea to produce carbromal.

Carbromal contains about 34 per cent of com-
bined bromine.

Description. — "Carbromal occurs as a white,
odorless, crystalline powder. One Gm. of Car-
bromal dissolves in about 3000 ml. of water, in
about 18 ml. of alcohol, in about 3 ml. of chloro-
form, and in about 14 ml. of ether. It is very
soluble in boiling alcohol, and dissolves in sulfuric,
nitric, or hydrochloric acid, from which acid solu-
tions it is precipitated by the addition of water. It
is dissolved by solutions of alkali hydroxides. Car-
bromal melts between 116° and 119°." N.F.

Standards and Tests. — Identification. — (1)
Ammonia is evolved when 200 mg. of carbromal
is boiled with 5 ml. of a 1 in 10 aqueous solution
of sodium hydroxide. (2) When the residue from
the ignition of a mixture of 100 mg. of carbromal
and 500 mg. of anhydrous sodium carbonate is dis-
solved in 5 ml. of hot distilled water, the solution
cooled, acidified with acetic acid, filtered, and 2
ml. of chloroform and a few drops of chlorine T.S.
added to the filtrate, a red-brown color is de-
veloped in the chloroform. Acidity. — The filtrate
obtained from 1 Gm. of carbromal shaken for
5 minutes with 20 ml. of distilled water is neutral
to litmus paper. Chloride. — The limit is 300 parts
per million. Sulfate. — The limit is 400 parts per
million. Residue on ignition. — Not over 0.1 per

cent. Readily carbonizable substances. — A solu-
tion of 500 mg. of carbromal in 5 ml. of sulfuric
acid has no more color than matching fluid A. N.F.
Uses. — Carbromal was introduced with the
idea that it combined sedative effects of bromine
with the narcotic action of the aliphatic series.
Being a monoureide, however, it is a feeble
hypnotic and sedative. Impens (Ther. Geg., 1912)
snowed that in the body some is broken down,
some is eliminated as urea and inorganic bromide,
and some remains undecomposed (see also Grun-
inger, Ztschr. ges. exp. Med., 1938, 103, 246).
The small dose makes it improbable that the
bromide component can play any important part
in the action of the drug. Takeda (Arch, internat.
Pharmacodyn. therap., 1911, 21, 203) concluded
from a study of distribution of the drug in the
body that its action must be due to the whole
molecule.

Carbromal, in sufficient dose, possesses some
somnifacient effect and is used in mild sleep-
lessness, often in combination with another central
nervous system depressant. In severe insomnia
it is very inferior to barbital. It continues to be
used as a sedative in neurasthenia, nervous in-
somnia, hysteria, chorea, whooping-cough, and
other similar conditions of hyperirritability of the
central nervous system. With ordinary caution
carbromal seems to be a safe drug. Nieuwenhuijse
(Pharm. J., 1916, 96, 327) reported a case in
which forty-five grains was taken, the patient re-
covering after sixty hours of narcosis.

Under the trade-marked names Abasin (Win-
throp-Stearns) and Sedamyl, an acetylcarbromal
(specifically iV-acetyl-Ar-bromodiethylacetylurea)
is available and is used similarly. For information
concerning this compound see Strasser (Wien.
Klin. Wchnschr., 1924, p. 594), also Reimers
(Dansk Tids. Farm., 1937, 11, 49), and Tebrock,
Medical Times, Dec, 1951).

Dose. — The sedative dose of carbromal is 300
to 600 mg. (approximately 5 to 10 grains) three
or four times daily; as a hypnotic, 0.6 to 1.2 Gm.
(approximately 10 to 20 grains) with hot water.

Storage. — Preserve "in well-closed contain-
ers." N.F.

CARDAMOM SEED. N.F. (B.P.)

Cardamomi Semen

"Cardamom Seed is the dried ripe seed of
Elettaria Cardamomum Maton (Fam. Zingiber-
acece). Cardamom Seed should be recently re-
moved from the capsules." N.F. The B.P. recog-
nizes, as Cardamom Fruit, the dried, nearly ripe
fruit of Elettaria cardamomum Maton var.
minus cula Burkill.

B.P. Cardamom Fruit; Cardamomi Fructus. Malabar
Cardamoms; Cardamoms. Cardomomi Semina; Semen
Cardamomi. Fr. Cardamomes. Ger. Kardamomsamen;
Malabarsamen. Sp. Semilla de Cardamomo.

The fruit of cardamom is official in most Phar-
macopoeias. The N.F. and the B.P. recognize only
the seeds, the former specifying that the seeds
must be recently removed from the capsules. This
avoids any confusion by manufacturers as to
whether the article designated as cardamom in a
formula is restricted to the seeds or not. On the

256

Cardamom Seed

Part I

other hand the pericarp contains some oil and
forms an excellent surface for the grinding of the
seeds. Furthermore, the decorticated seeds have
been known to be adulterated with seed of wild
cardamom and other foreign seeds which are not
detected except upon careful examination. Clev-
enger (J.A.O.A.C., 1934, 17, 121) found that
cardamom seed, imported as such, yields on the
average less volatile oil than that recently re-
moved from the husks and that the loss of volatile
oil in husk-protected seed is comparatively small
in 8 months, whereas the loss of volatile oil in
cardamom seeds removed from the shells is con-
siderable, amounting to approximately 30 per cent
in the same period of time.

The term cardamom has been applied to the
aromatic capsules of various plants, most of them
from India, belonging to the Zingiber acea. For-
merly the terms lesser, middle and larger carda-
moms were used to separate these various fruits,
but these words have been used so differently by
various writers that they no longer possess any
precise signification. The lesser cardamom of
most writers is the variety recognized by the
pharmacopeias and generally kept in the shops.
The other varieties, though circulating to some
extent in European and Indian commerce, are
little known in this country.

The official cardamoms are produced chiefly in
Ceylon and, to a lesser extent, in Malabar,
Mysore, and adjacent regions of India. They
have also been cultivated to some extent in trop-
ical America, some supplies being imported in
recent years from Guatemala.

The cardamom plant is a perennial herb with
a tuberous horizontal rhizome, sending up from
eight to twenty erect, simple, smooth, green and
shining, perennial stems, which rise from six to
twelve feet in height, and bear alternate, elliptical-
lanceolate, sheathing leaves. The flower-stalk pro-
ceeds from near the base of the stem, and lies
upon the ground, with the flowers arranged in a
panicle. The fruit is an ovoid, three-celled, locu-
licidally dehiscent capsule, containing many seeds
which are covered by an aril; during drying it is
said to lose three-fourths of its weight.

This valuable plant is a native of the moun-
tains of Indo- China, where it springs up spon-
taneously in the forests after the removal of the
undergrowth, and is very extensively cultivated
by the natives. For a detailed account of culture,
see Chem. Drug, 1912, p. 101, and Pharm. Era,
1920, 53, 365. The plant begins to yield fruit at
the end of the fourth year, and continues to bear
for several years afterward. The capsules just
before complete maturity are picked from the
fruit-stems, dried over a gentle fire or by sun heat,
and separated, by rubbing with the hands, from
the footstalks and adhering calyces." They are then
washed and bleached by exposure either to dew
and sun or to vapors of burning sulfur.

In Ceylon the capsular fruits are cut off with
scissors before they mature. They are then cured
by exposure to slow drying in the sun during dry
weather or by being placed on trays in the curing
house, during wet weather, and exposed to a
gentle heat. The artificially cured product is in-
ferior to that dried in the sun. Sometimes the

capsules are sprinkled with water and then sun-
bleached. This improves the color but increases
the number of undesirable split fruits. The re-
mains of the calyx at the summit of the capsule
and the stalk at the base are removed by machines
and the capsules graded by use of sieves into
longs, mediums, shorts and tiny. Split fruits, seeds
and broken shells are also removed. The capsules
are then bleached by placing them in trays over
burning sulfur. They are then air-dried and packed
in cases for shipment.

The most important varieties of cardamoms
are the Mysore (or Ceylon-Mysore), Malabar (or
Ceylon-Malabor), Alleppi and Mangalore. The
Mysore and Malabar varieties are now obtained
chiefly from plants cultivated in Ceylon, but
smaller amounts of these are still being produced
in India. The Mangalore variety comes from
plants grown in the vicinity of the port of Manga-
lore in India, the Alleppi from plants grown in
Travencore and Cochin. The bleached Mysore
variety is considered the best. It is ovoid to ovoid-
oblong, loculicidally dehiscent, yellowish white to
white, 12 to 20 mm. long, 7 to 9 mm. in diameter,
nearly smooth, the summit slightly beaked with
the remains of a style, the base rounded with a
scar of the stalk, 3-valved with thin dissepiments
and with 9 to 12 seeds which are aromatic and
moderately pungent, anatropous, irregularly angu-
lar and enclosed in a thin, membranous aril. The
Malabar variety of fruit is broadly ellipsoidal,
occasionally ovoid, somewhat three cornered, 10
to 17 mm. long, 6 to 8 mm. in diameter, grayish-
yellow, when half bleached, buff to yellow when
bleached, and contains 15 to 18 seeds with an
aromatic odor and aromatic, pungent taste. The
Alleppi variety is elongate-ovate, triangular in
cross section, greenish-brown or dirty yellow to
brown. The Mangalore variety resembles the
Malabar, but the fruits are frequently larger,
more spheroidal and possess a rougher external
coat; they rarely reach the United States. In 1953,
importations of cardamom seed amounted to
155,302 pounds; India, Ceylon, Guatemala and
Salvador supplied the drug.

Unofficial Varieties. — Besides the official
cardamoms the fruit of a large number of re-
lated plants has been more or less employed. The
more important of these are noted below.

Ceylon Cardamom. — This has been denomi-
nated variously cardamomum majus and carda-
momum longum, and is sometimes termed in Eng-
lish commerce long wild cardamom. It is the large
cardamom of Guibourt. In the East it is some-
times called grains of Paradise; but it is not the
product known with us by that name. (See
below.) It is derived from a plant cultivated in
Candy, in the Island of Ceylon, and also growing
wild in the forests of the interior, which was
designated by Sir James Edward Smith Elettaria
major, but is now generally acknowledged to be
only a variety of the official plant (Elettaria
Cardamomum var. $-major Thwaites). The fruit
is a lanceolate-oblong, acutely triangular capsule,
somewhat curved, up to 40 mm. long and 6 to 8
mm. broad, with flat and ribbed sides, tough and
coriaceous, dark brownish or grayish-brown, hav-
ing frequently at one end the long, cylindrical,

Part I

Cardamom Seed

257

three-lobed calyx, and at the other the fruit-
stalk. It is three-locular, and contains angular,
rugged, yellowish-red seeds, of a peculiar fra-
grant odor and spicy taste. Its effects are an-
alogous to those of the official cardamom. It is
used as a source of some of the oil of cardamom
and for flavoring.

Round or Siam Cardamom. — This is probably
the "Aucom-ov of Dioscorides and the Amomi uva
of Pliny, and is believed to be the fruit of
Amomum Kepnlaga Sprague and Burkill (Amo-
mum Cardamomum, Auths. Not L.) growing in
Siam, Sumatra, Java, and other East India
islands. The capsules are usually smaller than a
cherry, roundish or somewhat ovate, with three
convex sides, more or less striated longitudinally,
yellowish or brownish-white, and sometimes red-
dish, with brown, angular, cuneiform, shriveled
seeds, which have a spicy camphoraceous flavor.
They are sometimes, though rarely, met with con-
nected in their native clusters, constituting the
amomum racemosum, or amome en grappe, of the
French. They are similar in medicinal properties
to the official, but are seldom used except in the
southern parts of Europe.

Large Round Chinese Cardamom. — This variety
is yielded by Amomum globosum Loureiro, a
perennial, evergreen herb native to southern China
and found growing wild and under cultivation in
the Kwang-Tung province. The drug occurs as
round or globular, pale yellow capsules having an
average diameter and thickness of 15 mm., longi-
tudinally streaked, tapering at both ends, bearing
numerous long non-glandular hairs on its ex-
ternal surface and containing on the average 24
pyramidal or wedge-shaped seeds with a deep
furrow along one side. The seeds possess an agree-
ably aromatic odor and taste. They yield 4 to 6
per cent of volatile oil which is cooling to the taste
and possesses the odor of cardamom. Viehoever
and Sung (/. A. Ph. A., 1937, 26, 872) reported
on common and oriental cardamoms and conclude
the character and percentage yield of the round
Chinese cardamom suggests the possibility of
using the fruit as equal to the official Malabar
Cardamom.

Java Cardamom. — The plant producing this
variety is supposed to be the Amomum dealbatum
Roxburgh (4. maximum Roxburgh), growing in
Java and other Malay islands in the East. The
capsules are oval, or oval-oblong, often somewhat
ovate, from 1.5 to 3 cm. long, and from 8 to 15
mm. broad, usually flattened on one side and con-
vex on the other, sometimes curved, three-valved,
and occasionally imperfectly three-lobed, of a
dirty grayish-brown color, and coarse fibrous ap-
pearance. When soaked in water, they exhibit as
their distinguishing character from nine to thirteen
ragged membranous wings along their whole
length. The seeds have a feebly aromatic taste
and odor. This variety of cardamom affords but
a very small proportion of volatile oil, and is alto-
gether of inferior quality.

Madagascar Cardamom. — This is the Carda-
momum majus of Geiger and some others, and is
thought to be the fruit of Ajramomum angusti-
folium (Sonn.) K. Sch. (Amomum angustifolium
Sonnerat) growing in marshy grounds in Mada-

gascar. The capsule is ovate, pointed, flattened on
one side, striated, with a broad circular scar at the
bottom, surrounded by an elevated, notched,
corrugated margin. The seeds have an aromatic
flavor similar to that of official cardamom.

For the origins and descriptions of Bengal and
Nepal Cardamoms see U.S.D., 24th ed., p. 231.

Grains of Paradise. Grana Paradisi. — Under
this name and that of Guinea grains, and Mele-
geta or Mallaguetta pepper, are found in com-
merce small seeds of a round or ovate form, often
angular, and somewhat cuneiform, minutely rough,
reddish-brown to brown externally, white within,
of a feebly aromatic odor when rubbed between
the fingers, and of a strongly hot and peppery
taste. Two kinds of them are known in the English
market, one larger, plumper, and more warty,
with a short conical projecting tuft of pale fibers
on the umbilicus ; the other smaller and smoother
and without the fibrous tuft. The latter are the
more common. They are produced by Ajramomum
Melegueta (Roscoe) K. Sch. Their effects on the
system are analogous to those of pepper; but
they are seldom used except in veterinary prac-
tice, and to give pungency to spirits, wine, beer,
and vinegar. Thresh made a proximate analysis
of the seeds, and found volatile oil, resin, tannin,
starch, albuminoids, and an active principle in the
form of a straw-colored viscid, odorless fluid,
pungent, but not so hot as capsaicin, called
paradol (Pharm. J., 1884, p. 297).

Bastard or Wild Cardamom, the seeds of
Amomum xanthioides Wall., resembles true car-
damom in appearance, but is of a dirty green
color, and has a very biting, camphor- like taste.
It comes from Siam.

Description. — "Unground Cardamom Seed
occurs usually in agglutinated groups of 2 to 7
seeds and as separate seeds surrounded by an
adhering membranous aril. The individual seeds
are oblong-ovoid or irregularly 3- to 4-sided, from
3 to 4 mm. in length; convex on the dorsal side,
strongly longitudinally grooved on the ventral
side and coarsely tuberculated; externally pale
orange to dark brown. The odor is aromatic. The
taste is aromatic, pungent, and slightly bitter."
N.F. For histology see N.F. X.

"Powdered Cardamom Seed is brown to weak
yellow to light olive green. It consists chiefly of
fragments of perisperm, endosperm, embryo, and
seed-coat. The endosperm and perisperm cells are
filled with starch grains from 1 to 4n in diameter
or may contain one or more prisms of calcium
oxalate from 10 to 2 5n in diameter. The seed-coat
is characterized by its red to orange colored cells,
polygonal in surface view and about 20^ in diam-
eter. Fragments of pericarp tissue with spiral
vessels and with accompanying slightly lignified
fibers are relatively few." N.F.

The B.P. description of the seeds is not ma-
terially different from the above, but in addition
the B.P. describes the entire fruit. These are up
to about 2 cm. long, ovoid or oblong, green to pale
buff, plump or slightly shrunken, bluntly tri-
angular in section, shortly beaked at the apex,
nearly smooth or longitudinally striated, and
three-celled, in each cell two rows of seeds in an
adherent mass attached to an axile placenta.

258

Cardamom Seed

Part I

Standards and Tests. — Acid-insoluble ash. —
Not over 4 per cent. N.F. The B.P. requires not
less than 4.0 per cent v/w of volatile oil in the
seeds.

Constituents. — The flavor and therapeutic
action of cardamom is due to a volatile oil which
is present in proportions ranging from 2 up to 8
per cent. Cardamom oil consists chiefly of terpin-
ene and terpineol. There are present also consider-
able amounts of terpinyl acetate and some cineol.
The cardamom oil is quite unstable and loses its
characteristic flavor even when air is excluded.

In addition to their volatile oil the seeds con-
tain about 3 or 4 per cent of starch, a nitrogenous
gum, yellow coloring matter, etc. According to
Otte and Weiss (Pharm. Zentr., 1928, 69, 613) a
high ash is indicative of the mixture of shells with
the seeds.

The seeds should be powdered only when re-
quired for use, as they retain their aromatic prop-
erties best while in the capsule.

Adulterations.— Cardamoms have been adul-
terated with orange seeds and unroasted grains
of coffee. Powdered cardamom is frequently
adulterated with its own shells. Such powders
are of lighter, yellowish-brown color and under
the microscope show the presence of large-celled
shell parenchyma and woody fibers. The total
ash of the shells of cardamom is more than twice
as high as that of the seeds, which also applies to
the water-soluble ash. In recent years the chief
adulterants for the whole seed have been small
pebbles and seeds of Atnomum species.

Uses. — Cardamom is an agreeable and mild
aromatic, not markedly stimulating, and useful
chiefly as an adjuvant. Throughout the East
Indies it is largely consumed as a condiment.
It was known to the ancients, deriving its name
from the Greeks. In this country it is employed
chiefly as a flavoring agent and adjuvant to other
carminative drugs.

Dose, 1 to 2 Gm. (approximated 15 to 30
grains).

Storage. — Preserve "against attack by in-
sects." N.F.

Off. Prep. — Cardamom Oil, Compound Colo-
cynth Extract, N.F.; Compound Cardamom
Tincture, Compound Gentian Tincture, N.F.,
B.P.; Aromatic Powder of Chalk, Compound
Tincture of Rhubarb, B.P.

CARDAMOM OIL. N.F.

[Oleum Cardamomi]

"Cardamom Oil is the volatile oil distilled from
the seed of Elettaria Cardamomum (Linne)
Maton (Fam. Zingiberacea) ." N.F.

Fr. Essence de cardomome. Ger. Kardamomenol.

Description. — "Cardamom Oil is a colorless
or very pale yellow liquid with the aromatic,
penetrating, and somewhat camphoraceous odor
of cardamom, and a persistently pungent, strongly
aromatic taste. It is affected by light. Cardamom
Oil is miscible with alcohol. Cardamom Oil dis-
solves in 5 volumes of 70 per cent alcohol. The
specific gravity of Cardamom Oil is not less than
0.917 and not more than 0.947. The optical rota-

tion of Cardamom Oil is not less than +22° and
not more than +44° when determined in a 100-
mm. tube. The refractive index of Cardamom Oil
is not less than 1.4630 and not more than 1.4660
at 20°." N.F.

For further information concerning this oil see
under Cardamom.

This oil is official because it is a component of
compound cardamom spirit; it is occasionally
employed for its carminative effect.

The dose is 0.03 to 0.2 ml. (approximately
Y* to 3 minims).

Storage. — Preserve "in tight, fight-resistant
containers." N.F.

Off. Prep. — Compound Cardamom Spirit, N.F.

COMPOUND CARDAMOM SPIRIT.
N.F.

[Spiritus Cardamomi Compositus]

Mix 100 ml. each of cardamom oil and orange
oil, 10 ml. of cinnamon oil, 5 ml. each of clove
oil and anethole, and 0.5 ml. of caraway oil with
sufficient alcohol to make 1000 ml. N.F.

Alcohol Content. — From 68 to 74 per cent,
by volume, of C2H5OH. N.F.

The spirit is official only because it is an in-
gredient of compound glycerophosphates elixir;
its carminative effect is rarely, if ever, utilized
therapeutically.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

Off. Prep. — Compound Glycerophosphates
Elixir, N.F.

COMPOUND CARDAMOM
TINCTURE. N.F. (B.P.)

[Tinctura Cardamomi Composita]

B.P. Compound Tincture of Cardamom. Sp. Tintura de
Cardamomo Compuesta.

Prepare a tincture, by Process M (see under
Tinctures), from 20 Gm. of cardamom seed, in
moderately coarse powder, 25 Gm. of cinnamon,
in fine powder, 12 Gm. of caraway, in moderately
coarse powder, and 5 Gm. of cochineal, in fine
powder; macerate the mixed powders in 750 ml.
of a mixture of 50 ml. of glycerin and 950 ml. of
diluted alcohol, and complete the preparation to
1000 ml. by using first the remainder of this
menstruum, and then diluted alcohol. AT.F.

The B.P. formula calls for 14 Gm. of carda-
mom, 14 Gm. of caraway, 28 Gm. of cinnamon,
7 Gm. of cochineal, 50 ml. of glycerin, and 60
per cent alcohol as the menstruum to make
1000 ml. ; the tincture is prepared by percolation.

Alcohol Content. — From 43 to 47 per cent,
by volume, of C2H5OH. U.S.P.

Uses. — This is an agreeable aromatic tincture,
occasionally used as a carminative, but more
frequently as a vehicle, in which capacity it is
one of the most useful preparations available.

Dose, 2 to 8 ml. (approximately H to 2
flui drachms).

Storage. — Preserve "in tight, fight-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." A7.,?7.

Off. Prep. — Aromatic Eriodictyon Syrup;
Glycerinated Gentian Elixir, N.F.

Part I

Cascara Sagrada 259

CASCARA SAGRADA. U.S.P., B.P., LP.

Rhamnus Purshiana, [Cascara Sagrada]

"Cascara Sagrada is the dried bark of Rhamnus
Purshiana De Candolle (Fam. Rhamnacece.) . Cas-
cara Sagrada preferably should be aged for at
least one year before use." U.S. P. The B.P. and
LP. recognize the same source of drug as does
the U.S. P., but while the B.P. specifies that the
bark shall have been collected at least one year
before use, the LP. allows also the alternative of
heating it at 100° for one hour before use.

Sacred, Chittem, Dogwood, Coffee-berry, Bear-berry,
Bitter or Yellow Bark; Bear-wood. Cortex Rhamnus
Purshiana; Cortex Rhamni Americana. Fr. Cascara
sagrada ; £corce sacree. Ger. Amerikanische Faulbaum-
rinde; Amerikanische Kreuzdornrinde; Sagradarinde. It.
Cascara sagrada. Sp. Cascara sagrada.

A number of species of Rhamnus have been
described as growing in California, but according
to the best authority there are only four species —
R. alnijolia, L'Her., R. crocea, Nutt., R. Purshi-
ana, D. C, and R. californica, Esch. Of these
species, R. alnijolia is too rare in the cascara dis-
trict to be important; while the spinescent twigs,
the very thick, orbicular to oblong-obovate leaves,
and the small globose red fruit of R. crocea make
it so distinct that it cannot be confounded with
cascara, whose bark, moreover, it does not re-
semble. On the other hand, R. californica appears
to be very commonly confounded with the official
species by collectors, and to have yielded some of
the cascara sagrada bark of commerce. R. cali-
fornica is rare in northern California, but abun-
dant in the counties lying south and southeast-
erly, while R. Purshiana is abundant in northern
California, but scarce in the south, so that any
bark collected in northern California is probably
genuine. R. californica is chiefly distinguished
from the official species by its leaves being thin,
and, when not smooth, having a short close pubes-
cence, and the secondary veins of the under sur-
face not nearly so numerous (8 to 10 pairs),
straight, or fine as those of R. Purshiana. The
latter species has leaves with 10 to 15 pairs of
secondary veins. Rusby states that the two species
can be distinguished by the fact that in the
leaves of the R. californica the channel of the
midrib is altogether absent, or shallow, or incon-
spicuous.

Rhamnus Purshiana varies from a tall shrub to
a small tree, usually attaining a height of from 20
to 40 feet. Its leaves are rather thin, eliptic to
ovate-oblong, for the most part briefly acutely
pointed, remotely denticulate or sometimes at the
base obtuse, somewhat pubescent beneath, from
2 to 7 inches long and from 1 to 3 wide. The entire
greenish flowers are in somewhat umbellate
cymes; the sepals 5; the minute cucullate petals
bifid at the apex. The fruit is purplish-black,
broadly obovoid, 8 mm. long, 3-lobed, and 3-sided.
The seeds are convex on the back, with a lateral
raphe. It is found in California, Oregon, Wash-
ington, Idaho, Montana, and Southwest British
Columbia. For details of manner of collecting the
bark see an elaborate and illustrated article by
Johnson and Hindman (Am. J. Pkarm., 1914, p.
387), also "The Cascara Tree in British Colum-
bia," by J. Davidson, Bull. No. A108 Province of

British Columbia, 1942. Because of the rapid
destruction of natural sources of the bark, ex-
periments were conducted by the Bureau of Plant
Industry, U. S. Department of Agriculture, to
cultivate it and their results are now being com-
mercially applied in the Pacific Northwest and in
some of the Eastern States. The plant has also
been cultivated experimentally in Nairobi, British
East Africa (see Pharm. J., 192 7, 118, 449).

The Rhamnus californica, or Californian buck-
thorn or California coffee-berry is a shrub up to
15 ft. in height which yields a bark of a dark
brown color externally and bright yellow inter-
nally, having an intensely bitter taste, with a
persistent nauseous aftertaste, and very little
odor. It is said to be much more distinctly pur-
gative than that of R. crocea.

It does not seem possible to distinguish with
certainty between the barks of the two species
by their macroscopic appearance. The bark of
R. Purshiana is usually more red than is that of
R. californica, but it may be of a distinctly gray
color. The microscopic structure of the two barks
is, however, different. The phloem rays in R.
Purshiana are numerous, thin, for a long distance
nearly parallel and straight and converge at their
outer ends, run about three-quarters of the dis-
tance through the bark, and are one to four cells
in width. In R. californica the medullary rays are
occasionally broader, shorter, and have been re-
ported in some thicker pieces to range from one
to seven cells in width. There have also been found
authentic specimens of R. californica with phloem
rays closely simulating those of R. Purshiana.
Study of the comparative histology of these barks
of different ages is greatly needed to clarify the
situation. For further details and elaborations, see
Gathercoal, /. A. Ph. A., 1915, p. 15. According to
Sayre (Am. J. Pharm., March, 1897), the powder
of the barks can be distinguished by paying atten-
tion to the fact that R. Frangula contains no
stone cells, while in R. californica and R. Purshi-
ana such cells are abundant, occurring in large,
irregular groups below the cork and usually out-
side the region of the bast. R. Purshiana may also
be distinguished from R. californica by color
tests. After several days' maceration in dilute
alcohol the powder of R. Purshiana appears of an
orange-yellow color, R. californica of a purplish
color; or if 0.2 Gm. of the powdered bark be
placed in a small test tube, and there be added
2 ml. of potassium hydroxide test solution, R.
californica will give a blood-red and R. Purshiana
an orange-red color.

The bark of the Rhamnus crocea, the so-called
California mountain holly, occurs in slightly
curved pieces, externally of a dark brown color,
internally of a characteristic red delicately
streaked with numerous white veins. The odor is
somewhat aromatic, the taste warming and not
unpleasantly bitter. It is affirmed to be a tonic
and mild laxative.

Description. — "Unground Cascara Sagrada
usually occurs in flattened or transversely curved
pieces, occasionally in quills of variable length
and from 1 to 5 mm. in thickness. The outer sur-
face is brown, purplish brown or brownish red,
longitudinally ridged, with grayish or whitish

260 Cascara Sagrada

Part I

lichen patches, sometimes with numerous lenticels
and occasionally with moss attached. The inner
surface is longitudinally striate, light yellow,
weak reddish brown or moderate yellowish brown.
The fracture is short with projections of phloem
fiber bundles in the inner bark. The odor is dis-
tinct. The taste is bitter and slightly acrid."
U.S.P. For histology see U.S.P. XV.

"Powdered Cascara Sagrada is moderate yellow-
ish brown to dusky yellowish orange. It shows
numerous broken phloem fiber bundles with ac-
companying crystal fibers containing monoclinic
prisms of calcium oxalate; stone cells more or
less adherent, in small groups with thick, finely
lamellated and porous walls; fragments of reddish
brown to yellow cork; masses of parenchyma and
phloem ray cells colored reddish brown to orange
upon the addition of a solution of an alkali; starch
grains spheroidal, up to 8n in diameter; calcium
oxalate in monoclinic prisms or rosette aggregates
from 6 to 20n in diameter, occasionally up to
45m. in diameter." U.S.P.

Standards and Tests. — Identification. — (1)
An orange color is obtained on adding ammonia
T.S. to an aqueous extract (1 in 100) of cascara
sagrada. (2) A red to reddish brown color is pro-
duced on treating cascara with ammonia T.S. (3)
Ether is colored greenish yellow on shaking with
an extract prepared by boiling cascara sagrada
with water containing a small amount of alcohol
and filtering. On shaking a portion of the ether
solution with ammonia T.S. and diluting the latter
with water the mixture retains a distinct orange
pink color. Foreign organic matter. — Not over
4 per cent. U.S.P. Both the B.P. and the I.P. limit
ash to 6.0 per cent and require not less than 23.0
per cent of water-soluble extractive, but the B.P.
limits foreign organic matter to 1.0 per cent while
the I.P. restricts it to 4.0 per cent.

Constituents. — The cathartic activity of cas-
cara sagrada is attributable to the presence of hy-
droxy-methylanthraquinones, such as are found
also in aloe, rhubarb, senna and certain other
vegetable laxatives. As in these drugs too, a con-
siderable proportion of the active compounds
occur in glycosidic form, combined with the
sugars rhamnose and glucose.

Emodin ( l,3,8-trihydroxy-6-methylanthraqui-
none) was identified in cascara sagrada by both
Schwabe {Arch. Pharm., 1888, 226, 569) and
Jowett (Proc. A. Ph. A., 1905, 52, 228) ; the latter
investigator reported also the presence of isoe-
modin (isomeric with emodin), rhamnol, syringic
acid, pyrocatechuic acid and two fatty acids.
Sipple, King and Beal (J. A. Ph. A., 1934, 23,
205) isolated frangulin, the rhamnoside of emo-
din, while Green, King and Beal (/. A. Ph. A.,
1936, 25, 107 and 1938, 27, 95) found, besides
isoemodin, methylhydrocotoin (2,4,6-trimethoxy-
benzophenone) . Liddell, King and Beal (/. A. Ph.
A., 1942, 31, 161) later isolated aloe-emodin (1,8-
dihydroxy-3-hydroxymethylanthraquinone ) and
chrysophanic acid (l,8-dihydroxy-3-methylanthra-
quinone, also known as chrysophanol) ; they also
showed that the substituted anthraquinones are
markedly more active as cathartics when given as
a mixture than when administered separately to
guinea pigs.

On the basis of this later work it appears likely
that the substances purshianin and cascarin, more
than half a century ago announced as the active
principles of cascara sagrada, are impure forms
of one or more of the constituents described
above.

Uses. — Cascara sagrada belongs to a group of
vegetable cathartics whose activity depends on the
presence of one or more hydroxy-methylanthra-
quinones (see Constituents above, also Rhubarb).
The action of these principles is chiefly to excite
peristalsis in the colon, although after large doses
there may also be some effect on the upper bowel
(Oppenheimer and Mann, Am. J. Digest. Dis.,
1941, 8, 90). Cascara sagrada induces a single
solid or semi-solid stool in about 8 hours. Dis-
comfort or griping is very infrequent. It is not
recommended as a laxative when it is desired to
cleanse the entire bowel as large doses may pro-
duce an inflammatory condition (McGuigan,
J. A.M. A., 1921, 76, 513). It is useful in the
treatment of chronic constipation and frequently
appears to restore tone to the relaxed bowel and
thus produce a lasting beneficial effect. Prolonged
use may result in the unimportant, but sometimes
puzzling, condition known as melanosis coli
wherein the mucous membrane of the colon is
pigmented with melanin (Bockus, Willard and
Bank, J.A.M.A., 1933, 101, 1). Tyson (/. Pediatr.,
1937, p. 743) reported laxative effects from the
milk of nursing mothers taking cascara.

The concurrent administration of belladonna to
overcome any tendency to gripe is less popular
than formerly; the more rapid action of bella-
donna is complete before the cascara sagrada
reaches the lower bowel. Ordinarily a single dose
is given at bedtime but better results are some-
times obtained by the administration. of smaller
doses after meals. The bark itself is rarely used,
either the extract or the fluidextract being eligible
preparations. @

Dose, 0.6 to 2 Gm. (approximately 10 to 30
grains).

CASCARA SAGRADA EXTRACT.
N.F. (B.P.)

Powdered Cascara Sagrada Extract, Rhamnus Purshiana
Extract

"One Gm. of Cascara Sagrada Extract repre-
sents 3 Gm. of cascara sagrada." N.F.

B.P. Dry Extract of Cascara Sagrada ; Extractum Cas-
cara Sagrada; Siccum. Extractum Rhamni Purshianae.
Fr. Extrait de cascara sagrada. Ger. Sagradaextrakt. It.
Estratto di cascara sagrada idroalcoolico. Sp. Extracto
de C&scara Sagrada.

Mix 900 Gm. of cascara sagrada, in coarse
powder, with 4000 ml. of boiling water, macerate
the mixture during 3 hours, transfer it to a per-
colator and, after allowing it to drain, exhaust it
by percolation with boiling water. Collect 5000 ml.
of percolate, evaporate it to dryness, reduce the
residue to a fine powder, and add enough starch,
dried at 100°, to make the product weigh 300 Gm.
Mix thoroughly, and pass the extract through a
fine sieve. N.F.

The B.P. Dry Extract of Cascara Sagrada is
prepared by percolation of coarse drug and evap-
oration of the percolate to dryness under reduced

Part I

Castor Oil

261

pressure. The dry residue is granulated by pass-
ing it through a No. 22 sieve.

Uses. — Cascara sagrada extract represents the
activity of the bark, and provides a useful form
for administering the drug in capsules, pills and
tablets. 12

The usual dose is 300 mg. (approximately 5
grains), with a range of 120 to 500 mg. (approxi-
mately 2 to 7>2 grains).

Storage. — Preserve "in tight, light-resistant
containers, preferably at a temperature not above
30°." N.F.

CASCARA SAGRADA EXTRACT
TABLETS. N.F. (B.P.)

Cascara Tablets

B.P. Tablets of Cascara Sagrada. Sp. Tabletas de
Extracto de Cascara Sagrada.

"Cascara Sagrada Extract Tablets are prepared
from cascara sagrada extract." N.F.

Usual Sizes. — 2, 3, and 5 grains (approxi-
mately 120, 200, and 300 mg.), usually chocolate
coated.

CASCARA SAGRADA FLUID-
EXTRACT. N.F. (B.P.)

Rhamnus Purshiana Fluidextract

B.P. Liquid Extract of Cascara Sagrada; Extractum
Cascarae Sagradae Liquidum. Extractum Rhamni Purshi-
ana; Fluidum; Fluidextractum Rhamni Purshianas. Fr.
Extrait fluide de cascara sagrada. Ger. Sagradafluidex-
trakt. It. Estratto fluido di cascara sagrada. Sp. Ex-
tracto de cascara sagrada, fluido.

Prepare a fluidextract, by Process D, from 1000
Gm. of cascara sagrada, in very coarse powder.
Evaporate the percolate to 800 ml., and when it is
cold gradually add 200 ml. of alcohol and, if
necessary, enough water to make 1000 ml. Mix
thoroughly. N.F. The B.P. preparation is made
similarly.

Alcohol Content. — From 17 to 19 per cent,
by volume, of C2H5OH. U.S.P.

This preparation also represents the activity of
cascara sagrada. It is less pleasant but more effi-
cient than the aromatic fluidextract. W\

The usual dose is 1 ml. (approximately 15
minims) with a range of 0.6 to 2 ml. (approxi-
mately 10 to 30 minims).

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." N.F.

AROMATIC CASCARA SAGRADA
FLUIDEXTRACT. U.S.P. (B.P.)

B.P. Elixir of Cascara Sagrada; Elixir Cascarae Sagra-
dae. Extractum Rhamni Purshianse Fluidum Aromaticum.
It. Estratto fluido aromatico e deamarizzato di cascara
sagrada. Sp. Extracto Fluido Aromatico de Cascara
Sagrada.

Thoroughly mix 1000 Gm. of cascara sagrada
with 120 Gm. of magnesium oxide, moisten uni-
formly with 2000 ml. of boiling water, and set
aside in a shallow container for 48 hours, stirring
occasionally. Pack the mixture into a percolator,
and percolate with boiling water to exhaustion.
Concentrate the percolate, at a temperature not
above 100°, to 750 ml. and dissolve in it, at once,
40 Gm. of pure glycyrrhiza extract. When the
liquid has cooled, add 200 ml. of alcohol in which

2 Gm. of saccharin, 0.1 ml. of methyl salicylate,
0.65 ml. of anise oil, and 0.15 ml. of coriander oil
have been dissolved, and finally enough water to
make 1000 ml. Mix thoroughly. U.S.P.

The B.P. recognizes, as Elixir of Cascara Sa-
grada, a similar mixture, differing chiefly in the
absence of cinnamon oil and methyl salicylate,
and in lower proportion of anise oil.

In the U.S.P. X aromatic cascara fluidextract
was prepared with lime as a debitterizing agent,
but this agent was replaced by magnesium oxide
on the basis of the findings of Valaer (/. A. Ph. A.,
1931, 20, 1210) which demonstrated that lime
destroyed more of the active principles than did
magnesium oxide; also that preparations made
with lime were inferior in flavor to those made
with magnesium oxide. Valaer found that aro-
matic cascara sagrada fluidextract, even when
made by the use of magnesium oxide, contains
much less emodin than the plain cascara sagrada
fluidextract.

Alcohol Content. — From 17 to 19 per cent,
by volume, of C2H5OH. U.S.P.

This preparation, although somewhat more
pleasant, is less efficient as a laxative than cascara
sagrada fluidextract. [v]

The usual dose is 2 ml. (approximately 30
minims), with a range of 2 to 12 ml.

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." U.S.P.

CASTOR OIL. U.S.P., B.P., LP.

Oleum Ricini

"Castor Oil is the fixed oil obtained from the
seed of Ricinus communis Linne (Fam. Etiphor-
biacece)." U.S.P. The B.P. specifies that the oil
must be expressed from the seeds, while the LP.
is even more exacting in requiring that this be
done by a process of cold expression.

Fr. Huile de ricin. Ger. Rizinusol ; Ricinusol; Castorol.
It. Olio di ricino. Sp. Aceite de ricino; Aceite de castor.

The castor oil plant, or Palma Christi, is a
native of India and is now extensively cultivated
in the warmer regions throughout the world. In
India there are about seventeen different varieties
grown which are grouped into two types: The
first consists of tall shrubs or small trees, being
usually planted as a shade for other crops and
yielding large seeds which contain an abundance
of inferior oil. The second type includes the
herbaceous annuals, which, while they produce
small yields, yield a much better grade of fixed
oil.

The following description applies to the plant
as cultivated in cool latitudes. The stem is of
vigorous growth, erect, round, hollow, smooth,
glaucous, somewhat purplish towards the top,
branching, and from three to eight feet or more
in height. The leaves are alternate, peltate,
palmately six to eleven lobed, the lobes acute or
acuminate and serrate, smooth on both sides,
and of a bluish-green color. The flowers are
monoecious, stand upon jointed peduncles, and
form a pyramidal terminal raceme, of which the
lower portion is occupied by the male flowers,
the upper by the female. Both are destitute of

262

Castor Oil

Part I

corolla. In the staminate flowers the calyx is
divided into five oval, concave, pointed, reflected,
purplish segments, and encloses numerous sta-
mens, united into fasciculi at their base. In the
pistillate the calyx has three or five narrow
lanceolate segments, and the ovary, which is
roundish and three-sided, supports three linear,
reddish stigmas, forked at their apex. The fruit
is a roundish, glaucous capsule, with three pro-
jecting sides, covered with tough spines, and
divided into three loculi, each containing one
seed, which is expelled by the bursting of the
capsule.

The seeds are now produced in many parts
of Asia, Africa and America. During the First
World War, because of the value of castor oil
as a motor lubricant, vigorous efforts were made
to promote the cultivation of the plant in this
country. These efforts were not highly successful
but the plant is still being grown on a commercial
scale in Oklahoma. During and since World War
II, the plant has been cultivated on an increased
scale in South America, Thailand and Haiti. In
1952, a total of 140,9S2.669 pounds of castor oil
seeds was imported into the U. S. A., most of
which came from Brazil, Ecuador, Thailand,
India, Haiti and Ethiopia. During 1952 there
were imported into the U. S. A. 111,806.712
pounds of castor oil, principally from India,
Belgium, W. Germany, Netherlands, Peru, Argen-
tina. Mexico, Brazil and Paraguay.

The impurities found in commercial supplies
include hulls, sand, stones, pebbles, black, broken,
decorticated and immature castor seeds. Black
"beans" (seeds) are those whose kernels have
become discolored as a result of the seeds having
been wet. Black, decorticated and broken beans,
if not removed from the stock, have the effect of
increasing the acidity of the oil produced there-
from.

The Seeds. — These are albuminous, anatro-
pous, from 8 to 20 mm. long and 4 to 12 mm.
broad, oval, compressed, obtuse at the extremi-
ties, very smooth and shining and, in oil-produc-
ing varieties, usually of a grayish or ash color,
marbled with reddish-brown spots and veins, in
other varieties brown, black or variously mottled.
At one end of the seed is a small yellowish car-
uncle, from which an obscure longitudinal ridge
or raphe proceeds to the opposite extremity. Be-
neath the testa occurs a thin papery tegmen which
fits snugly about a whitish, oily endosperm, the
latter separated into plano-convex halves by the
embryo consisting of two papery cotyledons, a
short hypocotyl, and a plumule. In its general
appearance the seed is thought to resemble the
insect called the tick, the Latin name of which
has been adopted as the generic title of the plant.
Its variegated color depends upon a very thin
pellicle closely investing a hard, blackish shell,
within which is the kernel; the latter is highly
oleaginous, of a white color, and of a sweetish
taste succeeded by a slight degree of acrimony.
The seeds easily become rancid, and are then
unfit for the extraction of the oil. which is acrid
and irritating. The water distilled from the seeds
has a peculiar nauseous odor, quite distinct from
that of the oil.

The seeds are active poisons; three have pro-
duced fatal gastroenteritis in the adult. Exposure
to the dust of castor beans in agriculture or
industry causes conjunctivitis, pharyngitis, der-
matitis and, less frequently, asthmatic bronchitis
(Zerbst, Ind. Med., 1944, 13, 552). Poisonous
action of the beans, as first shown by Stillmark
in 1889, is due at least in part to an albumose
called ricin. This has been obtained as a white
amorphous powder soluble in water, neutral in
reaction; it is exceedingly poisonous. The toxic
symptoms, which frequently do not come on for
several hours after the ingestion of the poison,
are due primarily to the intensely irritant action
of the substance, and consist of nausea, vomiting,
colic, hemorrhagic gastroenteritis, stupor, convul-
sions, circulatory collapse, oliguria, albuminuria,
hematuria, uremia and jaundice (Koch and Cap-
Ian, Am. J. Dis. Child., 1942, 64, 485). Treatment
consists of gastric lavage, saline cathartics, main-
tenance of fluid and electrolyte equilibrium and
symptomatic measures. Muller {Arch. exp. Path.
Pharm., 1899, 42) stated that the poison also
has a direct action upon the medulla, leading to
fall of blood pressure and lessened respiratory
activity. Based on studies of the effect of ricin
on male albino rats, Thomson (/. Pharmacol.,
1950, 100, 370) concluded that the poison ap-
pears to interfere with some energy-yielding
process essential for maintenance of normal cel-
lular activity. For information concerning the-
chemistry of ricin see Spaeth (Ber., 1926, 63,
277); for study of its toxic action see the paper
of Thomson (loc. cit.). It is of interest that this
substance when injected in small doses produces
in the body an antitoxin analogous to those pro-
duced against bacteria.

The most important constituent of the castor
beans is the fixed oil, of which they yield from 45
to 50 per cent. The cake left after the expression
of the oil is known as castor pomace. From it has
been isolated a nitrogenous crystallizable body
which differs from alkaloids in not forming salts
with acids. This substance was first described
by Tuson in 1864 and named by him ricinine.
It is l,2-dihydro-4-methoxy-l-methyl-2-oxonico-
tinonitrile (C8H8N2O2) and has been synthe-
sized by Spaeth (Ber., 1925, 58, 2124); it is
soluble in water or chloroform but only sparingly
so in alcohol. It, too, is poisonous. A typical
zymogen is also present; it is soluble in fats
and in a mixture of fats and ethyl ether, and is
activated by acids. A non-toxic allergenic com-
ponent, designated CB-1A, is also present and
may cause serious disturbances (Bernton, South.
M. J., 1945. 38, 670; Figley et al., J. Allergy,
1950, 21, 545); the allergen is a polysaccharide
protein representing 1.8 per cent of defatted cas-
tor bean meal. Castor seeds consist of 20 per cent
of husks, which are rich in mineral constituents
but contain no oil, and 80 per cent of kernels.

Two methods may be economically used for
separating castor oil — extraction with an appro-
priate solvent, or expression, but the oil obtained
by extraction is unsatisfactory for medicinal use.
The expression may be hot or cold. The seeds
are first decorticated by being passed between
properly adjusted rollers and the kernels are

Part I

Castor Oil

263

separated from the husks by an air blast. The
medicinal oil, designated No. 1 grade, is expressed
cold, or with the kernels not warmer than 50°,
as above this temperature ricinine is dissolved.
The residue is further pressed, with elevation of
the temperature, or extracted with solvent; the
resulting oil, designated No. 3 grade, is used for
industrial or soap-making purposes. The press
cake is unfit for feeding animals as it contains
the poisonous constituents of the seed but it
finds some use as a fertilizer, and also in the
manufacture of tiles and certain plastics.

The albuminous principles which may have
accompanied the oil are removed by steaming
under vacuum, which also destroys any of the
enzyme that might be present; finally the oil is
dried and filtered. If not of satisfactory color
it may be bleached by treatment with fuller's
earth and activated carbon, followed by filtration.

Description. — "Castor Oil is a pale yellowish
or almost colorless, transparent, viscid liquid. It
has a faint, mild odor, and a bland, afterward
slightly acrid and usually nauseating taste. Castor
Oil is soluble in alcohol and is miscible with
dehydrated alcohol, with glacial acetic acid, with
chloroform, and with ether." U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 0.945 and not more than 0.965.
Distinction from most other fixed oils. — Castor
oil is only partly soluble in petroleum benzin, but
yields a clear liquid with an equal volume of
alcohol. Free fatty acids. — Not more than 7 ml.
of 0.1 N sodium hydroxide is required for neu-
tralization of the free fatty acids in 10 Gm. of
castor oil. Iodine value. — Not less than 83 and
not more than 88. Saponification value. — Not less
than 179 and not more than 185. U.S.P.

The B.P. gives the refractive index, at 40°, as
from 1.4695 to 1.4730, the optical rotation as not
less than +3.5°. The LP. specifies the refractive
index, at 20°, to be between 1.4774 and 1.4785;
the optical rotation, in a 200-mm. tube, should
be not less than +3°.

Composition. — The bulk of castor oil is
ricinolein, which is the ricinoleic acid [CH3-
(CH2)5CHOH.CH2.CH:CH(CH2)7COOH]
glyceride. Castor oil also contains a small quan-
tity of tristearin and of the glyceride of dihy-
droxystearic acid, together with from 0.30 to 0.37
per cent of unsaponifiable matter. The reported
proportions of fatty acids are: ricinoleic, 80 to
86 per cent; oleic. 7 to 9 per cent; linoleic, 3 to
3.5; saturated acids, 3 per cent. Pure ricinoleic
acid is a liquid at ordinary temperatures, solidi-
fying at about 5° to a hard crystalline mass. It
is soluble in alcohol, chloroform, or ether; insol-
uble in water. The pure acid is dextrorotatory,
and castor oil differs from most other fixed oils in
being dextrorotatory. When distilled in vacuo
ricinoleic acid yields normal heptoic aldehyde
and undecylenic acid. This reaction may be used
for the detection of castor oil. The viscosity of
castor oil exceeds that of all other natural fixed
oils. Because of the presence of free hydroxyl
groups in the molecule of ricinolein, castor oil
dissolves in alcohol.

Although castor oil is described as having a
"nauseating taste," some manufacturers produce

it practically free from unpleasant flavor and
taste.

On treating castor oil with concentrated sul-
furic acid the free hydroxyl groups of ricinoleic
acid are more or less completely sulfated, forming
Turkey-red oil, much used as a surface-active
agent in dyeing, printing and finishing of textiles.

Hydrogenated Castor Oil. — The glycerides of
ricinoleic acid and the other unsaturated acids
present in castor oil may be catalytically hydroge-
nated to form solid substances the melting point
of which increases with the degree of hydrogena-
tion. By such treatment ricinolein is converted
to a hydroxystearin, since saturation of ricinoleic
acid produces hydroxystearic acid. Hydrogenated
castor oil has been used as an ointment base, as
has also a similar product obtained by sulfating
the hydrogenated oil; the latter was official in
N.F. IX under the title Hydroxystearin Sulfate
(see in Part II).

Uses. — Castor oil is a cathartic. In the alkaline
portion of the intestine it is in part hydrolyzed,
under the influence of fat-splitting enzymes, into
glycerin and ricinoleic acid. The latter causes
marked local irritation of the intestinal mucosa,
thereby stimulating motor activity of the bowel
but without producing much griping. Because the
hastened peristalsis permits little time for absorp-
tion of water from the intestinal contents copious
liquid stools are produced in about 6 hours after
ingestion of the oil. As the catharsis washes out
the unhydrolyzed oil, the drug automatically
limits its action. Infants require a relatively
larger dose of the oil than do adults. Castor oil
has been preferred over other cathartics in the
treatment of food poisoning and also in cleansing
of the bowel in preparation for roentgen exami-
nation. Since ricinoleic acid is eventually ab-
sorbed, like any other fatty acid, in the small
bowel, little reaches the colon following small
doses of castor oil.

Obstetrics. — Although scientific evidence for
its efficacy is scant, it is common practice to give
60 ml. of castor oil by mouth, alone or with qui-
nine sulfate (200 mg. every hour up to five doses),
to induce labor in pregnancy at term. At least
this procedure keeps everyone concerned busy,
and toxic effects seldom result. Castor oil has
been used in abortifacient pastes for introduction
through the cervix into the uterus (Straus and
DeNosaquo, Arch. Path., 1945, 39, 91). Ricino-
leic acid is used in vaginal contraceptive creams
and jellies, in a concentration of about 0.75
per cent (Stromme and Rothnem, Internat. Rec.
Med. Gen. Pract. Clin., 1951, 164, 675; Hunter
et al., ibid., 674).

Dermatology. — Castor oil is sometimes applied
externally as a bland emollient to the skin, as a
5 to 10 per cent ointment, in seborrheic derma-
titis and other skin diseases. It is fairly commonly
employed as an ingredient of hair tonics, in con-
centrations of 0.5 to 20 per cent. It has been
used as a solvent for removing irritating sub-
stances from the eye. Sometimes medicinal
substances are suspended in the oil for ophthal-
mic application; thus, 50 mg. of chlortetracycline
hydrochloride may be suspended in 10 ml. of
castor oil for application to the conjunctiva.

264

Castor Oil

Part I

Castor oil does not become rancid on topical
application. Sodium ricinoleate solutions are used
by injection in sclerosing treatment of varicose
veins. Neutral sulfated castor oil has been used
in place of soap in cases of contact dermatitis
resulting from "airplane dope", machine cutting
oil, grease, plaster, etc. (Mummery, Brit. M. J.,
1944, 1, 660).

Administration. — Castor oil may be difficult
of administration because of its disagreeable taste
and its oleaginous and viscid character. A com-
mon method of disguising the taste is to adminis-
ter it floating on cinnamon water or orange juice,
or dispersed in the froth of sarsaparilla syrup
mixed with carbonated water. It is sometimes
given in the form of a sweetened, aromatized
emulsion, or as the N.F. Aromatic Castor Oil.
Entrekin and Becker (/. A. Ph. A., 1951, 40,
633) reported that simple syrup masked the
taste of castor oil in a 50 per cent emulsion at
least as effectively as any of the official or imi-
tation flavor syrups they tried, including the
combination of flavors in aromatic castor oil. It
has been said that the Arabs mask the taste of
castor oil by stirring it with heated milk, the
resulting emulsion being flavored with a syrup of
orange flowers. Another method of disguising the
taste of the oil is to add a drop of one of the
aromatic oils, as clove or wintergreen, and pour
the oil in a chilled spoon which is placed on ice;
when the oil becomes semisolid it is swallowed
before it liquefies.

Contraindications. — The irritant action of
castor oil causes congestion in the entire intestinal
area; it must be used with caution in menstruating
or pregnant women. The oil should not be used
as the cathartic in treatment of hookworm or
other infestation with tetrachloroethylene or
other fat-soluble vermifuge because it may in-
crease absorption of the vermifuge and thereby
increase its toxicity; a saline cathartic, such as
magnesium or sodium sulfate, is preferred for
such use. 0

The usual dose is 15 ml. (approximately 4
fluidrachms). with a range of 15 to 60 ml. The
maximum safe dose is usually 60 ml., and this
amount should seldom be exceeded in 24 hours.
For children the dose is 4 to 12 ml. (approxi-
mately 1 to 3 fluidrachms).

Storage. — Preserve "in tight containers, and
avoid exposure to excessive heat." U.S.P.

Off. Prep.— Flexible Collodion, U.S. P., B.P.;
Aromatic Castor Oil; Castor Oil Capsules, N.F.;
Ointment of Zinc Oxide and Castor Oil, B.P.

CASTOR OIL CAPSULES. N.F.

Capsulae Olei Ricini

"Castor Oil Capsules contain not less than 95
per cent and not more than 105 per cent of the
labeled amount of castor oil, and the oil from the
Capsules complies with the requirements of this
monograph for Castor Oil." N.F.

Usual Sizes. — 0.6. 1. 1.25, 2.5 and 5 ml. (ap-
proximately 10, 15, 20, 40 and 80 minims).

AROMATIC CASTOR OIL. N.F.

Oleum Ricini Aromaticum

Dissolve 3 ml. of cinnamon oil, 1 ml. of clove
oil, 0.5 Gm. of saccharin, 1 Gm. of vanillin, and
0.1 Gm. of coumarin in 30 ml. of alcohol, and add
sufficient castor oil to make 1000 ml. Mix thor-
oughly. AT.F.

Alcohol Content. — From 2 to 3 per cent, by
volume, of C2H5OH. N.F.

While the flavor of castor oil is masked by the
volatile oils, the oleaginous qualities are not
materially reduced. This preparation is taken in
the same dose as castor oil.

Storage. — Preserve "in tight containers." N.F.

OXIDIZED CELLULOSE.

[Cellulosum Oxidatum]

U.S.P.

"Oxidized Cellulose, dried in a vacuum over
phosphorus pentoxide for 18 hours, contains not
less than 16 per cent and not more than 24
per cent of carboxyl groups (— COOH)." U.S.P.

Absorbable Cellulose; Absorbable Cotton; Absorbable
Gauze; Cellulosic Acid. Oxycel (.Parke, Davis); Hemopak
(Johnson & Johnson).

When cellulose in the form of cotton or gauze
is treated with nitrogen dioxide there is produced
a product containing carboxyl groups, the degree
of oxidation with the nitrogen dioxide determin-
ing the number of these present. When the de-
gree of oxidation corresponds to the presence of
not less than approximately 16 per cent of car-
boxyl groups the product dissolves rapidly and
completely in dilute aqueous alkali solutions. In
this form, while retaining its fibrous structure,
the product is characterized by having a pro-
nounced hemostatic effect and being absorbable
when implanted in tissue.

Description. — "Oxidized Cellulose, in the
form of gauze or lint, is slightly off-white in
color, is acid to the taste and possesses a slight,
charred odor. Oxidized Cellulose is soluble in
dilute alkalies, but is insoluble in acids and in
water." U.S.P.

Standards and Tests. — Identification. — A
solution of 200 mg. of oxidized cellulose in 10 ml.
of 1 in 100 solution of sodium hydroxide, diluted
with 10 ml. of water, has not more than slight
haze and is substantially free of fibers and for-
eign particles after a minute's shaking. After
standing 10 minutes any swollen fibers initially
present are no longer visible. On acidifying with
diluted hydrochloric acid a white flocculent pre-
cipitate is produced. Loss on drying. — Not over
15 per cent, when dried in a vacuum desiccator
over phosphorus pentoxide for 18 hours. Residue
on ignition. — Not over 0.15 per cent. Nitrate or
nitrite nitrogen. — Not over 0.5 per cent as N.
Formaldehyde. — Not over 0.5 per cent, the for-
maldehyde in 1 Gm. of sample being distilled
into 1 in 100 sodium bisulfite solution, with which
the formaldehyde reacts to form an "addition"
compound. Following the distillation the uncom-
bined bisulfite in the distillate is oxidized by
titration with 0.1 N iodine; sodium bicarbonate
solution is then added to liberate the bisulfite

Part I

Cetrimide

265

from the formaldehyde-bisulfite compound which
is titrated with 0.1 N iodine. Each ml. of 0.1 N
iodine represents 1.501 mg. of formaldehyde.
U.S.P.

Assay. — About 500 mg. of oxidized cellulose,
previously dried over phosphorus pentoxide in a
vacuum desiccator for 18 hours, is covered with
a solution of calcium acetate and the hydrogen
ions released in the interaction between the cel-
lulose and calcium salt are titrated with 0.1 N
sodium hydroxide, using phenolphthalein as the
indicator. A blank titration is performed on the
calcium acetate solution. Each ml. of 0.1 N
sodium hydroxide represents 4.502 mg. of car-
boxyl (COOH) groups. U.S.P.

Uses. — Frantz and associates (Ann. Surg.,
1943, 118, 116; J.A.M.A., 1945, 129, 798)
found that oxidized cellulose exerts a hemostatic
effect through formation of an artificial clot,
with complete absorption of the cellulose when
it is implanted in tissues. The time of absorption
varies from 2 days to 6 weeks or longer, depend-
ing on the size of the oxidized cellulose implant,
the degree of oxidation of the cellulose, and the
adequacy of the blood supply in the area treated.

In surgery oxidized cellulose is used to control
moderate bleeding where suturing or ligation is
impractical or ineffective. It may be employed as
a sutured implant or as a temporary packing,
according to the particular surgical requirements ;
in neurological surgery small portions of oxidized
cellulose may be allowed to remain inside when
the wound is closed, to control oozing. Oxidized
cellulose should not be used for permanent pack-
ing or implantation in fractures because it inter-
feres with bone regeneration and may result in
cyst formation. It should not be used for surface
dressing, except for immediate control of hemor-
rhage, as it inhibits epithelialization. A case of
fatal intestinal obstruction due to adhesions re-
sulting from the use of oxidized cellulose gauze
in abdominal surgery was reported by DePrizio
(J.A.M.A., 1952, 148, 118), who considers use
of the material in areas of the abdomen where
loops of intestine are lying free as being ex-
tremely dangerous.

Because of the acid character of oxidized cel-
lulose, thrombin is inactivated by it and use of
the latter with the cellulose derivative is of
questionable value, if not actually contraindi-
cated; the hemostatic action of oxidized cellulose
is not enhanced by other hemostatic agents.

Oxidized cellulose is available in the form of
cotton pledgets, gauze discs, gauze pads, and
gauze strips.

Storage. — Preserve in "tight containers, pro-
tected from direct sunlight, and store in a cold
place, preferably in a refrigerator." U.S.P.

CETOSTEARYL ALCOHOL.

Alcohol Cetostearylicum

B.P.

This substance is a mixture of solid aliphatic
alcohols, consisting chiefly of stearyl and cetyl
alcohols; it is obtained by the reduction of the
appropriate fatty acids, or from sperm oils. For
information concerning the components of this

substance see under Cetyl Alcohol and Stearyl
Alcohol.

Description. — In white or cream-colored unc-
tuous masses, or almost white flakes or granules;
the odor is faint and characteristic, and the taste
is bland. On heating, it melts to a clear, colorless
or pale yellow liquid which is free of suspended
matter. Cetostearyl alcohol is insoluble in water,
soluble in ether, less soluble in 90 per cent alco-
hol and in light petroleum.

Standards and Tests. — Acetyl value. — Be-
tween 170 and 194. Acid value. — Not more than
0.1. Iodine value. — Not more than 3.0, deter-
mined by the iodine monochloride method.
Melting-point. — Not below 43°. Saponification
value. — Not more than 0.5. Water and lower
alcohols. — Not more than traces of water are
present, and the initial boiling-point is not below
300°.

Cetostearyl alcohol is officially recognized be-
cause of its use as a component of the important
hydrophilic ointment ingredient known as emulsi-
fying wax (see under this title).

CETRIMIDE.

Cetrimidum

B.P.

Cetrimide is defined as a mixture of alkylam-
monium bromides prepared by the condensation
of technical cetyl bromide with trimethylamine.
It consists largely of hexadecyltrimethylammo-
nium bromide, together with smaller amounts of
analogous alkyltrimethylammonium bromides, in-
organic salts (chiefly sodium bromide) and
water. It is required to contain not less than
81.5 per cent of alkyltrimethylammonium bro-
mides, calculated as Ci6H33(CH3)3N.Br, with
reference to the substance dried to constant
weight at 105°. B. P.

Cetyltrimethylammonium Bromide. CTAB. Cetavlon {Im-
perial Chemical Pharmaceuticals).

This quaternary ammonium antiseptic and de-
tergent, while not fully meeting the requirements
for maximum activity as set forth by Rawlins
et al. (see under Benzethonium Chloride), is
nevertheless practically useful, albeit it is used
in more concentrated solutions. The method of
synthesis is described in the definition above.

Description. — Cetrimide is a white to creamy-
white, vouminous, free-flowing powder, having
a faint but characteristic odor, and a bitter and
soapy taste. It is soluble in 10 parts of water,
and is almost completely soluble in alcohol. B.P.

Standards and Tests. — Identification. — (1)
An aqueous solution of cetrimide has low surface
tension and foams markedly on shaking. (2) A
yellow precipitate forms on adding a solution of
potassium ferricyanide to an aqueous solution of
cetrimide. (3) A white flocculent precipitate
forms on adding an aqueous solution of sodium
silicate to one of cetrimide. (4) Silver nitrate
solution produces a faint yellow opalescence when
added to a solution of cetrimide containing some
nitric acid; on standing in the dark for 30
minutes the opalescence becomes much more
intense. pH. — A 1 per cent solution in water
has a pH between 5.0 and 7.0. Arsenic. — The

266

Cetrimide

Part I

limit is 4 parts per million. Lead. — The limit is
20 parts per million. Loss on drying. — Not over
2.5 per cent, when dried to constant weight at
105°. Sulphated ash. — The limit is 15 per cent.
B.P.

Assay. — The procedure employed by the B.P.
is essentially the same as that specified by the
U.S. P. for benzalkonium chloride and benzetho-
nium chloride. Each ml. of 0.1 M potassium
ferricvanide represents 109.3 mg. of C16H33-
(CH3')3N.Br. B.P.

Uses. — The studies of Hoogerheide (/. Bad.,
1945, 49, 2 77) and of Muller (/. Path. Bact.,
1944, 56, 429) on the action of cetrimide on
various organisms indicate that it is a powerful
germicide; its pronounced surface-active proper-
ties make it also an excellent cleansing agent. As
with other quaternary ammonium antiseptics it
is incompatible with soap and other anionic de-
tergents; its antiseptic effect is considerably
reduced by organic matter.

A 1 per cent solution is recommended for
cleansing wounds and skin surrounding wounds;
it is also highly effective for removing dirt and
bacteria from the hands, and for cleansing and
sterilization of instruments and utensils (Williams,
Lancet, 1943, 1, 522). According to Williams
the concentration required to kill E. coli is con-
siderably greater than that required to kill most
other organisms. Although, according to Barnes
(ibid., 1942, 1, 531), it destroys leukocytes in
strengths of 1 to 1000 it is not irritant to tissues.
Toomey et al. (Arch. Pediatr., 1945, 62, 108)
found that preparations containing 0.2 to 1
per cent of cetrimide cleared lesions of impetigo
in an average of 5 days.

In a preliminary study of the efficacy of quater-
nary ammonium compounds as molluscacides.
Yaflejo-Freire et al. (Science, 1954, 119, 470)
found that a concentration of 5 parts per million
of cetyltrimethylammonium bromide killed all
Australorbis species snails; since snails serve as
the intermediate host of Schistosoma the poten-
tial importance of this property of quaternary
ammonium compounds is apparent.

CETYL ALCOHOL.

[Alcohol Cetylicum]

CH3(CH2)i4CHoOH

N.F.

"Cetyl Alcohol is a mixture of solid alcohols
consisting chiefly of cetyl alcohol." AT.F.

1-Hexadecanol; n-Hexadecj-1 Alcohol; Palmityl Alcohol.

Cetyl alcohol, both free and esterified, is an im-
portant constituent of spermaceti, and to a lesser
extent of other waxes. Formerly it was prepared
by heating spermaceti with alkali from which, on
dilution with water, cetyl alcohol separated, to-
gether with other higher alcohols present in
spermaceti. A newer process consists in saponify-
ing spermaceti with potassium hydroxide in a
medium of ethylene glycol, followed by distilla-
tion of the cetyl alcohol under vacuum. Much
cetyl alcohol is made by catalytic hydrogenation
of fatty acid mixtures, or fats, containing a large
proportion of palmitic acid; cetyl alcohol is the
alcohol corresponding to palmitic acid.

Description. — "Cetyl Alcohol occurs as unc-
tuous, white flakes, granules, cubes or castings.
It has a faint characteristic odor and a bland,
mild taste. Cetyl Alcohol dissolves in alcohol
and in ether, the solubility increasing with an
increase in temperature. It is insoluble in water.
Cetyl Alcohol melts between 45° and 50°." K.F.
Cetyl alcohol is also miscible with both vege-
table and mineral oils and fats.

Standards and Tests. — Distillation range. —
Not less than 90 per cent distils between 316° and
336°. Acid value. — Not more than 2. Iodine value.
— Not more than 5. Hydroxyl number. — 2 Gm.
of cetyl alcohol is warmed at 60° to 65° with
acetyl chloride in a toluene and pyridine solvent
medium; the hydroxyl group is thereby esterified,
forming cetyl acetate. The excess of acetyl chlo-
ride is hydrolyzed with water to acetic and hydro-
chloric acids, and these products, together with
the hydrochloric acid formed as a by-product of
the esterification process, are titrated with 1 N
sodium hydroxide, using phenolphthalein T.S. as
indicator. A blank test is performed under identi-
cal conditions. The difference in the volume of
sodium hydroxide solution required for the two
titrations is equivalent to the acetic acid required
for esterification and, therefore, to the content of
hydroxyl. By multiplying this difference by 56.10
and dividing by the weight of sample taken, the
hydroxyl number is calculated; this is defined as
the number of mg. of potassium hydroxide equiva-
lent to the hydroxyl content of 1 Gm. of sample.
The hydroxyl number of cetyl alcohol is not less
than 218 and not more than 238 (the theoretical
value is 231.4). N.F.

Uses. — Cetyl alcohol, though not itself an
emulsifying agent, is an emulsifying aid whose
stabilizing property appears to be due- to its hy-
drating capacity. It may be used in either oil-in-
water or water-in-oil emulsions. It is widely em-
ployed in the formulation of "washable" ointment
bases.

The water-binding property of cetyl alcohol is
apparent from the fact that the addition of 4 per
cent of the alcohol to petrolatum increases the
amount of water which petrolatum will absorb
from a range of 9 to 15 per cent to one of 39
to 52 per cent. Addition of 1 per cent of cetyl
alcohol to hydrogenated peanut oil nearly doubles
its water-binding capacity.

The stability and "skin qualities" of many lo-
tions may be enhanced by incorporating cetyl
alcohol, according to Dean et al. (J. A. Ph. A.,
Prac. Ed., 1949, 10, 430). To facilitate extempo-
raneous preparation of lotions containing cetyl
alcohol they used a stock composition made by
melting 36 Gm. of cetyl alcohol on a water bath
and adding a solution of 4 Gm. of sodium lauryl
sulfate in 900 ml. of water, warmed to 55°, with
constant stirring; a viscous, translucent liquid
results. This stabilizer may be used to make up
one-fourth to one-third of the final volume of a
lotion; it is particularly useful when used in this
way to suspend calamine, titanium dioxide, or
the precipitate of white lotion.

Maren and Edwards (/. A. Ph. A., 1943, 32,
255) found cetyl alcohol to be an excellent dis-
persing agent for mercury and for calomel in the

Part I

Chalk, Prepared 267

preparation of ointments for use as prophylactic
agents against venereal diseases; penetration of
the ointments is also enhanced. Prophylactic
ointments of this type, containing cetyl alcohol,
were employed during the war for the armed
forces.

A mixture of cetyl and stearyl alcohols, for use
in preparing emulsifying wax to be employed in
formulating emulsifying ointment and hydrous
emulsifying ointment, is official in the B.P. under
the title cetostearyl alcohol (see under this title).
The British product Lanette Wax SX, used in
the formulation of many medicinal and cosmetic
creams and lotions, is a mixture of partially sul-
fated cetyl and stearyl alcohols. A composition
said to have emulsifying properties similar to
those of the wax consists of 9 parts of cetyl
alcohol and 1 part of sodium lauryl sulfate
(Duponol C). Halden's Emulsifying Base, an-
other British product which has come to the at-
tention of prescribers in this country, is a mixture
of partially phosphated esters of cetyl and stearyl
alcohols with liquid petrolatum and white petro-
latum.

The therapeutically desirable qualities of cetyl
alcohol were observed many years ago by Grimm
(Derm. Ztschr., 1899, 6) who called attention to
the fact that it is absorbed and obstinately
retained by the epidermis, imparting a charac-
teristic velvety texture to the skin. It has been
found useful in the treatment of chapped hands,
weeping eczema, and prurigo.

For formulas of several useful creams made
with cetyl alcohol see Green (/. A. Ph. A., Prac.
Ed., 1946, 7, 297).

Abbott and Allport (Pharm. J., 1943, 151, 52)
proposed a solution of 10 per cent of cetyl alcohol
and 10 per cent of shellac, in acetone, as an
enteric coating for pills and tablets.

Storage. — Preserve "in well-closed contain-
ers." N.F.

PREPARED CHALK. N.F. (B.P.)

Creta Prasparata, Drop Chalk

"Prepared Chalk is a native form of calcium
carbonate freed from most of its impurities by
elutriation, and containing, when dried at 180°
for 4 hours, not less than 97 per cent of CaCC>3."
N.F. The B.P. rubric is the same, except that it
is referred to the substance dried to constant
weight at 105°.

B.P. Chalk; Creta. Creta Laevigata. Fr. Craie preparee.
Ger. Kreide; Schlammkreide. Sp. Creta Preparada.

Calcium carbonate occurs in nature in several
different forms, of which the most abundant is
limestone. Other native forms include calcite (a
crystalline variety belonging to the hexagonal sys-
tem including also Iceland spar and marble),
aragonite (a crystalline form belonging to the
rhombic system), chalk, pearl, coral and various
shells. In the presence of carbon dioxide lime-
stone dissolves in water to form calcium bicar-
bonate; underground waters containing the latter
sometimes lose carbon dioxide causing the calcium
to deposit as carbonate in the form of the stalag-
mites and stalactites frequently found in caves.

Chalk occurs abundantly in many parts of

Europe and America. It exists in massive beds,
and very frequently contains nodules of flint, and
fossil remains of land and marine animals. More
or less alumina and ferric oxide are also found
in it.

Because of the gritty particles which it contains,
chalk is unfit for medicinal use until it has been
prepared as follows: After reducing it to a very
fine powder, the chalk is agitated with water and
from this suspension the coarser particles deposit,
leaving a turbid liquid which, after being de-
canted, is set aside to permit the very small
particles to settle; this process is called elutri-
ation, or "water-sifting." The soft mass remain-
ing after the clear supernatant liquor is decanted
is dropped upon an absorbent surface in small
portions, which when dried have a conical shape.
This part of the operation is known as trochisca-
tion.

The by-product of the manufacture of pre-
pared chalk, which contains earthy impurities, is
commonly sold as whiting.

Description. — "Prepared Chalk is a white to
grayish white, microcrystalline powder, often
prepared in cones. It is odorless and tasteless,
and is stable in air. Prepared Chalk is practically
insoluble in water and is insoluble in alcohol. It
dissolves with effervescence in diluted hydro-
chloric acid, and in diluted nitric acid." N.F.

Standards and Tests. — Identification. — Pre-
pared chalk responds to the identification tests
under Precipitated Calcium Carbonate. Acid-
insoluble residue. — Not more than 20 mg. of
residue is obtained from 1 Gm. of prepared chalk.
Heavy metals. — The limit is 40 parts per million.
N.F. The B.P. specifies arsenic and lead limits of
4 and 20 parts per million, respectively.

Assay. — About 250 mg. of prepared chalk,
previously dried at 180° for 4 hours, is dissolved
in a dilute solution of hydrochloric acid, the
solution boiled to expel carbon dioxide and then
assayed by the method employed for calcium
bromide. Each ml. of 0.1 N potassium perman-
ganate represents 5.005 mg. of CaC03. N.F. The
B.P. assay is performed by dissolving the chalk
in a measured excess of 1 A" hydrochloric acid with
and water, and titrating the excess acid with
1 N sodium hydroxide, using methyl orange
indicator.

Uses. — Prepared chalk is an excellent antacid;
as the salts which it forms in the stomach and
bowels, if not astringent, are at least not purga-
tive, it is useful for treating diarrhea accompanied
by acidity. It is also used in acidity of stomach,
when a laxative effect is to be avoided. It is one
of the best antidotes for oxalic acid. Because
of the slight absorbability of calcium from the
intestines it has been the impression that there
was no danger of alkalosis from the continued use
of calcium carbonate but Kirsner and Palmer
(J. A.M. A., 1941, 116, 384) noted the occurrence
of alkalosis in a considerable proportion of pa-
tients with peptic ulcers who were taking large
doses of calcium carbonate. The symptoms, how-
ever, in these cases cleared immediately when
sodium chloride was administered in conjunction
with the antacid.

Externally it has been used as an application

268 Chalk, Prepared

Part I

to burns and ulcers, which it moderately stimu-
lates, while absorbing the ichorous discharge and
thus preventing it from irritating the diseased
surface or the sound skin. It is also of value in
various skin conditions as a desiccant dusting
powder, being considerably more efficient in its
absorbing properties than is talc.

It is given internally in the form of powder,
or suspended in water by means of acacia or
bentonite (see Chalk Mixture). Prepared chalk is
preferred over precipitated calcium carbonate
for preparing chalk mixture, the former being
more impalpable and also more adhesive. 12

Dose, from 1 to 4 Gm. (approximately 15 to
60 grains) three times a day after meals or more
often.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep. — Chalk Mixture; Compound Chalk
Powder, N.F.; Aromatic Powder of Chalk, B.P.

CHALK MIXTURE.

Mistura Cretae
Sp. Mixtura de Creta.

N.F.

Mix 500 ml. of bentonite magma with 400 ml.
of cinnamon water, add 30 ml. of this mixture to
60 Gm. of prepared chalk and 0.3 Gm. of sac-
charin sodium in a mortar, and mix well to form
a smooth, uniform paste. Gradually incorporate
the remainder of the diluted magma and finally
enough purified water to make 1000 ml. N.F.

Through several revisions of the U.S. P., chalk
mixture was directed to be freshly prepared by
adding distilled water and cinnamon water to
compound chalk powder, the latter consisting
of 30 per cent of prepared chalk. 20 per cent of
powdered acacia, and 50 per cent of sucrose.
The resulting product, while therapeutically ac-
ceptable, did not represent a particularly good
dispersion of the chalk, and it spoiled readily
through fermentation. The present formula,
utilizing the superior dispersing agent bentonite
and the non-fermentable sweetener saccharin
sodium, is a definite improvement over the earlier
formula.

Use. — Chalk mixture has for many years been
widely used as an antacid both for the stomach
and the intestines; it is a palatable form for the
administration of chalk. S

Dose, 15 ml. (approximately 4 fluidrachms).

COMPOUND CHALK POWDER. N.F.

Pulvis Cretae Compositus

Mix 300 Gm. of prepared chalk, 200 Gm. of
acacia, in fine powder, and 500 Gm. of sucrose,
in fine powder, and pass the product through a
No. 60 sieve. N.F.

Use. — Compound chalk powder is an excel-
lent antacid for gastric or intestinal conditions.
It is employed in the treatment of diarrheas asso-
ciated with intestinal acidity. S

Dose, 2 to 8 Gm. (approximately ^ to 2
drachms).

AROMATIC POWDER OF CHALK.
B.P.

Pulvis Cretae Aromaticus

The B.P. Aromatic Powder of Chalk contains

25 per cent of chalk, 10 per cent of cinnamon,
8 per cent of myristica, 4 per cent of clove, 3 per
cent of cardamom, and 50 per cent of sucrose.

The Aromatic Chalk Powder of N.F. IX was
prepared as follows : Triturate 60 Gm. of freshly
grated myristica with 250 Gm. of prepared chalk
until they are reduced to a fine powder; add 80
Gm. of cinnamon, in fine powder, 30 Gm. of clove,
in fine powder, 20 Gm. of cardamom seed, in fine
powder, and 560 Gm. of sucrose, in fine powder,
and triturate the whole until a uniform mixture
is obtained.

Use. — Aromatic chalk powder is a warm stimu-
lant and astringent, as well as an antacid, and is
used in diarrhea attended by acidity in the ab-
sence of inflammation.

Dose, from 0.6 to 4 Gm. (approximately 10 to
60 grains), suspended in a mucilaginous and
sweetened vehicle.

Off. Prep. — Aromatic Powder of Chalk with
Opium, B.P.

AROMATIC POWDER OF CHALK
WITH OPIUM. B.P.

Pulvis Cretae Aromaticus cum Opio

The B.P. requires this powder to contain 2.5
per cent of powdered opium, equivalent to 0.25
per cent of anhydrous morphine (limits, 0.235 to
0.265).

Aromatic Powder of Chalk and Opium. Pulvis Cretae et
Opii Aromaticus.

Aromatic Powder of Chalk with Opium is pre-
pared by mixing 975 Gm. of aromatc powder of
chalk with 25 Gm. of powdered opium.

Uses. — The inclusion of opium increases the
efficacy of compound chalk powder in diarrhea.
The preparation also provides a means of ad-
ministering small doses of opium, when required,
to children. Forty grains of the powder contain a
grain of opium.

Dose, for adults, from 0.6 to 4 Gm. (approxi-
mately 10 to 60 grains).

ACTIVATED CHARCOAL. N.F.

Carbo Activatus

"Activated Charcoal is the residue from the
destructive distillation of various organic mate-
rials, treated to increase its adsorptive power."
N.F.

Medicinal Charcoal; Active Carbon. Carbo Medicinalis.
Fr. Charbon active officinal. Ger. Medizinische Kohle.
Sp. Carbon Vegetal Activado.

The term charcoal is applied generically to the
carbonaceous residue which is left after heating
organic matter in the absence of oxygen or, in
other words, after its destructive distillation.
There are several kinds of charcoal commercially
available which are named after the organic mat-
ter from which they are derived, such as wood
charcoal, bone charcoal, blood charcoal, et cetera.
In ancient times wood was charred by partial
combustion in earthen ovens so arranged that the
supply of oxygen would be insufficient for the
combustion of all of the wood. This method
wastes most of the valuable volatile products (see
Acetic Acid). In modern processes the wood char-

Part I

Charcoal, Activated

269

coal is made by heating wood or other organic
matter in closed systems. Much industrial char-
coal is now made from industrial refuse, such as
the waste liquor from wood-pulp, paper, and
molasses.

While the process of adsorption is selective
insofar as the nature of the substance adsorbed
is concerned, the extent of it is dependent both
on the development of a large surface area in the
charcoal and a conditioning or activation of its
surface. Destructive distillation of organic matter
tends to be molecularly disruptive, so that ex-
tensive development of surface occurs in the
manufacture of charcoal but special treatment is
required to activate the surface. Such activation
may be effected by treating the charcoal, at high
temperature, with steam and carbon dioxide; air
in small quantities may be admitted as a mild
oxidant for certain contaminating substances.
Strong dehydrating substances, such as sulfuric
or phosphoric acid, or zinc chloride, are also em-
ployed in preparing some activated charcoals;
their action, presumably, is to break down or to
assist in breaking down organic substances so
that carbonization may be facilitated. For many
purposes, certainly when used medicinally, acti-
vated charcoals or carbons, as they are more often
called, must be washed with acid and water to
remove any inorganic matter that may be present.

Two principal types of activated carbons are
supplied commercially. One type is made for
adsorption of gases or vapors, the other for use
in liquids. Gas and vapor adsorbent carbons were
formerly made from coconut shells because of
the hard, dense structure of such shells but other
nut shells have been utilized and methods de-
veloped for using softer charcoals to which the
required hardness and density are imparted by in-
corporation of a binder. Such carbons find use in
gas masks, in recovery of valuable solvent vapors
from air, and in certain catalytic operations.

Activated carbons employed in liquid systems
for removing color, taste, odor, and other im-
purities— sometimes called decolorizing carbons —
are made from bones, wood charcoal, lignite, and
paper mill waste liquor that contains lignin and
cellulose degradation products. They are ground
to a very fine powder, from 70 to 98 per cent
passing through a 325-mesh screen. Particles of
such size are smaller than 45 microns (0.002 inch)
and the number of them in one pound is approxi-
mately fifty thousand billion. The total surface
area, including that of the pores and capillaries,
of a pound of properly activated carbon is of the
order of 50 acres.

Adsorptive action of the various carbons is not
limited to substances having color, odor or taste.
Hydrogen or hydroxyl ion, some neutral salts, and
many organic compounds are adsorbed by various
carbons. Some carbons, at least, may be prepared
with highly developed and specific adsorbing
powers.

Before the development of activated carbons,
the medical profession considered willow charcoal
to be the most satisfactory carbon for medical
use. Today it is recognized, however, that a
purified activated charcoal is materially superior
to willow charcoal.

Suchy and Rice (/. A. Ph. A., 1935, 24, 120)
tested five brands of activated charcoal, bone
black, and willow charcoal for ability to adsorb
strychnine from solution after 24 hours' contact.
One gram of the most effective activated charcoal
removed 500 mg. of strychnine; the least effec-
tive brand of activated charcoal removed 90 mg.;
bone black removed 35 mg. and willow charcoal
only 11 mg. Mutch (Brit. M. /., 1934, 1, 320),
studying the adsorption efficiencies of 30 different
charcoals by measuring the amount of methylene
blue adsorbed, obtained coefficients ranging from
0.5 to 85. Rosin and Beale (/. A. Ph. A., 1935, 24,
630) found that there was considerable difference
between the various brands of activated chars;
the best of the 8 brands they tested adsorbed 2.4
times as much hydrogen sulfide and 4.2 times as
much methylene blue as wood charcoal.

The N.F. IX recognized Purified Animal Char-
coal, also called bone black, which is prepared
from bone and purified by removing the sub-
stances which are dissolved by hot hydrochloric
acid. Before the introduction of activated char-
coal, this form of charcoal was widely used for
the purposes for which the more efficient activated
charcoal is currently employed.

Description. — "Activated Charcoal is a fine,
black, odorless, tasteless powder free from gritty
matter." N.F.

Standards and Tests. — Loss on drying. —
Activated charcoal loses not more than 15 per
cent of its weight on drying at 120° for 4 hours.
Residue on ignition. — Not over 4 per cent. Acidity
or alkalinity. — On boiling 3 Gm. of activated char-
coal with 60 ml. of water for 5 minutes, then
filtering, a filtrate free from color and neutral to
litmus paper results. Chloride. — The limit is 0.2
per cent. Sulfate. — The limit is 0.2 per cent.
Sulfide. — Lead acetate paper is not blackened
when held in the vapor from a boiling mixture of
500 mg. of activated charcoal with 20 ml. of water
and 5 ml. of hydrochloric acid. Cyanogen com-
pounds.— On distilling a mixture of 5 Gm. of
charcoal, tartaric acid and water, the distillate,
received in water alkalinized with sodium hydrox-
ide T.S., is not colored blue by ferrous sulfate
solution. Acid-soluble substances. — Not over 35
mg. of residue is obtained on boiling 1 Gm. of
activated charcoal with a mixture of water and
hydrochloric acid, filtering, adding sulfuric acid
to the filtrate, evaporating to dryness and ignit-
ing to constant weight at a dull red heat. Heavy
metals. — The limit is 50 parts per million. Uncar-
bonized constituents. — On boiling 250 mg. of acti-
vated charcoal with 10 ml. of sodium hydroxide
T.S. and filtering, a colorless filtrate is obtained.
Adsorptive power. — (1) One Gm. of activated
charcoal absorbs completely 100 mg. of strych-
nine sulfate from 50 ml. of water, the test being
performed with mercuric potassium iodide T.S.
on a portion of the filtrate obtained from the
mixture. (2) In this test two portions of a
methylene blue solution are measured; to one
portion activated charcoal is added and, after
vigorous shaking, each portion is filtered and the
volume of 0.1 N iodine required to react with the
methylene blue in an aliquot of each portion de-
termined by a residual titration utilizing 0.1 N

270 Charcoal, Activated

Part I

sodium thiosulfate. At least 0.7 ml. less of 0.1 N
iodine should be required to react with the
methylene blue to which the charcoal has been
added than that required by an equivalent amount
of methylene blue without charcoal. N.F.

Uses. — The adsorptive properties of activated
charcoal prompted its trial in the treatment of
many and varied diseased conditions, but no
striking benefits have been observed. It has been
prescribed in dyspepsia to reduce hyperacidity
and to adsorb gaseous products of fermentation,
though its effectiveness in the latter respect, when
wetted, has been questioned. Activated charcoal
may adsorb enzymes, vitamins and minerals, and
hence interfere with digestion (Emery, J.A.M.A.,
1937, 108, 202). In the intestinal tract it will
remove many irritating substances, such as the
toxic amines and organic acids of decomposed
foods, probably also bacteria themselves (Dietzel
et al., Apoth. Ztg., 1932, 47, 283). Large doses,
either alone or mixed with equal amounts of
kaolin, have been administered for diarrhea in
chronic ulcerative colitis and other conditions.
Many surgeons have reported it to be of value as
a dressing for suppurating wounds of various
types. Charcoal poultices have been used to ab-
sorb odors from gangrenous and other foul
wounds (Regan and Henderson, Proc. Mayo,
1944, 19, 268).

A 2 per cent aqueous suspension of activated
charcoal has been administered intravenously in
the nonspecific treatment of a variety of infec-
tions (Saint-Jaques, Lancet, 1934, 1, 418) but
Davis {Lancet, 1936, 2, 1266) found no bene-
ficial effect and described reactions resembling
those, produced by the injection of foreign
proteins.

Use as Antidote. — Charcoal is used as an
antidote in various forms of poisoning, especially
mercuric chloride, strychnine, phenol, atropine,
oxalic acid, mushroom, and other poisons for
which no efficient antidote is available. Dinge-
manse and Laqueur {Biochem. Ztschr., 1926, 169,
235), as a result of experiments on pigs' stom-
achs, showed that it would absorb corrosive sub-
limate not only when it is dissolved in gastric
contents but also the mercury which had been
bound with the protein of the stomach wall (see
also Leschke, Munch, med. Wchnschr., 1931, 78,
1908). It is a component of universal antidote
mixtures such as the following: activated carbon,
2 parts; magnesium oxide and tannic acid, of each
one part. The mixture is given in teaspoonful
doses with a little water. Fantus and Dyniewicz
(J. A.M. A., 1938, 110, 1656) found activated
charcoal to be an effective antidote for phenol-
phthalein. Moench (N. Y. State J. Med., 1950,
50, 308) used it instead of thiuram disulfide in
treating patients with chronic alcoholism.

Gemmell and Todd (Pharm. J., 1945, 154, 126)
found activated charcoal to be generally satis-
factory for removing pyrogens from solutions of
inorganic salts to be injected though, because of
ease of contamination of the resultant solutions,
these had to be sterilized immediately after final
filtration. S

Activated charcoal finds many uses in chemical
syntheses. Sometimes it is employed to remove

products of side reactions in order that the main
product may be left in purified form; again a
substance which will not form satisfactory crys-
tals will often be found to do so when its solution
is treated with carbon to remove certain im-
purities. A novel application of activated carbon
is in the production of penicillin, where it has
been used to adsorb the penicillin from a rela-
tively weak solution, then to yield it in concen-
trated form by treating the carbon with a suitable
solvent to elute the penicillin. A similar applica-
tion in the manufacture of streptomycin and of
certain hormones has also been made. In munici-
pal water purification plants, powdered activated
carbon is used for elimination of odor and taste;
dosages of 10 to 20 pounds of carbon per million
gallons of water are ordinarily sufficient. For
further discussion of commercial industrial appli-
cations of activated carbon see Helbig (J. Chem.
Educ, 1946, 23, 98).

The dose of charcoal varies widely. In ordinary
gastric conditions 0.6 to 1 Gm. (approximately 10
to 15 grains) will be sufficient, but in intestinal
conditions doses of 4 to 6 Gm. (1 to l1/* drachms)
or higher may be employed. In cases of poisoning
still larger quantities may be given. Thus in
mercury bichloride poisoning doses of two or
three tablespoon fuls are given.

Storage. — Preserve "in well-closed contain-
ers." N.F.

CHENOPODIUM OIL. N.F. (B.P.) LP.

American Wormseed Oil, [Oleum Chenopodii]

"Chenopodium Oil is the volatile oil distilled
with steam from the fresh, above-ground parts of
the flowering and fruiting plant of Chenopodium
ambrosioides Linne var. anthelminticum (Linne)
A. Gray (Fam. Chenopodiacece). It contains
not less than 65 per cent, by weight, of ascaridol,
C10H16O2." N.F. The B.P. and LP. definitions
provide for an oil identical with that recognized
by the N.F.

B.P. Oil of Chenopodium. LP. Aetheroleum Cheno-
podii. Oleum Chenopodii Anthelmintici -Sithereum; Oleum
Chenopodii Anthelminthici; Essentia Chenopodii. Fr. Es-
sence de chenopode vermifuge. Gcr. Wurmsamenol ;
Chenopodiumol. It. Essenza di chenopodio. Sp. Esencia de
quenopodio.

For description of the plant from which this
oil is derived see Chenopodium, Part II. Weiland
et al. {Univ. Maryland Exp. Sta., Bull. 384, 1935)
found that ascaridol is distributed throughout the
plant but that the greater portion is in the seed,
with leaves and seed stems containing smaller
amounts, and the smallest proportion occurring
in the stalk. The highest concentration of ascaridol
is in plants that have matured to the point where
most of the seeds have darkened in color. Cheno-
podium oil is distilled in relatively large amounts
in Maryland.

Description. — "Chenopodium Oil is a pale
yellow to orange-yellow liquid, having a peculiar,
unpleasant odor, and a bitter, burning taste.
Chenopodium oil dissolves in 8 volumes of 70
per cent alcohol." N.F. The oil darkens on
standing.

Standards and Tests. — Specific gravity. —
Not less than 0.950 and not more than 0.980.

Part I

Chenopodium Oil 271

Optical rotation. — The optical rotation of the oil,
in a 100-mm. tube, is between — 4° and — 8°.
Refractive index. — Not less than 1.4740 and not
more than 1.4790 at 20°. Heavy metals. — The oil
meets the requirements of the test for Heavy
metals in volatile oils. N.F.

Assay. — About 2.5 Gm. of the oil is diluted
to 50 ml., in a volumetric flask, with 90 per cent
acetic acid, and an aliquot portion added to a
cooled mixture of potassium iodide solution, hy-
drochloric acid and glacial acetic acid. The
volume of the aliquot added (from a burette) is
read 2 minutes after withdrawal, to permit ade-
quate drainage. After the reaction mixture has
stood for exactly 5 minutes at a temperature be-
tween 5° and 10° the liberated iodine is titrated
with 0.1 ^ sodium thiosulfate. At the same time,
a residual blank titration is performed. The dif-
ference between the volumes of sodium thio-
sulfate solution required for the two titrations
represents the iodine liberated by the ascaridol.
Although the amount of iodine liberated by the
peroxide ascaridol is not in stoichiometric pro-
portion it is produced in proportion to the amount
of ascaridol present (for discussion see Reindol-
lar, /. A. Ph. A., 1939, 28, 589). Each ml of 0.1 N
sodium thiosulfate has been found by experiment
to be equivalent to 6.65 mg. of ascaridol,
C10H16O2. N.F. The B.P. and LP. assays are the
same as that of the N.F.

Reindollar and Munch (/. A. Ph. A., 1931, 20,
443) attempted to develop a method of biological
assay. They experimented with goldfish, earth-
worms, and porcine ascarides, but found that none
of them yielded results parallel to the ascaridol
content. The Committee on Hygiene of the
League of Nations, however, in 1925 provision-
ally adopted a test on earthworms.

Constituents. — In 1907 Kremers, in attempt-
ing fractional distillation of chenopodium oil,
found that a large part consisted of a liquid which
could not be distilled because it underwent an ex-
plosive decomposition when heated. Schimmel &
Co. (1908) succeeded in isolating this fraction by
distillation at reduced pressure and gave to it the
name of ascaridol. Ascaridol (spelled ascaridole
in England), which makes up from 45 to 70 per
cent of the oil, is an unsaturated terpene perox-
ide having the formula C10H16O2. It may explode
with considerable violence either when heated or
upon treatment with certain organic acids.

Henry and Paget (/. Chem. S., 1921, 119,
1714) found chenopodium oil to consist of about
60 per cent ascaridol, 15 per cent cymene, 10 per
cent of a levorotatory terpene, and small amounts
of other hydrocarbons. In a subsequent study
(Schim. Rep., 1927) they isolated, in addition to
the above, ascaridol glycol (about 5 per cent),
alpha-terpinene, paracymol, and traces of methyl
salicylate, salicylic acid, butyric acid, dextro-
camphor, paramenthadiamine, limonene, and di-
methylethylene oxide. The chemical nature of
ascaridol is discussed by Pagent (/. Chem. S.,
1938, 829).

The question as to whether ascaridol is the
sole active substance of chenopodium oil cannot
be answered with certainty. It is the most potent

fraction of the oil but other components may
possess some anthelmintic properties.

Uses. — Chenopodium oil is used as an anthel-
mintic. Brunning {Ztschr. exp. Path. Ther., 1906,
3, 564) showed that one part in 5000 paralyzed,
although it did not kill, the roundworm of dogs,
and that one part in 200 had a distinct antiseptic
action. In mammals, if given in sufficient dose,
it depresses the spinal cord and finally kills by
arrest of respiration. According to Salant and
Livingston (Am. J. Physiol., 1915, 38) cheno-
podium oil in doses of 0.02 ml. per kilogram, or
more, produces lowering of the blood pressure
through a depressant action on the heart and cen-
tral nervous system. The oil has a burning taste
and causes salivation and gastric irritation. It is
readily absorbed from the gastrointestinal tract
and is excreted in part by the lungs. Constipa-
tion may result from a depressant effect on the
intestine.

Although it is one of the most efficient drugs
against the roundworm and the hookworm (Rousis
and Bishop, J. A.M. A., 1920, 74, 1768), cheno-
podium oil has been largely superseded by less
poisonous drugs. It has been administered along
with carbon tetrachloride or tetrachloroethylene,
in the proportion of one part of the oil to two to
five parts of the latter liquids (Brown, J.A.M.A.,
1934, 103, 651), for mixed hookworm and round-
worm infestations. This combination is also ad-
vised for whipworm infestation (J.A.M.A., 1944,
125, 320). Since the oil paralyzes rather than
kills worms, its use must be followed by a purga-
tive to expel the worms. It is much less efficacious
against tapeworms, although it has been used for
dwarf tapeworm. Several authors, including
Barnes and Cort (J.A.M.A., 1918, 71, 350), have
also found it useful in the treatment of amebic
dysentery. E

Toxicology. — With proper care chenopodium
oil is a relatively safe anthelmintic (Smillie,
J. A.M. A., 1939, 113, 410), but it is not a drug to
be used carelessly. Mild toxic symptoms are fre-
quent. Levy (J.A.M.A., 1914, 63, 1946) reviewed
twelve cases of serious poisoning of which nine
ended fatally (see also Guy ton, J. A.M. A., 1946,
132, 330). Children, the aged, and malnourished
persons are particularly susceptible to poisoning.
The oil is contraindicated in patients with renal,
cardiac or hepatic disease or ulceration of the
gastrointestinal tract. The experiments of Salant
(J. A.M. A., 1917, 69, 2016) showed an accumu-
lative tendency in the toxicity of this drug; an
increased sensitiveness to a second dose per-
sisted 5 to 9 days after the first dose.

The symptoms of poisoning by chenopodium
oil — which may not appear for several hours after
taking the oil — are nausea, vomiting, headache
followed by drowsiness, ringing in the ears, and
sometimes deafness and impaired vision. In the
fatal cases there develop coma and convulsions.
Respiration is slow. The blood pressure falls.
Hematuria, albuminuria or jaundice may be ob-
served. In the milder cases of chenopodium poi-
soning the symptoms usually pass off spontane-
ously within a few hours; in the severe cases
catharsis with magnesium sulfate, a high fluid
intake and circulatory stimulants, especially epi-

272 Chenopodium Oil

Part I

nephrine and atropine, are recommended. Alco-
holic beverages should be avoided.

Dose. — The dose and method of administra-
tion of the oil differ according to the weight,
age and nutritive state of the patient as well as
with the type of infection. Fasting or catharsis is
usually not prescribed before its administration
but food should be withheld until the purgative
has acted. Administration of oil should not be re-
peated in less than two or three weeks. It is most
conveniently administered in gelatin capsules, or
on a lump of sugar, and must be followed by a
purgative such as magnesium or sodium sulfate
or castor oil. For roundworm infestation two or
three doses of from 0.2 to 0.3 ml. (approximately
3 to 5 minims) each, at intervals of one or two
hours may be administered to well-nourished
adults. For hookworm, two or three doses of 0.5
to 1 ml. each (approximately 8 to IS minims)
have been used. For poorly nourished persons
the doses should be reduced in proportion to the
weight. For children, 0.05 ml. (approximately
34 minim) per year of age divided into two or
three parts is used. It is important that the dose
should be measured by volume and not by the
number of drops because of the variable size of
the latter.

Usual dose — Caution! As an anthelmintic for
adults, single dose, 1 ml. (approximately 15
minims). N.F.

Storage. — Preserve "in tight containers and
avoid exposure to excessive heat." N.F.

CHERRY JUICE. U.S.P.

Succus Cerasi

"Cherry Juice is the liquid expressed from the
fresh ripe fruit of Prunus Cerasus Linne (Fam.
Rosacea). Cherry Juice contains not less than
1.0 per cent of malic acid (aHcOs)." U.S.P.

Succus Cerasorum. Fr. Sue de cerise. Cer. Kirschensaft.

In a grinder coarsely crush washed, stemmed,
unpitted, sour cherries so as to break the pits but
not mash the kernels. Dissolve 0.1 per cent of
benzoic acid in the mixture, allow to stand at
room temperature (possibly for several days)
until a portion of the filtered juice produces a
clear solution when mixed with half its volume
of alcohol, remaining so for 30 minutes. Press out
the juice from the mixture and filter it. U.S.P.

Prunus Cerasus L. (Cerasus vulgaris Mill.),
the sour, pie or Morello cherry, is a round-headed
tree native to Asia Minor and possibly south-
eastern Europe and naturalized in North America
where a number of varieties occur both in the
wild and cultivated condition. The trees give off
suckers readily from the roots and frequently are
seen forming fence-rows in the country. The bark
is gray to grayish-brown and marked with promi-
nent transverse lenticels; the leaves are thick,
parchment-like, ovate, obovate or ovate-lanceo-
late, abruptly acute or acuminate at the summit,
and serrate along the margin. The flowers are
white and appear, before or with the leaves, in
small umbels arising from axillary buds. The
fruit is a spherical, depressed-globular, red, soft-
fleshed, acid drupe.

There are two well-marked groups of sour
cherries, (1) the Amarelles whose fruits are pale
red, possess colorless juice and are somewhat
flattened above and below, and (2) the Morellos
whose fruits are dark red with dark-colored juice
and are spherical to cordate. Most of the fruits
are used for pies and considerable are produced
for canning in Michigan, New York, Wisconsin
and California.

The N.F. VI recognized under Prunus Cerasus
the entire fresh ripe fruit of this species which
it described as follows: "A spherical, depressed,
globose or cordate drupe, with a circular, elevated
scar at the summit representing the remains of
the style, and a circular scar at the base repre-
senting the point of attachment of the pedicel;
up to about 20 mm. in length and 18 mm. in
breadth; externally pale red to dark red, glabrous;
internally showing a membranous epicarp, a fleshy
mesocarp containing a light red to dark red juice,
and a subglobose, stony, light brown endocarp
within which occurs a globular, exalbuminous
seed, the latter consisting of a light brown coat
enveloping a fleshy, oily embryo. Odor of the
crushed fruit characteristically aromatic; taste
pleasantly acidulous." N.F. VI.

Because of the availability of cherries only dur-
ing part of the year the juice instead of the fresh
fruit was made official. For such use the juice is
permitted to be extracted during the fruit season
and kept until such time as required for prepara-
tion of the syrup. The percentage composition
of the fresh fruits of sour cherries is as follows:
Water, 79.82; protein, 0.67; free acid, calculated
as malic acid, 10.24; pectin and cellulose, 6.7;
ash, 0.73.

Description. — "Cherry Juice is a clear liquid
with an aromatic, characteristic odor, and a sour
taste. It is affected by light. The color of the
freshly prepared Juice is red to reddish orange."
U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 1.045 and not more than 1.075.
Refractive index. — Not less than 1.3500. Residue
on ignition. — Not less than 35 mg. and not more
than 55 mg. from 10 ml. of juice. pH. — Between
3.0 and 4.0. Non-volatile residue. — Not less than
500 mg., when 5 ml. of juice is placed in a tared
half petri dish on a boiling water bath for 1 hour,
then in a vacuum desiccator for 16 hours. Iden-
tification.— On adding alkaline cupric tartrate
T.S. to cherry juice which has been treated with
lead acetate T.S., then with sodium oxalate
solution to remove excess lead, and the mixture
filtered, a red precipitate is produced on heating.
Volatile acids. — Not more than 1.5 ml. of 0.1 TV
sodium hydroxide is required to neutralize the
volatile acids distilled with steam from 25 ml. of
cherry juice. Arsenic. — The limit is 0.4 part per
million. Lead. — The limit is 5 parts per million.
U.S.P.

Assay. — A 10-ml. portion of juice is heated
with calcium carbonate, during which step the
malic acid, for which the assay is made, forms
soluble calcium malate. The excess of calcium
carbonate is removed by filtration, and the cal-
cium in the filtrate is precipitated as the oxalate.
This is filtered off, and the oxalic acid combined

Part I

Cherry, Wild 273

in it estimated by titration with 0.1 N potassium
permanganate. Each ml. of 0.1 N potassium per-
manganate represents 6.705 mg. of malic acid
(the hydrogen equivalent of malic acid is two
since one molecule of it, being dibasic, forms one
molecule of calcium oxalate). U.S. P.

Uses. — Cherry juice, because of its acidity as
well as its pleasant flavor, is an excellent vehicle,
especially for salty drugs.

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." U.S.P.

CHERRY SYRUP. U.S.P.

Syrupus Cerasi

Syrupus Cerasi Fructus; Sirupus Cerasorum. Fr. Sirop
de cerise. Ger. Kirschsirup.

Dissolve 800 Gm. of sucrose in 475 ml. of
cherry juice by heating on a water bath; cool,
and remove the scum. Add 20 ml. of alcohol and
enough purified water to make 1000 ml. Mix
well. U.S.P.

Alcohol Content. — From 1 to 2 per cent, by
volume, of C2H5OH. U.S.P.

This popular vehicle is much used for admin-
istering salty or bitter drugs, also for masking
iron preparations. It contains no tannin, as does
wild cherry syrup.

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." U.S.P.

WILD CHERRY. U.S.P.

Prunus Virginiana, Wild Black Cherry Bark

"Wild Cherry is the carefully dried stem bark
of Prunus serotina Ehrhart (Fam. Rosacea), free
of borke and preferably having been collected in
autumn." U.S.P.

Prunus Serotina. Virginian Prune Bark; Rum, Whisky
or Cabinet Cherry. Cortex Pruni Virginians. Fr. Ecorce de
cerise de Virginie. Ger. Virginische Traubenkirschenrinde.
Sp. Cerezo Silvestre.

The genus Prunus now includes the plums,
almonds, peaches, apricots, and cherries, and com-
prises over one hundred and fifty species. They
are generally distributed in the warm temperate
regions of the northern hemisphere, being espe-
cially abundant in eastern Asia. In the United
States there are about forty indigenous species.

Linnaeus, in his Species Plantarum, describes
under the name of P. virginiana a tree, the state-
ments concerning which are equally applicable to
the black cherry and choke cherry. The speci-
men now in the Linnaean herbarium is that of the
choke cherry. For this reason the binomial, P.
virginana L., has been restricted by many botan-
ists to the choke cherry. But since Linnaeus did
not consider his herbarium specimens as types
and as there is no certainty that he used the
specimen now in the Linnaean herbarium as a
basis for the description which is equally ap-
plicable to both cherries, we are left only the old
synonymy upon which to interpret the species
and that is entirely that of the black cherry. We
are inclined to the opinion that Linnaeus, in rec-
ognizing only one American species of this group,
regarded the choke cherry and wild cherry as
conspecific. Botanists of today reserve the name
P. virginiana for the choke cherry while Ehrhart

coined the name P. serotina for the black cherry.

The choke cherry is distinguished from the
wild black cherry by the following characteristics :
The choke cherry has deciduous calyx lobes;
oblong-obovate pointed endocarp (or stone) ;
leaves broadly oval to oblong-obovate, and usu-
ally abruptly acuminate; inner bark with a rather
disagreeable odor. The ripe fruit is a dark crim-
son color. The wild black cherry has persistent
calyx lobes; the endocarp (or stone) oblong-
obovate, usually gradually acuminate; leaves ob-
long or lanceolate-oblong, usually gradually acumi-
nate; the inner bark and leaves possess an aro-
matic odor. Michaux observed specimens of these
trees on the banks of the Ohio, from 80 to 100
feet high, with trunks from 12 to 15 feet in cir-
cumference, but as usually met with in the At-
lantic States the tree is much smaller. The trunk
is regularly shaped, and covered with a rough
blackish bark, which detaches itself semicircu-
larly in thick narrow plates. The leaves are alter-
nate, oval-oblong, or lanceolate-oblong, acuminate,
unequally serrate, smooth on both sides, of a
beautiful brilliant green; the petioles are fur-
nished with one or more reddish conspicuous
glands; the stipules lanceolate and glandular-
serrate, early deciduous. The flowers are small,
white, and occur in long erect or spreading
racemes. They appear from March in Texas to
June in the St. Lawrence River valley, and are
followed by globular drupes, about the size of a
pea, and when ripe of a shining blackish-purple
color.

This tree is found throughout the United States
from the Atlantic coast as far west as North
Dakota to eastern Texas. It extends also along
the western mountain ranges from Mexico to
Peru. It is highly valued by the cabinet-makers
for its wood, which is compact, fine-grained, sus-
ceptible of polish, and of a light red tint which
deepens with age.

Wild cherry bark is collected in autumn and
should be carefully dried and stored in closed
containers protected from light and moisture.

Virginia, Indiana, North Carolina and Mich-
igan furnish much of the bark of commerce.

The chief substitute and adulterant for this
drug is the bark of the Prunus virginiana L. (P.
nana DuRoi) commonly known as choke cherry
bark. This differs from the bark of the wild black
cherry by exhibiting no stone cells in the pericycle,
by having medullary rays from 1 to 4 cells in
width and by having more rosette aggregates of
calcium oxalate in its phloem than monoclinic
prisms. Ground wild cherry bark has frequently
been adulterated with wood of the same species.
Farwell reports that the bark of P. demissa
(Nutt.) Walpers, a tree from west of the Rocky
Mountains, has been found in commerce. It is
much darker and the lenticels are much more
prominent. The preparations made from it re-
semble the official wild cherry bark in color, odor
and taste. For details of histology of wild cherry
bark and its adulterants see A Text Book of
Pharmacognosy by Youngken, 6th ed.

Description. — "Un ground Wild Cherry usu-
ally occurs in transversely curved pieces up to 8
cm. in width and from 0.5 to 8 mm. in thickness.

274 Cherry, Wild

Part I

The outer surface of rossed bark is moderate
brown to light olive-brown, smooth, except for
numerous lenticel-scars. The outer surface of un-
rossed bark is weak reddish brown and glossy
(young bark) to olive gray (older bark), with
light-colored, transversely elongated lenticles or
roughened and flaky with light-colored lichens.
The inner surface is weak reddish brown to weak
orange, with fine, reticulate striations and numer-
ous minute fissures. The fracture is short and
granular. The odor is distinct, resembling bitter
almond when macerated in water. The taste is
astringent, aromatic, and agreeably bitter." U.S.P.
For histology see U.S.P. XV.

''Powdered Wild Cherry is light brown to light
yellowish brown. It contains few fragments of
reddish brown to yellowish orange cork; numer-
ous, frequently elongated stone cells, with short
branches, or of a wavy and irregular outline, and
with thick, lamellated, porous, strongly lignified
walls; few. moderately elongated sclerenchyma-
fibers which are frequently accompanied by crys-
tal-fibers, containing monoclinic prisms of cal-
cium oxalate, and also rosette aggregates, from
10 to 75m. in diameter; numerous fragments of
parenchyma; and numerous simple, nearly spher-
ical to 2- to 5-compound starch grains, the indi-
vidual grains from 2 to 15n in diameter." U.S.P.

The bark is obtained indiscriminately from all
pans of the tree, though that of the roots is con-
sidered to be most active. It is commonly be-
lieved also that the bark has greater activity when
collected in autumn than in the spring.

Constituents. — All parts of the wild cherry,
including the leaves, fruit, and the bark of the
stem and of the root, yield on infusion with water
hydrocyanic acid. This substance does not exist
as such in the plant but is formed by hydrolysis
of a cyanogenetic glycoside in the presence of
the enzyme emulsin. At one time the glycoside
was believed to be amygdalin; it is probably
D-mandelonitrile glycoside or prunasin, which is
isomeric with prulaurasin found in the cherry
laurel (see also Bitter Almonds, under Bitter Al-
mond Oil). Benzaldehyde and glucose are the
other products of the hydrolysis of the glycoside.

The amount of hydrocyanic acid yielded by
the bark ranges from 0.05 to 0.35 per cent. Ac-
cording to Stevens and Judy {Am. J. Pharm.,
1895. p. 534). the hydrocyanic content is higher in
the bark of the root than of the stem, the bark
of young trees gives a greater yield than that of
old trees, and thick bark more than thin bark.

Besides the cyanogenetic principle, wild cherry
bark contains tannic acid — according to Peacock
(/. A. Ph. A., 1923. 12, 774) about 3 per cent—
and a fluorescent bitter principle which on hy-
drolysis yields 6-methylesculetin. Benzoic acid,
trimethylgallic acid and p-coumaric acid are also
present.

Uses. — On the theory that hydrocyanic acid
is a cough sedative, wild cherry bark has been
popularly employed in the treatment of bronchitis
of various types, but is of little if any remedial
value. Its most frequent use is as a flavoring
agent, especially for cough-syrups.

Dose, from 2 to 4 Gm. (approximately 30 to
60 grains).

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep.— Wild Cherry Syrup, U.S. P.; Com-
pound White Pine Syrup, N.F.

WILD CHERRY FLUIDEXTRACT.
X.F.

Fluidextractum Pruni Virginians

Prepare the fluidextract from wild cherry, in
coarse powder, by Process B (see under Fluid-
extracts). Moisten the drug with a menstruum
of 1 volume of glycerin and 2 volumes of water,
in the proportion of about 600 ml. for each 1000
Gm. of drug; pack loosely in a cylindrical perco-
lator and macerate during 1 hour. Then add a
menstruum of 2 volumes of alcohol and 1 volume
of water, in the proportion of 375 ml. for each
1000 Gm. of drug, and macerate 2 hours longer.
Percolate rapidly, and complete extraction of the
drug with a menstruum of 1 volume of alcohol
and 3 volumes of water. X.F.

Maceration with the first menstruum — contain-
ing no alcohol — is for the purpose of inducing
the hydrolytic action to produce hydrocyanic acid
and benzaldehyde (see under Wild Cherry). The
second menstruum, while higher in alcohol con-
tent than the third, actually becomes weaker be-
cause of dilution with the first when in contact
with the drug.

Alcohol Content. — From 14 to 18 per cent,
by volume, of C2H5OH. X.F.

Wild cherry fluidextract is more useful as a
flavoring agent than as a therapeutic agent. The
dose given by the N.F. is 2 ml. (approximately
30 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

WILD CHERRY SYRUP. U.S.P.

Syrupus Pruni Virginianae

Syrupus Pruni Serotins. Syrup of Virginian Prune.
Sp. Jarabe de Cerczo Silvestre.

Moisten 150 Gm. of wild cherry, in the form
of coarse powder, with 100 ml. of water, pack into
a cylindrical percolator, and pour sufficient water
upon the drug to saturate it and leave a layer of
water above it. Close the lower orifice, cover the
percolator, macerate the drug during 1 hour, then
allow the percolation to proceed rapidly. Collect
400 ml. of percolate, using additional water as
menstruum. Filter the percolate, if necessary, add
to it 675 Gm. of sucrose, effect solution by agita-
tion, then add 150 ml. of glycerin, 20 ml. of
alcohol, and enough water to make 1000 ml.
Strain the product, if necessary.

The syrup may also be prepared by allowing
the percolate from the wild cherry to drop on the
sucrose placed in a second percolator; the syrup
from the second percolator is collected in a grad-
uated bottle containing the alcohol and glycerin.
Enough water is added to the drug to make 1000
ml. of finished syrup. U.S.P.

This formula was developed bv Reed. Burrin
and Bibbins (/. .4. Ph. A., Prac. Ed., 1940, 1, 73)
in an effort to eliminate, as far as possible, the
incompatibilities, especially with alkaloidal salts,

Part I

Chiniofon

275

of the formula previously official. Their modi-
fication involved an increase in the glycerin con-
tent and its addition after extraction of the bark
rather than its inclusion in the menstruum. That
an improved product was obtained was confirmed
by Rasanen and Burt (Am. J. Pharm., 1943, 115,
292).

This syrup should never be made by adding
fluidextract to simple syrup. The fluidextract fre-
quently precipitates when mixed with syrup; also,
the syrup when made by the official process is far
superior in flavor. Wild cherry syrup is largely
used as a vehicle for cough mixtures. The syrup
contains hydrocyanic acid and benzaldehyde (see
under Wild Cherry) which contribute to its char-
acteristic odor; the amounts are therapeutically
insignificant. The syrup is used mainly as a
flavored vehicle.

Incompatibilities. — Wild cherry syrup pre-
cipitates solutions of alkaloidal salts with forma-
tion of insoluble tannates of the alkaloids. The
tannin in the syrup forms ink-like compounds
with iron salts. The syrup also produces a pre-
cipitate with antipyrine, the compound coagu-
lating; a few grains of tragacanth are necessary
to keep it in suspension.

Dose, 4 to 15 ml. (1 to 4 fluidrachms).

Storage. — Preserve "in tight containers, pref-
erably at a temperature not exceeding 25°." U.S.P.

CHINIOFON. U.S.P., (B.P.), LP.

[Chiniofonum]

"Chiniofon is a mixture of 7-iodo-8-hydroxy-
quinoline-5-sulfonic acid, its sodium salt, and so-
dium bicarbonate. It contains not less than 26.5
per cent and not more than 29.0 per cent of iodine
(I)." U.S.P. The LP. states that this substance
is a mixture of four parts by weight of 7-iodo-
8-hydroxyquinoline-5-sulfonic acid and one part
by weight of sodium bicarbonate; not less than
26.5 per cent and not more than 29.0 per cent
of iodine, and not less than 18.0 per cent, and not
more than 22.0 per cent of sodium bicarbonate,
are required. The B.P. recognizes Chiniofon So-
dium as sodium 8-hydroxy-7-iodoquinoline-5-
sulfonate and requires it to contain not less than
33.3 per cent of I.

B.P. Chiniofon Sodium. Chiniofon Powder. Quinoxyl
(Burroughs Wellcome); Anayodin (Bischoff) ; Yatren.
Pulvis Chiniofoni. Sp. Quiniofon.

Chiniofon is the product obtained by the inter-
action of 4 parts of 7-iodo-8-hydroxyquinoline-
5-sulfonic acid and 1 part of sodium bicarbonate,
this being approximately the proportion of these
substances required to form the sodium salt of
the acid component. As the reaction to form the
sodium salt is not complete the mixture contains
varying quantities of uncombined reactants. The
starting point in the synthesis of 7-iodo-8-hy-
droxyquinoline-5-sulfonic acid is 8-hydroxyquino-
line. The latter is dissolved, at a temperature
below 0°, in fuming sulfuric acid and after 24
hours the mixture is poured on crushed ice, a
copious precipitate of needle-like crystals of
8-hydroxyquinoline-5-sulfonic acid being pro-
duced. After recrystallization this acid is dis-
solved in a boiling aqueous solution of potassium

carbonate and potassium iodide, treated with
bleaching powder, and then acidified with hydro-
chloric acid, producing finally 7-iodo-8-hydroxy-
quinoline-5-sulfonic acid. This is mixed with so-
dium bicarbonate; depending on whether or not
water is present the interaction of the acid with
the bicarbonate is more or less complete. Thus
the product recognized by the LP. contains both
substances in unreacted form, the U.S. P. product
represents a nearly completed reaction, and the
B.P. product is apparently entirely a sodium de-
rivative of chiniofon.

Description. — "Chiniofon occurs as a canary
yellow powder with not more than a slight odor.
Chiniofon effervesces when moistened with water.
It has a bitter taste, but leaves a distinctly sweet-
ish after-taste. One Gm. of Chiniofon dissolves in
25 ml. of water. It is insoluble in alcohol, in ether,
and in chloroform." U.S.P. The B.P. describes
chiniofon sodium as an almost white, pale cream,
or pinkish-cream crystalline powder.

Standards and Tests. — Identification. — (1)
On addition of a mineral acid chiniofon effer-
vesces and liberates iodohydroxyquinolinesulfonic
acid. (2) A deep emerald green color forms on
adding 5 drops of ferric chloride T.S. to 10 ml.
of a 1 in 100 solution of chiniofon. (3) A dense
white precipitate forms on adding 5 ml. of cupric
sulfate T.S. to 10 ml. of a 1 in 100 solution of
chiniofon. (4) On adding 2 ml. of chloroform to
a mixture of 5 ml. of 1 in 100 solution of chinio-
fon, hydrochloric acid and 1 drop of sodium ni-
trite T.S. the chloroform is colored violet. Inor-
ganic iodine. — No violet color appears in 5 ml. of
chloroform when it is agitated with 5 ml. of a 1
in 100 solution of chiniofon, slightly acidified with
diluted hydrochloric acid, and mixed with a drop
of ferric chloride T.S. Iodide. — Not more than
a slight opalescence results on the addition of
1 ml. of diluted nitric acid and 1 ml. of silver
nitrate T.S. to 5 ml. of a 1 in 100 solution of
chiniofon. U.S.P. The B.P. makes no mention of
effervescence taking place on addition of acid to
chiniofon sodium.

Assay. — About 400 mg. of chiniofon is dis-
solved in sodium hydroxide T.S. and heated with
a potassium permanganate solution to decompose
the compound and oxidize the iodine to iodate ion.
After acidification sodium bisulfite is added,
which reduces iodate to iodide. The excess of
sodium bisulfite is destroyed by potassium per-
manganate with the excess of the latter being
finally carefully adjusted so as to produce only a
faint yellow color of iodine, sufficient to give a
blue color with starch T.S. The iodide is now
titrated with 0.05 N silver nitrate, the end point
being the discharge of the blue color due to de-
pletion of iodide ions essential to the starch-iodide
color reaction. Each ml. of 0.05 N silver nitrate
represents 6.346 mg. of iodine. U.S. P. The LP.
employs the same assay for iodine, except that
0.1 iV silver nitrate is used for the titration.

In the B.P. assay for iodine the sample is
heated in a nickel crucible with sodium car-
bonate, the mixture leached with water, the re-
sulting solution neutralized and then acidified
with a definite amount of sulfuric acid, bromine
added as an oxidant while generating carbon

276

Chiniofon

Part I

dioxide from marble, the excess of bromine re-
moved with phenol, and the iodate thus produced
from the iodine in chiniofon determined by add-
ing potassium iodide and titrating with 0.1 N
sodium thiosulfate.

The assay for sodium bicarbonate, specified by
the I. P., is based upon evolution of carbon dioxide
from an acidified sample and diffusion of the gas
into a measured amount of 0.1 N barium hydrox-
ide solution, the excess barium hydroxide being
titrated with 0.1 AT oxalic acid, using phenol-
phthalein indicator.

Uses. — Chiniofon has been widely used in
amebic dysentery (Leake. J. A.M. A., 1932, 98,
195). Its active component, iodohydroxyquinoline-
sulfonic acid, and related compounds have also
been used as surgical dusting powders, and for
treatment of gonorrhea and diphtheria. Pfeiler
{Klin. Wchnschr., 1921, 58, 1413) claimed that
chiniofon. intravenously administered, was highly
effective in treating actinomycosis of cattle.

Amebiasis. — Chiniofon appears to be much
more active against the ameba in the intestine
than it is in vitro; there is little correlation be-
tween i?i vitro and in vivo amebicidal action. For
growth or survival of amebae, bacteria appear
to have an important role in the culture medium.
It has been suggested that some drugs, especially
antibiotics and sulfonamides, are effective ame-
bicides, in vivo, by virtue of their eliminating
bacteria, on which protozoa are dependent, from
the intestinal contents {Armstrong et al., South
African Med. J., 1950, 24, 121; Wright and
Coombes. Lancet, 1948, 1, 243). Differences in
intestinal flora may account for the presence or
absence of symptoms in infested persons (Ellen-
berg. Am. J. Digest. Dis., 1946. 13, 356). On the
other hand, direct amebicidal action has been
demonstrated with chlortetracycline ( Hewitt et al.,
Science, 1950. 112, 144) and other antibiotics.

For treatment of intestinal amebiasis a non-
absorbable drug, nontoxic to the host by virtue
of poor absorption, has been sought. Since proto-
zoa are buried deep in submucosal tissue, out of
contact with the contents of the intestinal lumen,
this objective is probably inadequate; it would
appear that the ameba may be reached only
through the blood stream. Knight and Miller
{Ann. Int. Med., 1949. 30, 1180) studied iodine
concentrations in blood during administration not
only of chiniofon but also of the related com-
pounds diiodohydroxyqin and iodochlorhydroxy-
quin. Chiniofon produced the smallest inciease
in the level of iodine, diiodohydroxyqin the great-
est, and iodochlorhydroxyquin functioned inter-
mediately in this respect. On the seventh day of
administering these compounds the iodine levels
were as follows: with chiniofon, in a dose of 2.25
Gm. (representing 641 mg. of iodine) daily, it
was about 100 micrograms per 100 ml.; with
iodochlorhydroxyquin. given in a dose of 0.75
Gm. (representing 278 mg. of iodine) daily, it
was about 450 micrograms per 100 ml.; with
diiodohydroxyquin. given in a dose of 1.73 Gm.
(representing 1.25 Gm. of iodine) daily, it was
about 700 micrograms per 100 ml. The concen-
tration of iodine did not rise after the seventh
day. Making allowance for the dose, and the

content of iodine represented, it is apparent that
the degree of absorption, expressed as percent-
age, was the greatest with iodochlorhydroxyquin.
The studies clearly demonstrate that the drugs
are absorbed to some extent.

While in patients with liver damage adminis-
tration of chiniofon or related compounds, rather
than of arsenicals such as carbarsone, is generally
preferred, the former must nevertheless be used
with caution. They are contraindicated in patients
in whom iodine therapy is undesirable. For
hepatic or other visceral amebiasis administra-
tion of chloroquine phosphate along with an
antibiotic is currently preferred (emetine was
formerly used). With diiodohydroxyquin and
iodochlorhydroxyquin being available, chiniofon
is less popular than it once was in consequence
of its disadvantage in causing in some patients
diarrhea and a sensation of perianal scalding.
O'Connor and Hulse {Am. J. Digest. Dis., 1935,
2, 568) reported that chiniofon is more effective
and safer than carbarsone. Anderson and Reed
{Am. J. Trop. Med., 1934, 14, 269) found the
amebicidal activity of chiniofon to be so low that
dangerously large doses are required to produce
therapeutic -results in dysentery; they preferred
iodochlorhydroxyquin.

The standard practice (Bull. U. S. Army M.
Dept., 1945, 4, 2 78) has been to employ either
chiniofon or carbarsone. or alterating courses of
each drug, in treating amebic dysentery or the
asymptomatic carrier state; the chiniofon is given
orally, in tablet or powder form. Bed rest is
essential, and a soft diet is usually necessary be-
cause of the severe watery diarrhea produced in
ambulatory patients, particularly if large doses
(1 Gm. three times daily) are used (see Faust,
Trans. Stud. Coll. Phys., 1943, 2, 101). Re-
evaluation of therapy of amebiasis in which older
drugs are compared with antibiotics (chlortetra-
cycline. oxytetracycline, chloramphenicol) indi-
cated that no single agent, except possibly oxy-
tetracycline, was entirely satisfactory; better
results were obtained, both in immediate response
to treatment and in lowered incidence of relapse,
with combinations of emetine hydrochloride,
chiniofon and carbarsone. which showed good
initial response and a moderate incidence of re-
lapse, or with combinations of oxytetracycline
with emetine, carbarsone. chiniofon or chloro-
quine diphosphate, or with a combination of
oxytetracycline, chloroquine diphosphate and
bismuth glycoarsanilate, all of which gave both
good initial response and low incidence of relapse
(Martin et al., J.A.M.A., 1953, 151, 1055).

Use in Enemas. — If amebic ulcers persist in
the lower colon after oral therapy, retention
enemas containing up to 3 Gm. of chiniofon in
300 ml. of water are indicated nightly or on alter-
nate nights for 5 to 10 days; these should be
preceded by a cleansing enema of water. Seda-
tives, such as opium tincture, may be required
to enable retention of the enemas. Oral adminis-
tration should be discontinued or reduced to half
the usual dose while enemas are in use. Manson-
Bahr (Brit. M. J., 1941, 2, 255) advocated chinio-
fon enemas in conjunction with oral administra-
tion of emetine bismuth iodide.

Part I

Chloral Hydrate 277

Dose. — The usual dose is 250 mg. (approxi-
mately 4 grains) by mouth 3 times daily for 7
days, with a range of dose of 250 to 750 mg.
The LP. gives the maximum single dose as 1 Gm.,
and the maximum daily dose as 3 Gm. For chil-
dren the dose is 60 mg. for each 10 pounds of
body weight, administered three times daily. As
a retention enema a solution of 0.5 to 2.5 Gm.
per 100 ml. of water is instilled into the rectum
in acute cases and in those which do not respond
to other forms of therapy.

Storage. — Preserve "in tight containers."
U.S.P.

CHINIOFON TABLETS. U.S.P. (LP.)

[Tabellje Chiniofoni]

"Chiniofon Tablets contain an amount of iodine
(I) corresponding to not less than 25 per cent
and to not more than 29 per cent of the labeled
amount of chiniofon." U.S.P. The LP. specifies
the same limits.

LP. Tablets of Chiniofon; Compressi Chiniofoni. Sp.
Tabletas de Quiniofon.

Usual Size. — 250 mg. (approximately 4
grains), enteric coated.

CHLORAL HYDRATE. U.S.P., B.P, LP.

Chloral, [Chloral Hydrate]
CCl3CH(OH)2

"Chloral Hydrate contains not less than 99.5
per cent of C2H3CI3O2." U.S.P. The B.P. requires
not less than 99.0 per cent, and the LP. not less
than 98.0 per cent, of the same constituent.

Hydrated or Hydrous Chloral; Trichlorethylidene Glycol.
Chloralum Hydratum. Fr. Hydrate de chloral ; Hydrate de
chloral cristallise. Ger. Chloralhydrat. It. Idrato di cloralio.
Sp. Hidrato de cloral.

Though discovered in 1832, by Liebig, it was
not until 1869 that the remedial properties of
chloral hydrate were announced by Otto Liebreich,
of Berlin.

Chloral hydrate is still produced by the method
of Liebig, in which chlorine is reacted directly
with alcohol, in the presence of a catalyst, at low
temperature. The mechanism of this reaction ap-
pears to involve the formation, successively, of
the following series of intermediate compounds:
ethylhypochlorite, CH3.CH2OCI; acetaldehyde,
CH3.CHO; acetal, CH3.CH(OC2H5)2; mono-
chloracetal, CH2C1.CH(0C2H5)2; dichloracetal,
CHCl2.CH(OC2H5)2; trichloracetal, CCI3.CH-
(OC2H5)2; chloral alcoholate, CCI3CHOH.-
OC2H5; and anhydrous chloral. CCI3.CHO. The
last-named, which is a colorless liquid, is con-
verted to the official chloral hydrate, CCI3.CH-
(OH)2, by mixing with water. Production of the
hydrate involves more than mere addition of a
molecule of water of crystallization; this is indi-
cated by assigning to chloral hydrate the formula
CC13.CH(0H)2, rather than CCI3.CHO.H2O.

Description. — "Chloral Hydrate occurs as
colorless, transparent, or white crystals, having
an aromatic, penetrating, and slightly acrid odor,
and a slightly bitter, caustic taste. It slowly
volatilizes when exposed to air. One Gm. of
Chloral Hydrate dissolves in 0.25 ml. of water,

in 1.3 ml. of alcohol, in 2 ml. of chloroform, and
in 1.5 ml. of ether. It is very soluble in olive oil
and is freely soluble in turpentine oil." U.S.P.
Chloral hydrate liquefies between 50° and 58°,
according to the B.P.

Solutions of chloral hydrate are quickly de-
composed by light (to hydrochloric acid, trichlor-
oacetic acid and formic acid), according to
Danckwortt (Arch. Pharm., 1942, 280, 197), but
under ordinary storage conditions decompose
very slowly. Aqueous solutions of chloral hydrate
are also likely to develop molds, hence such
solutions should not be kept for a long period
without a preservative.

Most alkaloids are dissolved by a solution of
hydrated chloral.

Standards and Tests. — Identification. — (1)
Alkali and alkali earth hydroxides decompose
chloral hydrate with production of chloroform
and the formate of the base employed. (2)
Phenyl isocyanide, a poisonous substance recog-
nizable by its disagreeable odor, results when
chloral hydrate is warmed with a few drops of
aniline and of sodium hydroxide T.S. Acidity. —
A 1 in 20 solution of chloral hydrate in alcohol
does not at once redden moistened blue litmus
paper. Residue on ignition. — Not over 0.1 per
cent. Chloride. — Silver nitrate T.S. does not at
once produce opalescence when added to a 1 in
20 solution of chloral hydrate in alcohol. Readily
carbonizable substances. — 500 mg. of chloral hy-
drate shaken with 5 ml. of sulfuric acid during
1 hour does not impart more color than repre-
sented by matching fluid P. U.S.P.

The B.P. requires that a 10 per cent w/v solu-
tion of chloral hydrate in water be not more
acid than pH 4.0. The B.P. and LP. both have
a test for absence of chloral alcoholate in which
no yellow precipitate should be produced within
one hour when sufficient 0.1 A7" iodine solution is
added to a warm, alkaline solution of chloral
hydrate to color the latter a deep brown. The
LP. specifies that an aqueous solution of chloral
hydrate, on heating, should give no smell of
benzene.

Assay. — A sample of about 4 Gm. of chloral
hydrate is dissolved in water and 30 ml. of 1 N
sodium hydroxide added which decomposes
chloral hydrate to form a molecule of chloroform
and one of sodium formate; after 2 minutes the
excess of alkali is titrated 1 N sulfuric acid, using
phenolphthalein T.S. as indicator. Each ml. of
1 N sodium hydroxide is equivalent to 165.4 mg.
of C2H3CI3O2. U.S.P.

Incompatibilities. — When triturated with
phenol, camphor and certain other organic sub-
stances chloral hydrate causes liquefaction. It
lowers the melting point of theobroma oil in
suppositories. In aqueous solution it is incom-
patible with alkalies, which decompose it with
formation of chloroform and formate; this re-
action occurs also with sodium derivatives of
barbiturates (which are alkaline), the acid form
of the barbiturate being simultaneously precipi-
tated. Hydroalcoholic solutions of chloral hydrate
containing also soluble salts or sugar frequently
separate into two layers. Hargreaves (/. A. Ph. A.,
1932, 21, 571) investigated this incompatibility

278 Chloral Hydrate

Part I

and found that the concentrations of chloral hy-
drate, alkali bromide and alcohol were the
variables which determined whether or not sepa-
ration occurred. In general, the presence of 10
per cent or less of alcohol did not produce separa-
tion, regardless of the concentrations of chloral
hydrate or salt ; with higher concentrations of
alcohol separation occurred if sufficient chloral
hydrate or salt was present. Examination of the
oily layer showed it to contain chloral, alcohol,
chloral alcoholate. and a small quantity of dis-
solved salt. Adams (/. Pharmacol., 1943, 78,
340) concluded that, contrary to popular notion,
chloral alcoholate is less hypnotic and less toxic
than chloral hydrate.

Uses. — Chloral hydrate is one of the best
sedative and hypnotic drugs. It is used chiefly for
insomnia but also in patients undergoing morphine
or alcohol withdrawal, or with delirium tremens.
As with all hypnotics, it is a poor analgesic and
will not control pain or febrile delirium in ordi-
nary doses. Systemically it depresses the central
nervous system, dulling sensory and motor func-
tions of the brain.

Locally applied, as camphorated chloral for
example, chloral hydrate is irritant and produces
erythema, warmth and slight local anesthesia.
Absorption from mucous surfaces is prompt.

The soundness of sleep produced by chloral
hydrate is proportional to the quantity ingested.
High doses depress the motor side of the spinal
cord and respiratory center but sensory function
is affected only after excessive doses. In high dose
it tends to lower blood pressure, probably through
central medullary depression and peripheral cu-
taneous vasodilatation. After toxic quantities in
patients with heart disease there is direct myo-
cardial depression. In such doses it produces
profound coma with anesthesia. Death is gen-
erally due to respiratory nerve center paralysis,
though sometimes also to circulatory failure.
Chloral has little effect on secretions, though
after large doses output of urine may decrease.
It is excreted by the kidneys, probably partly
unchanged, and partly as urochloralic acid; this
acid reduces Fehling"s solution. The theory of
Liebreich which led to introduction of this drug
into medicine, that it was decomposed by body
alkalies with liberation of chloroform, has been
disproved.

Chloral hydrate is used internally in medicine
as a hypnotic, sedative and anticonvulsant; exter-
nally it is used as a local rubefacient, anesthetic
and antiseptic. For relief of insomnia without
pain it is one of the best hypnotics; it merits
wider use. The facility of use of barbiturates
has tended to displace chloral hydrate. It is also
useful in obstinate forms of sleeplessness, as in
delirium tremens and certain types of insanity.
Its action is very prompt, sleep generally begins
within 15 or 30 minutes after oral administration ;
the effect usually lasts 4 to 8 hours. Older pa-
tients who are intolerant of barbiturates usually
tolerate chloral hydrate well. In wakefulness
caused by pain it is considerably inferior to opi-
ates but even then is often a valuable adjuvant.
In circulatory weakness it should be used with
caution since it may depress the heart but danger

with therapeutic doses is slight (Alstead, Lancet,
1936, 1, 938). As a somnifacient it is rarely
necessary to give more than 600 mg. (approxi-
mately 10 grains) at one time.

Chloral hydrate is also of value in treating
various convulsive disorders. Determination
whether to give chloral hydrate depends upon
the severity, rather than the type, of convulsions.
In tetanus and strychnine poisoning, in which
death may be the direct result of spasm, it is
one of the most frequently employed remedies.
It was administered rectally in olive oil as part
of the formerly popular Stroganoff treatment for
eclampsia. On the other hand, since in epilepsy
chloral does not lessen the convulsive tendency
it is not often used prophylactically. In "status
epilepticus," however, it may be distinctly helpful.
It is also occasionally used in severe hysteria
and chorea. Certain local spasms, such as laryn-
gismus stridulus, asthma, and hiccough, are at
times benefited by its use.

Formerly chloral hydrate was commonly used
as a local remedy for its antiseptic and analgesic
properties. It is still occasionally used as an in-
gredient of anodyne liniments. |v)

Toxicology. — Occasionally chloral hydrate
may produce skin lesions, but except for paralde-
hyde it is of all hypnotic drugs the least sensi-
tizing to the skin. The findings in chloral poisoning
are : A delirium stage, deepening sleep, then coma.
Pupils first contract, then dilate. Respirations
decrease in number. The pulse weakens and slows,
but later may become rapid and irregular. The
temperature falls. Muscles relax. Sensibility and
reflex action are diminished or completely abol-
ished. The immediate cause of death is generally
paralysis of respiration but there may also ap-
pear to have been simultaneous cardiac arrest.

Treatment of acute poisoning should include
gastric lavage. Hypertonic glucose should be
given intravenously to combat shock, promote
diuresis, and protect the liver from damage
which occasionally is severe enough to cause
jaundice. Respiratory and circulatory- stimulants
— as picrotoxin, strychnine, pentylenetetrazol,
and caffeine — should be given as the case may
demand. External heat should be applied to
avoid chilling. Inhalation of oxygen-carbon
dioxide mixture and artificial respiration may be
necessary*.

Chloral hydrate may be given in solution with
a flavored syrup or simple aromatic vehicle, but
should be well diluted with water or milk to avoid
gastric irritation. Solutions of chloral hydrate
undergo decomposition when exposed to light
(see above) and should, therefore, be protected
from light. Often gelatin capsules are a conven-
ient dosage form though there may be after-
taste if the vehicle is oily. It is too irritant to
inject but is quite effective rectally in olive oil.

Dose. — The usual dose is 600 mg. (approxi-
mately 10 grains), by mouth, 1 to 3 times daily,
with a range of dose of 0.25 to 1 Gm. The maxi-
mum safe dose is usually 1 Gm. and the total dose
in 24 hours should generally not exceed 3 Gm.
Moore (West Virg. M. J., 1953, 49, 292), who
gives a resume of experience with chloral hy-
drate, reports that as much as 2 Gm. may be

Part I

Chloramine-T

279

safely given at one time for soporific effect; in
obtaining electroencephalogram sleep records the
same dose may be administered.

Storage. — Preserve "in tight containers."
U.S.P.

CHLORAMINE-T. N.F. (B.P.) (LP.)

Chloramine, [Chloramina-T]

CH3.C6H4.S02.N(Cl)Na.3H20

"Chloramine-T contains the equivalent of not
less than 11.5 per cent and not more than 13
per cent of active CI." N.F. The B.P., which rec- .
ognizes this chemical as Chloramine and defines
it as toluene-/>-sulphonsodiochloroamide, requires
it to contain not less than 98.0 per cent and not
more than the equivalent of 103.0 per cent of
C7H702NClSNa.3H20. The I.P. name for the
substance is Tosylchloramide Sodium, the rubric
being the same as that of the B.P.

B.P. Chloramine; Chloramina. I.P. Tosylchloramide
Sodium; Tosylchloramidum Natricum. Sodium Para-
toluenesulf onchloramide ; Chlorazene (Abbott): Tochlorine;
Tolamine. Natrii Sulfaminochloridum; />-Toluol-sulfonchlora-
midnatrium. Fr. Chloramine-T; Mianine. Ger. Chloramin;
Mianin. Sp. Cloramina; Cloramina-T.

This compound was first made by Chattaway
in 1905 but it was not used in medicine until
1915, when Dr. Dakin employed it in his well-
known researches on germicides.

Chloramine-T may be prepared from toluene
by the following reactions: Toluene is converted
to ^-toluenesulfonic acid by the action of sulfuric
acid at elevated temperature. The sodium salt
of the sulfonic acid is treated with phosphorus
pentachloride, yielding />-toluenesulfonyl chloride;
the chloride is converted to /»-toluenesulfonamide
by treatment with ammonia and the amide is
reacted with sodium hypochlorite in the presence
of alkali so that only one of the amide hydrogen
atoms is replaced by chlorine, the other being
substituted by sodium (see also under Dichlora-
mine-T). As ^-toluenesulfonyl chloride is an
abundant by-product in the manufacture of sac-
charin it may be used for the synthesis of the
chloramine.

Description. — "Chloramine-T occurs as a
white to light yellow, crystalline powder, having
a slight odor of chlorine. It slowly decomposes
on exposure to air, losing chlorine, and is affected
by light. When heated to between 95° and 100°,
Chloramine-T loses its water of hydration with-
out decomposition. A solution of Chloramine-T
(1 in 20) is alkaline to litmus paper and to phe-
nolphthalein T.S. One Gm. of Chloramine-T dis-
solves in 7 ml. of water at 25° and in about
2 ml. of boiling water. It dissolves in alcohol
but the solution decomposes on standing. It is
insoluble in chloroform, and in ether." N.F.

Standards and Tests. — Identification. — (1)
Iodine is liberated on adding potassium iodide
T.S. to a 1 in 20 aqueous solution of chlora-
mine-T; bromine is not similarly displaced from
sodium bromide unless the mixture is acidified
(distinction from dichloramine-T) . (2) Chlorine
is liberated and a white turbidity or precipitate,
soluble in sodium hydroxide T.S., is produced
when hydrochloric acid is added dropwise to a

1 in 20 aqueous solution of chloramine-T. Readily
carbonizable substances. — A solution of 200 mg.
of chloramine-T in 5 ml. of sulfuric acid is not
deeper in color than matching fluid A. N.F.

The B.P. includes two tests which are not de-
scribed in the N.F. One of these is for limit of
the ortho compound and directs boiling a mixture
of 2 grams of chloramine, 10 ml. of water and
1 gram of sodium metabisulfite, cooling to 0°,
filtering, washing and drying, in a vacuum desic-
cator, the resulting precipitate and determining
its melting point, which should be not less than
134°. The other test is for the limit of sodium
chloride, which must not be present in a quan-
tity exceeding 15 mg. when determined by dis-
solving, at room temperature, 1 gram of chlora-
mine in 15 ml. of dehydrated alcohol and weighing
the residue.

Assay. — About 500 mg. of chloramine-T is dis-
solved in water, 5 ml. of potassium iodide T.S.
and 5 ml. of acetic acid are added, and the iodine
liberated by the "active" chlorine is titrated with
0.1 N sodium thiosulfate, using starch T.S. as
indicator. Each ml. of 0.1 N sodium thiosulfate
represents 1.773 mg. of active CI. The hydrogen
equivalent of chlorine in this assay is two, as it
is reduced from a positive valence of one to a
negative valence of one in the reaction with io-
dide. N.F.

The B.P. and I.P. assays utilize the same reac-
tions as does the N.F. The result, however, is
expressed in terms of C7H702NClSNa.3H20,
each ml. of 0.1 N sodium thiosulfate consumed
being equivalent to 14.09 mg. of the former.

Bebie (/. A. Ph. A., 1920, 9, 974) found that
solutions of chloramine — provided the latter were
pure — showed no perceptible deterioration after
six months' storage.

Uses. — Chloramine is a powerful germicide
introduced by Dakin et al (Brit. M. J., 1916, 1,
160). In World War I, this was a great advance
in the management of wounds. It has also been
employed against bacterial (Am. J. Pub. Health,
1944, 34, 719) and protozoal (War Med., 1944,
5, 46) contamination of water; a little citric acid
masks the unpleasant taste. According to Hamil-
ton, when tested by the Hygienic Laboratory
method chloramine-T showed a phenol coefficient
of about 50, one part in 2000 being sufficient to
destroy Bacillus typhosus in two and one-half
minutes. But Tilley (/. Agricul. Res., 1920, 20,
85) found that in the presence of organic matter
(blood serum) its strength was greatly reduced, a
1 in 500 solution requiring 2 hours to kill typhoid
bacilli. Tilley tested chloramine also against other
bacteria and while in most cases he found it to
approach mercuric chloride in effectiveness he
observed that it failed to kill the tuberculosis
organism in 10 minutes and required 24 hours to
destroy anthrax spores.

Although the action of chloramine-T appears
to depend on its forming hypochlorous acid,
which then releases nascent oxygen as the active
agent (McCullouch, Disinfection and Sterliza-
tion, 1945), its range of usefulness is somewhat
different from that of the inorganic chlorinated
metal compounds, i.e., the "hypochlorites." Be-
cause of lesser tendency to irritate and longer

280

Chloramine-T

Part I

duration of action, together with the fact that it
is not rendered ineffective as rapidly by organic
matter, chloramine-T is generally preferable to
the alkaline chlorinated metal compounds; how-
ever, chloramine-T has less solvent action on
undesirable necrotic tissue than have the inorganic
compounds. S

Toxicology. — Taylor and Austin (/. Exp.
Med., 1918, 27, 635), and Fantus and Smith
(/. Pharmacol, 1914, 14, 259) found that chlora-
mine, when introduced into the blood stream, is
a violent systemic poison. It ranks close to mer-
curic chloride in toxicity, being fatal to mice
in the proportion of 10 mg., and for the rabbit
of 25 mg., per Kg. of body weight. It is depres-
sant to the entire central nervous system. Feinberg
and Watrous (/. Allergy, 1945, 16, 209) reported
development of asthma and hay fever in indi-
viduals exposed to chloramine vapor.

Chloramine-T, in 0.2 per cent solution, has
been employed as an antiseptic mouth wash.
Aqueous solutions' of 0.1 to 0.2 per cent concen-
tration have been used for irrigation of the blad-
der, uterus, and other internal cavities. As a
surgical disinfectant for wounds it may be used
in 1 or 2 per cent concentration, sometimes as
high as 4 per cent. Chloramine-T should not be
confused with the inorganic chloramines, ob-
tained by interaction of ammonia and chlorine,
employed or formed in water purification proc-
esses; also, it should not be confused with
dichloramine.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

CHLORAMPHENICOL. U.S.P., B.P, LP.

D( — )-Threo-l-p-nitrophenyl-2-dichloroacetamido-
1 3-propanediol, [Chloramphenicol]

NOc

==\ HN-C0CHC1.

H I
-C— C— CH2OH

OH H

^ /

"Chloramphenicol contains not less than 90
per cent of C11H12CI2N2O5. Chloramphenicol
conforms to the regulations of the federal Food
and Drug Administration concerning certification
of antibiotic drugs. Chloramphenicol not intended
for parenteral use is exempt from the require-
ments of the tests for Depressor substances,
Pyrogen, and Sterility." U.S.P.

The B.P. defines Chloramphenicol as d-( — )-
threo-2 -dichloroacetamido- 1-p-nitrophenyl-l :3-
propanediol, an antibiotic substance produced by
the growth of Streptomyces Venezuela or pre-
pared synthetically. The LP. merely defines it as
d( — )-threo-l-/>-nitrophenyl-2-dichloroacetamido-
1, 3-propanediol. The B.P. provides no assay
rubric; the LP. requires not less than 97.0 per
cent and not more than the equivalent of 103.0
per cent of C11H20O5N2CI2, calculated with ref-
erence to the substance dried at 105° for 2 hours.

I. P. Chloramphenicol; Chloramphenicolum. Chloro-
mycetin {Parke, Davis).

History. — In the course of a study of ap-
proximately 6000 samples of soil gathered from
all parts of the world Burkholder, of Yale Uni-

versity, isolated from a soil sample collected in
a mulched field near Caracas, Venezuela, a new
strain of actinomycete which he named Strepto-
myces Venezuela. Cultures of the organism were
found to possess marked bacteriostatic activity,
and from such cultures the new antibiotic sub-
stance chloramphenicol, more frequently referred
to by its trade-marked name Chloromycetin, was
isolated in 1947 (see Ehrlich et al., Science, 1947,
106, 417). Soon demonstrated to be highly ef-
fective in the treatment of scrub typhus, epidemic
typhus, Rocky Mountain spotted fever, and ty-
phoid fever, chloramphenicol was quickly estab-
lished as an important chemotherapeutic agent
for a wide array of bacterial infections. In two
years it was not only isolated in pure form and
a fermentation process for its production as a
relatively pure substance developed but, in addi-
tion, its chemical structure was determined, its
synthesis accomplished, and commercial produc-
tion by synthesis achieved.

Biosynthesis. — The technics used for biosyn-
thesis and recovery of chloramphenicol conform
in broad aspects with the principles described
in the general article on antibiotics (Part II) and
have been discussed in some detail by Olive
(Chemical Engineering, 1949, 56, 107 (Octo-
ber)). The nutrient medium consists of wheat
gluten, glycerin, sodium carbonate and sodium
chloride. The broth from the fermentation tank
is filtered, extracted with amyl acetate, and the
latter solution concentrated under vacuum to the
point of crystallization of crude chloramphenicol.
The impure antibiotic is dissolved in hot water,
treated with carbon to remove impurities, and
finally crystallized from this solution. For discus-
sion of the dynamics of chloramphenicol biosyn-
thesis see Legator and Gottlieb, in Antibiotics
and Chemotherapy, 1953, 3, 809. Structurally dis-
similar amino acids, such as phenylalanine, on the
one hand, and leucine and isoleucine, on the
other, appear to be equally effective as precursors
for the biosynthesis of the antibiotic in chemically
defined media (Gottlieb et al, J. Bact., 1954, 68,
243). The unnatural amino acid norleucine was
the most effective precursor of the several com-
pounds tested. The authors found very little dif-
ference in the gross physiology of Streptomyces
Venezuela under conditions that favor biosyn-
thesis of chloramphenicol and those under which
no synthesis occurred.

Chemical Synthesis. — Manufacture of chlo-
ramphenicol by chemical synthesis involves 10
principal reactions with a total of about 30
steps; it is described in some detail by Olive
(loc. cit.), but other syntheses are reported in
greater detail in a series of papers in J.A.C.S.,
1948, 71, 2458-2475. Starting with ^-nitrobromo-
acetophenone. successive steps in the commercial
synthesis consist of condensation with methena-
mine, an acid hydrolysis, acetylation, hydroxy-
methylation, a reduction with aluminum isopropy-
late, another acid hydrolysis, neutralization, sepa-
ration of the active isomer from a mixture of
four isomers through use of d-camphorsulfonic
acid, neutralization, and a final reaction with
methyl dichloroacetate. The synthetic product is
identical in biologic properties with the antibiotic

Part I

Chloramphenicol 281

produced by biosynthesis (Smadel et al., Proc.
S. Exp. Biol. Med., 1949, 70, 191).

Description. — "Chloramphenicol occurs as
fine, white to grayish white or yellowish white,
needle-like crystals or elongated plates. Its solu-
tions are practically neutral to litmus. It is
reasonably stable in neutral or moderately acid
solutions. Its alcohol solution is dextrorotatory
and its ethyl acetate solution is levorotatory. One
Gm. of Chloramphenicol dissolves in about 400
ml. of water. It is freely soluble in alcohol, in
propylene glycol, in acetone and in ethyl acetate.
Chloramphenicol melts between 149° and 153°."
U.S.P.

Structural Considerations. — The chloram-
phenicol molecule (see structure above) comprises
two important moieties, the 2-acylamidopropa-
nediol side chain, embodying two asymmetric
carbon atoms, and the para-nitrophenyl group.
Both of these moieties have biological significance,
the para-nitrophenyl group in terms of possible
toxicity for the patient (see under Toxicology)
and the propanediol side chain in terms of anti-
microbial activity. There are four possible
stereoisomers of chloramphenicol, but only the
D-threo form is antibiotically active. The stereo-
chemical configuration of the side chain is specific
in conferring antibiotic properties on the com-
pound. No such specificity is required in the aro-
matic part of the molecule; the ortho- and meta-
nitro analogs, as well as analogs in which the
nitro group is replaced by a halogen, have appre-
ciable antibiotic activity although not as much
as the para-nitro compound.

Esters of chloramphenicol are easily prepared
and one of these — the palmitate, formed by re-
placing one of the hydroxyl groups of the propa-
nediol side chain with palmitate — has become a
popular dosage form for infants and for adminis-
tration to patients having difficulty in swallowing
a capsule (see below). The palmitate has very
little antibiotic action, but undergoes hydrolysis
in the gastrointestinal tract, where it is converted
to the active alcohol form of chloramphenicol
(Glazko et al., Antibiotics and Chemotherapy,
1952, 2, 234).

Stability. — Chloramphenicol is a thermostable
antibiotic both in the dry crystalline condition
and in solution. Boiling in distilled water for 5
hours does not impair its antimicrobial activity
and at room temperature (25°) aqueous solutions
are stable for at least 25 hours over a pH range
of about 2 to 9. But in more alkaline solutions
it is destroyed rapidly; at a pH of 10.8 more
than 87 per cent is inactivated in 24 hours at
25° (Bartz, /. Biol. Chem., 1948, 172, 445).

Studying the kinetics of chloramphenicol degra-
dation, Higuchi et al. (/. A. Ph. A., 1954, 43,
129) concluded that destruction of the antibiotic
in solution is a first order reaction with hydro-
lytic cleavage at C — CI bonds and elsewhere,
probably at the amide linkage, predominating.
They found the rate to be independent of ionic
strength of the medium and largely independent
of pH over the range 2.0 to 7.0. Monohydrogen
phosphate ions, undissociated acetic acid, and
citrate-citric acid systems catalyzed destruction
of the molecule.

The chloramphenicol molecule has three sites
that are vulnerable to attack by bacterial en-
zymes. These are the secondary hydroxyl group,
which is readily oxidized; the dichloroacetyl side
chain, which is readily hydrolyzed; and the nitro
group, which can be reduced to amino. Despite
the susceptibility of the molecule to attack by
bacteria in vitro, emergence of bacterial strains
with acquired resistance to chloramphenicol is
not a major clinical problem in therapy. The
greater stability of chloramphenicol, in compari-
son with the tetracycline antibiotics (see Chlor-
tetracycline Hydrochloride and Oxy tetracycline
Hydrochloride) undoubtedly is responsible, in
part, for the better performance of this drug
in in vitro bacterial sensitivity tests.

Standards and Tests. — Identification. — (1)
Chloramphenicol, when reduced with zinc dust,
yields a red-violet to purple color on adding
benzoyl chloride and ferric chloride T.S. (2)
After heating with alcoholic potassium hydroxide
T.S. chloramphenicol responds to tests for chlo-
ride. Specific rotation. — Between +17° and +20°,
when determined in dehydrated alcohol solution
containing 500 mg. of chloramphenicol in each
10 ml. Absorptivity. — The absorptivity as deter-
mined in the control assay is not less than 289
and not more than 307. pH. — The saturated solu-
tion has a pH between 4.5 and 7.5. Depressor
substances. — Chloramphenicol, used in a test
dose of 0.6 ml. of a solution containing 5 mg.
per ml., meets the requirements of the test.
Pyrogen. — Chloramphenicol, used in a test dose
of 1 ml. per Kg. of a solution containing 5 mg.
per ml., meets the requirements of the test.
Safety. — Chloramphenicol, used in a test dose
of 0.5 ml. of a solution in sterile saline T.S.
containing 2 mg. per ml., meets the requirements
of the test. Sterility. — Chloramphenicol is re-
quired to be free of bacteria, molds and yeasts.
Content variation. — The weight of chlorampheni-
col packaged in sterile form and intended' for
parenteral administration is not less than 85 per
cent of the labeled amount. U.S.P.

Assay. — Chloramphenicol is assayed by the
official microbial assay. A control assay is based
on determination of absorptivity (1%, 1 cm.) at
278 run, which is taken as 298 for pure chloram-
phenicol; this is the basis of the LP. assay.

Action. — Absorption. — Chloromycetin is a
most efficient broad-spectrum antibiotic. It is
absorbed rapidly from the gastrointestinal tract
and generally is given by the oral route for sys-
temic medication, although the intravenous or
intramuscular route may be used safely in emer-
gency cases requiring rapid establishment of a
therapeutic concentration in the plasma or when
the patient is unconscious or unable to accept
oral administration. It is absorbed following
rectal administration also. Topically, the drug is
effective in pyogenic skin infections and in oph-
thalmologic practice.

Following a single oral dose of Chloromycetin
the maximum concentration is attained in the
serum in 2 to 4 hours and may be from 2.5 to
4 times as great as the maximum achieved fol-
lowing equivalent dosage with Aureomycin or
Terramycin (Welch, Ann. N. Y. Acad. Sc, 1950,

282 Chloramphenicol

Part I

53, 253). Doses of 0.5 Gm. and 1 Gm. of Chloro-
mycetin yield maximum plasma levels of about
4 micrograms and 8 to 9 micrograms respectively,
per ml.; a dose of 2 Gm. gives a maximum of
about 15 micrograms per ml. At dosage levels of
1 Gm. or higher, the time during which the serum
concentration remains above any given submaxi-
mal value is longer for Chloromycetin than for
Aureomycin or Terramycin. Similar results are ob-
tained with multiple doses ranging from 0.25 Gm.
to 1 Gm. given every 6 hours. A dose of 0.25 Gm.
every 6 hours usually maintains plasma levels
continuously above 2 micrograms per ml.

Excretion. — Urinary excretion of Chloromy-
cetin is rapid, but concentrations in the urine are
considerably lower than those of Terramycin and.
especially at lower dosage levels, than those of
Aureomycin. As single oral doses are increased
from 0.5 to 2 Gm., total urinary output of anti-
biotic increases relatively more for Chloromycetin
than for Aureomycin or Terramycin (Welch, loc.
cit.), but on a multiple dosage regime, total 24-
hour urinary excretion of Chloromycetin is very
much less than excretion of Aureomycin. The
principal excretion products are unchanged chlo-
ramphenicol, a hydrolysis product of chloram-
phenicol, and a conjugate of chloramphenicol
with glucuronic acid (Glazko et al., J. Biol.
Chem., 1950, 183, 679).

Chloromycetin, like Aureomycin and Terra-
mycin, is excreted also in the feces. At all dosage
levels Terramycin appears in greatest amount in
the feces. Aureomycin and Chloromycetin show
reverse trends in fecal excretion as doses are
increased from 0.5 to 2 Gm.: the amount of
Aureomycin increases from about 50 micrograms
to about 700 micrograms per gram wet weight;
Chloromycetin recovery, on the other hand, de-
creases from approximately 500 micrograms to
about 300 micrograms per gram wet weight.

Distribution. — The total urinary and fecal
excretion of all three antibiotics falls short of
accounting for the total dose administered, sug-
gesting that relatively large amounts of all three
antibiotics are destroyed in the body. The data
of Welch {loc. cit.) suggest that the destruction
or binding of Chloromycetin may be greater than
for Aureomycin or Terramycin. It may be sig-
nificant in this respect that Smith et al. (J. Bact.,
1948, 55, 425) found 45 per cent of chloram-
phenicol to be bound by serum. Chloromycetin
attains concentrations several times those of Au-
reomycin or Terramycin in the spleen, bile, and
heart of experimental animals. In man it reaches
therapeutic concentrations in the cerebrospinal
fluid. Chloromycetin is absorbed through the
rectal mucosa and is one of the few antibiotics
that achieve clinically effective blood levels when
given by this route.

For discussion of the effects of chloramphenicol
on the hematopoietic system of man. see under
Toxicology.

Uses. — Chloromycetin is effective both in
vitro and clinically against all rickettsias. against
brucellar, and most of the commonly encountered
pathothenic bacteria, whether gram-positive or
gram-negative. Because serious side effects (v.i.)
developed with indiscriminate clinical use, its

therapeutic indications have become restricted
to certain serious infections which do not respond
to other chemotherapeutic (antibiotic) agents. It
is the antibiotic of choice for typhus and for
treating typhoid fever and related enteric dis-
orders. It also inhibits the syphilis organism,
although it is not the drug of choice in this
infection and is not widely used for it. It has
some efficacy in actinomycosis and against some
infections due to large viruses but is inactive
clinically against fungus infections.

Rickettsial Infections. — Typhus is a dreaded
scourge that has been the aftermath of war in all
parts of the world since the dawn of recorded
history. Chloromycetin, properly used, can help
to relieve mankind of this pestilence (Smadel,
Bull. U. S. Army M. Dept. J., 1949, 9, 117;
whether of the louse-borne type or of the mite-
borne type (scrub typhus). Dramatic evidence of
the efficacy of Chloromycetin came in 1947,
within a few months of its discovery. An epi-
demic of typhus in Bolivia had already claimed
60 fives when Payne et al. (J. Trop. Med., 1948,
51, 68) were dispatched to the scene with a
supply of the antibiotic. In 22 cases treated with
Chloromycetin there were no deaths, while there
was 28 per cent mortality in a similar untreated
group of patients for whom there was no drug
available. When recovery7 occurred without treat-
ment, there was a prolonged illness (fever aver-
aged 18 days) and a long period of convalescence.
In the treated group, fever began to drop in a
few hours and 1.5 Gm. of drug daily for 2 to 3
days brought about complete remission of symp-
toms. This experience was soon repeated in
Mexico and in Malaya (Smadel, loc. cit.) where
during epidemic typhus all patients treated with
Chloromycetin had normal temperature restored
within 2 to 3 days after first administration of
the drug. Later Smadel et al. (Am. J. Hyg., 1950.
51, 216) reported successful prophylaxis of 30
out of 31 individuals exposed to R. tsutsugamushi
disease in a hyperendemic area; laboratory find-
ings confirmed incipient infection in 22 of the
31 cases. The prophylactic dose given was 3 to
4 Gm. orally at intervals of 4 to 7 days for 4 to
6 weeks. All forms of typhus, including murine
and recrudescent (Brill's disease) respond equally
well to Chloromycetin; it is effective even when
administered late in the disease (Smadel. J. Clin.
Inv., 1949, 28, 1196). The early experience with
Chloromycetin in treatment of tvphus has been
reviewed by Smadel (J.A.M.A., 1950, 142, 315).

Other rickettsial infections also respond rapidly
to Chloromycetin given in divided doses (4 to 6
hour intervals). Parker et al. (Am. J. Med., 1950,
9, 308) obtained alleviation of fever in all but

1 of 16 patients with Rocky Mountain spotted
fever within 24 hours after the first dose of
Chloromycetin and remission of eruption after

2 days : the initial dose was 2 to 3 Gm. for adults
or 0.75 to 2 Gm. for children, followed by 0.5
to 1 Gm. and 0.25 to 0.75 Gm.. respectively
every 4 to 8 hours. The total dose averaged
11.4 Gm. over 1.8 to 6.8 (av. 4.6) days. These
observations conformed to the earlier report of
Pincoffs et al. (Ann. Int. Med., 1948, 29, 656)
with a series of 15 patients. The drug is equally

Part I

Chloramphenicol 283

effective in children and adults (Reilly and Earle,
J. Pediatr., 1950, 36, 306). Virtually all more
recent studies have confirmed the earlier success
story of Chloromycetin in Rocky Mountain spot-
ted fever.

Among the other rickettsial diseases that
respond dramatically to chloramphenicol are
boutonneuse fever (due to R. conorii and trans-
mitted by the dog tick), rickettsialpox, and Q
fever.

Typhoid Fever and Other Enteric Infec-
tions.— Following exhaustive study of broad-
spectrum antibiotics, Chloromycetin has emerged
as the drug of choice for treatment of typhoid. In
the pre-chloramphenicol period, diagnosis of ty-
phoid indicated at best 3 to 4 weeks of serious
illness followed by a long period of convalescence.
Today the report of Woodward {Ann. Int. Med.,
1949, 31, S3) is typical: In a series of 21 typhoid
patients he found that "Irrespective of the height
of the preceding fever, the age of the patient, or
the day of illness treatment was begun, Chloro-
mycetin therapy was followed in all instances by
fall of temperature to normal levels within 4.5
days after the initial treatment." More recent
reports, while providing more statistics, have not
altered the conclusion expressed by Woodward
in 1949 that "Chloromycetin is unequivocally
the drug of choice in typhoid fever."

The antibiotic is best given in 4 to 6 divided
oral doses totaling 50 mg. per Kg. per day for
adults. For children the total daily dose, but
not the frequency of administration, should be
reduced in proportion to weight. On such a regi-
men, the digestive disturbances accompanying
typhoid and paratyphoid usually disappear in
about a week and the enlarged spleen rapidly
returns to normal size. Since normal temperature
may be restored before intestinal lesions heal,
care must be taken to prevent hemorrhage and
perforation. Subsidence of temperature should
not induce a false sense of security. If perforation
should occur, mixed therapy with intramuscular
penicillin and streptomycin should be instituted
at once while oral Chloromycetin is continued.

Even when no complications occur, Chloromy-
cetin therapy should be continued for 2 to 3 days
after restoration of normal temperature. Usually,
it is unnecessary to continue full dosage longer
than one week. If longer therapy seems desirable
to minimize the chance of relapse, the total daily
dosage (but not the number of doses) may be
reduced to two-thirds the original dose for the
first 2 days and then cut to one half the full
dose for the remainder of the time. To avoid risk
of blood dyscrasia (see under Toxicology),
therapy should generally not be continued more
than 2 weeks or repeated too frequently.

Tapering off of doses is contrary to general
recommendations for antibiotic therapy, but may
be practiced safely with Chloromycetin in typhoid
and paratyphoid infections because the causal
organisms do not develop resistance to the anti-
biotic in vivo although they do acquire resistance
in vitro. The discrepancy between in vivo and
in vitro results may be due to the fact that Chlo-
romycetin markedly enhances phagocytosis.

In the presence of chloramphenicol, Eber-

thella typhosa is modified with respect to the
H and the 0 antigens (de Rosnay and du Pas-
quier, Compt. rend. soc. biol., 1952, 146, 1742).
This has clinical significance; for instance,
Widal's reaction for patients having typhoid
should be carried comparatively with normal and
chloramphenicol-treated strains of E. typhosa
(Seelinger and Vorlaender, Ztschr. Immun. exp.
Ther., 1953, 110, 128). Organisms exposed to
Chloromycetin, either in vitro or by treatment
of the patient with the drug, induce a lower anti-
body titer than do unexposed organisms (Bruni
and Magudda-Borzi, Minerva Med., 1953, 43, 8).
Moreover, the titer produced by treated E. ty-
phosa is more transient than that produced by
normal organisms. This probably accounts for the
relapses that may occur after an attack of typhoid
has yielded in 5 or 6 days to Chloromycetin, and
emphasizes the need for prolonging therapy be-
yond the febrile period. When relapse occurs,
Chloromycetin remains the drug of choice and
therapy with it should be reinstituted at once.
However, when this becomes necessary, patients
should be observed carefully for evidence of
blood dyscrasias and the drug should be discon-
tinued at the first symptom of hematopoietic
disturbance.

Normally corticosteroid hormones have been
considered to be contraindicated in systemic in-
fectious disease and unadvised for joint use with
antibiotics. However, typhoid fever (and perhaps
typhus) treated with Chloromycetin appear to be
exceptions. Wisseman et al. (J. Clin. Inv., 1954,
33, 264) treated 18 typhoid patients and 8 cases
of scrub typhus with Chloromycetin and oral cor-
tisone, the latter in total doses of 10.7 mg. per
Kg. for 1 day or 6.4 to 8.1 mg. per Kg. twice
daily for from 2 to 4 days. On a mixed schedule
of Chloromycetin and cortisone, the febrile pe-
riod subsided in 6 hours, and defervescence was
followed by a general sense of well being and
improved appetite which facilitated maintenance
of adequate liquid and caloric intake. They re-
ported that the antipyretic effect of cortisone
was transient and that the drug did not directly
affect the course of infection. They emphasized
that, in such mixed therapy, the cortisone and
Chloromycetin should be continued for as long
as the antibiotic would be administered if used
alone.

Mortality from shigellosis and infant diarrhea
has been greatly reduced since the advent of
Chloromycetin therapy. Ross et al. {J. A.M. A.,
1950, 143, 1459) treated 35 children, aged 1 to 7
years and passing Shigella sonnei or Sh. para-
dysentery in their stools, with average doses of
250 mg. every 4 hours for 6 to 11 days. Stool
cultures of 33 of the patients became negative in
12 to 36 hours; in one instance cultures remained
positive for 48 hours and in one for 6 days.

Smellie (Proc. Roy. Soc. Med., 1950, 43, 766)
reported similar results from England for pa-
tients, aged 1 to 9 months, with infantile diar-
rhea. Of 27 cases (17 of them critical), 26
showed marked improvement soon after chloram-
phenicol was started and this was followed by
progressive uneventful recovery. Doses were 75
mg. of drug per pound of body weight per day,

284 Chloramphenicol

Part I

administered at 3 to 4 hour intervals for from
7 to 14 days — average time 10 to 12 days.

Other Systemic Bacterial Infections. —
Usefulness of Chloromycetin in bacterial diseases
is not limited to infections of the gastrointestinal
tract. Penicillin is the drug of choice in all dis-
eases amenable to its action; but when penicillin
fails, other antibiotics, including Chloromycetin,
frequently are successful, either alone or jointly
with penicillin. For example, Ahern and Kirby
(J. A.M. A., 1952, 50, 33) reported successful
use of Chloromycetin and penicillin in bacterial
endocarditis that failed to respond to penicillin
alone.

Respiratory Infections. — Pneumococcic
pneumonia (Gilpin and Rohrs, Am. Pract., 1951,
2, 937); Friedlander's pneumonia, due to Kleb-
siella pneumonia (Kirby and Coleman, Am. J.
Med., 1951, 11, 179); and pneumonias due to
other bacteria (Recinos et al., New Eng. J. Med.,
1949, 241, 733) all respond well to Chloromy-
cetin. '

Chronic nontuberculous bronchopulmonary in-
fections (often difficult to cure because of exten-
sive tissue damage, bronchial obstruction, or
interference with drainage) were treated success-
fully with Chloromycetin in 11 patients by
Hewitt and Williams' {New Eng. J. Med., 1950,
242, 119) after penicillin had been used without
clinical benefit in about half of them. The causal
organisms included Escherichia coli, Klebsiella
pneumonia, and Hemophilus influenza.

Urinary Infections. — Mixed infections of
the genitourinary tract frequently are more sus-
ceptible to Chloromycetin than to other broad-
spectrum antibiotics, especially when species of
Proteus or of Pseudomonas are among the of-
fenders. These organisms sometimes are elimi-
nated by a high dosage schedule (1 Gm. every
half hour for 3 doses). Following such high
dosage, blood titers may reach 50 to 60 micro-
grams per ml. Often, however, polymyxin is re-
quired to eliminate Proteus and Pseudomonas.
Hewitt and Williams (loc. cit.) and Chittenden
et al. (J. Urol., 1949, 62, 771) reported on nearly
150 patients with varied urinary tract infections
treated with Chloromycetin. Excellent results
were obtained in acute pyelonephritis and infec-
tions of the lower tract uncomplicated by major
structural damage or obstruction. In chronic in-
fections, fair to good clinical results were obtained
in most cases, but recurrences and treatment
failure were common when there was serious
anatomic defect or mechanical obstruction.

Mixed urinary infections, involving pyogenic
cocci and gram-negative bacilli sometimes yield
more promptly to Chloromycetin and penicillin
used together than to Chloromycetin alone. Mem-
bers of the colon-aerogenes group of organisms
are particularly susceptible to Chloromycetin
(Garvey et al., South. M. J., 1950, 43, 85).

Meningeal Infections. — A notable peculiar-
ity of Chloromycetin is its ability to pass
readily into the cerebrospinal fluid, where the
concentration of the antibiotic may be 50 per
cent of the concentration in the blood. This
probably accounts for the effectiveness of Phe

drug in treating meningitis of various origins
and neurosyphilis. McCrumb et al. (Am. J. Med.,
1951, 10, 696) treated 15 patients, ranging in
age from 10 months to 45 years, for meningo-
coccic meningitis. Three patients also had menin-
gococcemia and 7 were critically ill. Oral Chloro-
mycetin produced rapid restoration of normal
temperature in all, regardless of age or severity
of disease, and spinal fluid previously positive
for meningococci became negative in all cases
36 hours after onset of treatment. Doses for
children were 250 mg. orally every 4 hours and
for adults 1 Gm. orally thrice daily.

Other cases of meningitis cured by oral ad-
ministration of chloramphenicol include infections
due to E. coli (Ebsworth and Leys, Lancet, 1951,
261, 914), alpha Streptococcus (Hagen et al.,
Antibiotics and Chemotherapy, 1952, 2, 147),
B. proteus (Darnley, Neurology, 1952, 2, 69),
Salmonella typhosa (Boettner et al., South. M. J.,
1951, 44, 197), pneumococci (Riley. /. Pediatr.,
1950, 37, 909), and Hemophilus influenza (Mc-
Crumb et al., J.A.M.A., 1951, 145, 469). Among
111 cases of purulent meningitis, caused by H.
influenza (35), N. intracellidaris (49), D. pneu-
monia (17), and other organisms, including Str.
viridans, beta-hemolytic, and nonhemolytic strep-
tococci, Parker et al. (Antibiotics Annual, 1954-
1955, p. 26) had only 6 failures (6.3 per cent)
when oral Chloromycetin was used.

Intrathecal injection of 1 mg. of Chloromy-
cetin per Kg. of body weight is credited by
Trindade and Nastari (Rev. paid, med., 1950, 36,
369) with curing meningitis due to Shigella para-
dysenteria and resistant to other forms of medi-
cation. The same authors also employed the
intracisternal route successfully (J. A.M. A., 1951,
147, 1757).

Brucellosis. — It has been found that acute
brucellosis responds either to Aureomycin or
Chloromycetin. Woodward, Smadel and associates
(/. Clin. Inv., 1949, 28, 968) have indicated the
effectiveness of Chloromycetin in chronic infec-
tions with Brucella suis, Br. abortus, and Br.
melitensis. In 40 patients believed to have chronic
brucellosis Ralston and Payne (J. A.M. A., 1950,
142, 159) found partial to complete relief of
symptoms in 35; the periods of observation
ranged from 3 to 8 months. These investigators
called attention to the difficulty of proof of diag-
nosis in evaluating specific drug therapy of
chronic cases of brucellosis. Later reports have
emphasized the value of antibiotics, especially
when used jointly with sulfadiazine and specific
antigen, in treatment of brucella infections. For
further discussion see under Chlor tetracycline
Hydrochloride and Oxytetracycline Hydrochlo-
ride.

Whooping Cough. — In pertussis, Macrae
(Lancet, 1950, 258, 400) gave Chloromycetin
orally to 5 infants, 8 to 26 weeks of age, severely
ill and considered to have a poor prognosis. The
initial dose of 250 mg. was followed by 125 mg.
every 6 hours for 7 days, then 125 mg. every
12 hours for a further 7 days; the improvement
was dramatic, with all symptoms disappearing in
5 to 12 days. Today many physicians consider

Part I

Chloramphenicol 285

Chloromycetin the drug of choice for treating
whooping cough. High therapeutic efficacy and
low toxicity are in the favor of this antibiotic.

General Systemic Applications. — Other gen-
eral applications of Chloromycetin in systemic
bacterial infections have been reviewed by Hin-
shaw (Calif. Med., 1953, 79, 282), by Finland
(New Eng. J. Med., 1952, 247, 317; ibid., 555)
and by Woodward (Internat. Forum, 1953, 1,
No. 1). Use of the drug in infections of specific
systems has been reviewed in the J.A.M.A., 1952,
volume 150, as follows: blood stream and
heart (Herrell, p. 1450) ; respiratory tract (Ro-
mansky and Kelser, p. 1447); gastrointestinal
tract (Hughes, p. 1456) ; genitourinary tract
(Nesbit and Baum, p. 1459) ; skeletal system
(Altemeier and Largen, p. 1462). For discussion
of Chloromycetin in tropical diseases, see the
symposium on "Use of Antibiotics in Tropical
Diseases" (Ann. N. Y. Acad. Sc, 1952, 55, 969
to 1284).

Venereal Diseases. — Penicillin is the drug of
choice in most cases of syphilis and gonorrhea but
when penicillin is contraindicated or in gonorrheal
or syphilitic urethritis, especially when compli-
cated by presence of other organisms, Chloro-
mycetin often is successful. Butler et al. (Am.
J. Syph. Gonor. Ven. Dis., 1952, 36, 269) found
a single oral dose of 3 Gm. Chloromycetin cura-
tive in 103 cases of gonorrheal urethritis in males.
Similar results were achieved in 92 per cent of
51 male patients by Robinson and Wells (ibid.,
1952, 36, 264) following a single intramuscular
injection of 1 Gm. Chloromycetin. These inves-
tigators used the same treatment successfully for
7 cases of granuloma inguinale. Previously, Herb
et al. (J. Ven. Dis. Inform., 1951, 32, 177) had
treated granuloma inguinale in 43 patients with
intramuscular injection of 4 Gm. Chloromycetin
in 8 ml. saline every 3 or 4 days. Healing of le-
sions was rapid in all patients. All but 3 patients
were completely healed within 3 weeks of the
first injection. Donovan bodies disappeared in the
first 24 to 48 hours in all but 3 who required 96
hours. Granuloma inguinale yields promptly to
oral Chloromycetin also. Zeiss and Smith (Am.
J.^Syph. Gonor. Ven. Dis., 1951, 35, 294) gave
9 patients 500 mg. Chloromycetin orally every
6 hours for 12.5 days. Inguinal, vulvar, perianal,
and penoscrotal lesions of 1 month's to 12 years'
duration and from 5.5 to 106 sq. cm. in size were
healed 60 to 100 per cent upon discharge from
the hospital and were completely healed when
examined from 2.5 months to 1 year later.

Numerous reports indicate Chloromycetin to
be effective in treatment of early syphilis. These
have been cited by Welch and Lewis (Antibiotic
Therapy, 1953). Effective dosage schedules range
from 250 mg. thrice daily for the first day and
then twice daily until 7 to 12 doses have been
taken (total 1.75 to 3 Gm.) to 1 Gm. every 6
hours for 10 days (total 40 Gm). Romansky
(Antibiotics Annual, 1953-1954, p. 218) recom-
mends 60 mg. per Kg. for eight days. In most
cases, there is evidence of initial healing of le-
sions within 24 hours followed by rapid resolution
and complete healing in a few days. The rela-

tively high concentration attained by Chloro-
mycetin in the cerebrospinal fluid (see above)
makes this drug useful also in treating neuro-
syphilis.

Although Chloromycetin is curative in many
instances of venereal infections, penicillin, be-
cause it can be given in massive doses and, if
necessary, for long periods of time with no risk
of toxicity, remains the drug of choice for sus-
ceptible infections, such as syphilis and gonorrhea
when these are without complications.

Virus Infections. — The position of Chloro-
mycetin in treating infections of virus etiology
remains to be established. There are numerous
reports of successful treatment of a variety of
virus diseases, but failures also have been re-
ported for the same diseases. Possibly the dis-
crepancies are due to differences in sensitivity of
different strains of the several viruses and the
difficulty of clearly recognizing and identifying
the strains as they exist under clinical conditions.

Primary atypical (virus) pneumonia often
yields quickly to Chloromycetin. The experiences
of Liedholm (Svenska Lakartid., 1949, No. 44),
Hewitt and Williams (New Eng. J. Med., 1950,

240, 119), and of Recinos et al. (ibid., 1949,

241, 733) in treating this disease seem typical.
Adult patients generally become afebrile in 48
hours or less on a regimen of 1 to 3 Gm. daily
in divided doses, 4 to 6 hours apart. When
therapy is continued for a total of 5 to 6 days,
recovery usually is uneventful. However, Eaton
(Proc. S. Exp. Biol. Med., 1950, 73, 24) ob-
tained only indifferent results with Chloromy-
cetin in experimental infections with primary
atypical pneumonia virus.

Fagin and Mandiberg (/. Michigan M. Soc,
1950, 49, 182) hold that Chloromycetin is effec-
tive in curing psittacosis in human patients.
Several similar reports have appeared subse-
quently.

Chloromycetin was "uniformly effective" in
terminating attacks of mumps in children and
in adults treated by Ghalioungi (Lancet, 1950, 2,
75). An initial dose of 2.5 Gm. was followed by
500 mg. every 5 hours until a total of 24 Gm. was
administered. Normal temperature was restored
and pain was relieved in 24 to 36 hours. But
Nickerson and Worden (Can. Med. Assoc. J.,
1952, 66, 17) found the drug ineffective in 57
cases.

Localized Infections. — Chloramphenicol, like
other broad-spectrum antibiotics, has useful ap-
plications in dermatology, ophthalmology, oto-
laryngology, and other branches of medicine
dealing with infections primarily localized in one
tissue or organ. While local application alone
often is sufficient to control and to eradicate
infection, local treatment should be supported by
systemic administration in treating deep-seated
infections or infections likely to spread. In some
instances systemic therapy is more practicable
than is topical.

Aron-Brunetiere et al. (Presse med., 1952, 60,
424) obtained complete cure or considerable im-
provement in nearly 50 per cent of more than
200 patients with acne rosacea by prescribing

286 Chloramphenicol

Part I

1 Gm. Chloromycetin daily for 2 days, followed
by 0.75 Gm. daily for 4 days and 0.5 Gm. for

2 days. Distinct improvement was seen in 19
per cent of the patients, but about 30 per cent
failed to respond. Some of the unresponsive cases
were cured by administration of 6 Gm. of Aureo-
mycin daily for 8 days. For other data see Phil-
pott (Postgrad. Med., 1955, 17, 205).

Storck and Rinderknecht (Dermatologia, 1950,
101, 231) advocated Chloromycetin in eczema
when a bacterial factor was the predominating
or exclusive etiologic agent. Forty patients with
circumscript or with generalized chronic recur-
ring eczema were treated with 25 or 50 per cent
ointment or with a spray consisting of an oil-
water emulsion of Chloromycetin. In severe
cases, topical application was supported by oral
administration of 250 mg. twice to four times
daily for 4 to 20 days, depending on the severity
of the condition. Twenty patients were cured in
a few days; 8 were much improved, and 4 were
slightly improved.

Eye infections often yield to instillation of a
solution containing 2.5 mg. Chloromycetin per
ml., according to Leopold (Arch. Ophth., 1951,
45, 44). In 103 patients with conjunctivitis of
various origins, doses were given every 10 min-
utes for 6 doses, then every 30 minutes for the
next 4 doses, after which the schedule was
lengthened to instillation once an hour for 5
hours, and ultimately increased to once every 6
hours for 2 days. Improvement was notable in
71 patients. Thirty-three patients with keratitis
responded well to the same solution, augmented
by systemic Chloromycetin.

Roberts (Am. J. Ophth., 1951, 34, 1081) con-
cluded that chloramphenicol was useful in experi-
mental herpetic infection of the eye if used
early in the course of infection but of little value
if used later. In 65 patients with varied ocular
infections treated 2 to 3 times daily with 0.1 or
0.2 per cent solutions of chloramphenicol in saline
or a 1 per cent ointment, 49 responded by com-
plete healing in 2 weeks, 12 gave fair response.
Some of the infections responding well to Chloro-
mycetin had resisted treatment with other anti-
biotics. In a later study with 200 cases,
essentially similar results were obtained by the
same author. However, hemolytic staphylococcal
infections respond more slowly than do infections
due to other organisms, according to Roberts (loc.
cit.) and he recommends sodium sulfacetamide
for such instances.

Trachoma may be ameliorated by topical
Chloromycetin supported by systemic therapy for
at least 4 days (Pijoan et al., J. Trop. Med.
Hyg., 1950, 53, 193; Magnol, Am. J. Ophth.,
1951, 34, 481). Infections of relatively short
duration were healed in a week, but in chronic
trachoma healing was incomplete.

Toxicology. — The toxicity of Chloromycetin
is low. Baron (Handbook of Antibiotics, 1950)
lists the LD50 for mice as 109.5 to 202.6 and
245 mg. per Kg., intravenous; 1320, intraperi-
toneal; and 2640, oral. The intravenous MLD
for dogs is 150 mg. per Kg. Chronic toxicity also
is low, and for some time after Chloromycetin
became available it was considered virtually non-

toxic. Incidence of nausea, vomiting, diarrhea,
and skin eruptions following use of the drug is
not unknown but is less frequent than after
dosage with Aureomycin or Terramycin. Since
Chloromycetin is excreted rapidly and is not
acutely toxic, recovery from most infections
amenable to a short course of treatment with it
is uneventful.

However, that presence of the para-nitro-
phenyl group in the molecule might confer anti-
hemopoietic properties on Chloromycetin was
suggested in 1949 by Smadel (Am. J. Med., 1949,
7, 671) and in the same year Volini et al. (Proc.
Central Soc. Clin. Res., 1949, 22, 74) observed
marrow depression in 3 patients receiving from
30 to 60 Gm. of Chloromycetin over periods of 9
to 13 days. The para-nitrobenzene group gener-
ally has been assumed to be responsible for these
effects. However, Pratt and Dufrenoy (Antibi-
otics, 2nd ed., 1953, Lippincott) pointed out that,
if the drug does cause hematopoietic abnormali-
ties, there may be valid reasons for looking at
the -CO-NH- group in the side chain as a poten-
tial trouble-maker.

Recurring reports of aplastic anemia, some-
times fatal, following use of Chloromycetin led
the Food and Drug Administration in cooperation
with the National Research Council to initiate
a special study of Chloromycetin in relation to
blood dyscrasias. The results of the extensive
survey covering all reported cases of blood dys-
crasias in the United States since 1949 were
presented by Lewis et al. (Antibiotics and Chemo-
therapy, 1952, 2, 601) who also cited all the
pertinent earlier literature. A subsequent survey
by Welch et al. (ibid., 1954, 4, 607) reported
1448 cases of blood dyscrasias from all causes,
culled from records in all of the 48 states and
including those of all major medical centers in
the United States. The F. D. A. group segre-
gated all reported instances of blood dyscrasias
into groups as follows: A — chloramphenicol alone
involved; B — chloramphenicol with other drugs
(including other antibiotics, except penicillin;
sulfonamides; arsenicals; anticonvulsants; barbit-
urates; and antipyretics); C — chloramphenicol
not involved; and D — unclassified, due to insuffi-
cient information.

The salient features of the first report are that
in group A (chloramphenicol alone) there were 55
cases of blood dyscrasias, 42 per cent of them
fatal; in group B (chloramphenicol plus other
drugs) 143 cases, 57 per cent of them fatal; and
in group C (chloramphenicol not involved) there
were 341 cases, 46 per cent of which terminated
in death. Of the several blood disorders con-
sidered (aplastic anemia, pancytopenia, granulo-
cytopenia, thrombocytopenia, etc.), aplastic ane-
mia commands most attention because of its
uniformly bad prognosis. In the three groups of
cases mentioned above, incidence of this condi-
tion was: 44 in group A, 95 in group B, and 157
in group C. The percentage of fatalities in the
respective groups were: 52 in group A, 77 in
group B, and 62 in group C.

In the second survey, attention was focused
on cases that were not encountered in the first
investigation or that had developed later. In this

Part I

Chloramphenicol 287

series of 1448 cases only 29 instances of dys-
crasias, 26 of them aplastic anemia, were found
in group A (chloramphenicol only) whereas 88
cases, 54 of them aplastic anemia, were discovered
in group B (chloramphenicol with other drugs)
and 1050 patients with blood dyscrasias, 269 of
them aplastic anemia, were recorded in group C
(chloramphenicol not involved). It is interesting
that in group C, classes of drugs that seemed to
be associated with more than 100 cases each were
"analgesics, antipyretics, and other coal-tar com-
pounds" (167 cases, 22 of them aplastic anemia),
sulfonamides (105 cases, 26 aplastic anemia), and
antibiotics other than chloramphenicol (101 cases,
including 27 instances of aplastic anemia). The
27 cases were distributed as follows: Terramycin,
11; Aureomycin, 9; and streptomycin, 7. It is
significant that of the cases developing hemato-
poietic disorders during or following Chloromy-
cetin therapy, the majority had had two or more
courses of treatment or unusually prolonged
treatment with the drug. Women appeared to be
more subject to the untoward effects than men.

The results of the F. D. A. study, considered
in conjunction with the many thousands of pa-
tients to whom Chloromycetin has been adminis-
tered with only beneficial effect and in the light
of the fact that there appears to have been no
sudden increase in blood disorders following in-
troduction of Chloromycetin into the physicians'
armamentarium, indicate that the drug is not
dangerous when used according to sound prin-
ciples of antibiotic therapy. The incidence of
aplastic anemia following Chloromycetin therapy
has been estimated to be about one case in 40,000
receiving the drug. The facts revealed by the
report do emphasize the danger of promiscuous
use of any antibiotic.

Valuable and illuminating as the F. D. A. study
was, especially because of the vast facilities
available to the organization and the large num-
ber of case reports studied, it was essentially an
investigation in retrospect. Doyle et al. (Anti-
biotics Annual, 1953-1954, p. 268) initiated a
carefully controlled study to determine whether
early blood or bone marrow depression occurred
in a group of 43 patients (aged 4 days to 12 years)
receiving therapeutic doses of antibiotics; 33 of
the patients were given Chloromycetin. Complete
peripheral blood count (hemoglobin, reticulocytes,
platelets, red blood cells, white blood cells, and
differential) and bone marrow aspiration were
done on hospital admission (before any therapy),
and peripheral examination was made every sec-
ond day during a ten-day course of therapy and,
along with marrow examination, ten days after
admission and again six to eight weeks after dis-
charge. In none of the cases studied was there
any evidence of bone marrow or peripheral blood
depression regardless of the antibiotic or com-
bination of antibiotics given. In a study of pos-
sible chronic effects of prolonged or intermittent
use of Chloromycetin, Saslaw et al. (Antibiotics
Annual, 1954-1955, p. 383) administered the drug
to 45 monkeys in a 2-year study. The drug was
given over periods varying from 15 to 22 months.
They observed no drug-induced hematologic alter-
ations in normal monkeys or in those made anemic

(by daily bleeding) or nutritionally cytopenic
before institution of the drug. Similar negative
results were obtained in irradiated monkeys. These
experiments and those cited above illustrate the
present inability to estimate the potential hazard
of a new drug in causing agranulocytosis (Os-
good, Ann. Int. Med., 1953, 39, 1173).

Although, under normal circumstances, Chloro-
mycetin generally is free of untoward reactions,
the labels on all formulations of chloramphenicol
intended for internal use carry the following
statement: "Warning: Blood dyscrasias may be
associated with intermittent or prolonged use. It
is essential that adequate blood studies be made."
The literature describing chloramphenicol has the
following statement conspicuously displayed:
"Certain blood dyscrasias (aplastic anemia,
thrombocytopenic purpurea, granulocytopenia,
and pancytopenia) have been associated with the
administration of Chloromycetin. It is essential
that adequate blood studies be made when pro-
longed or intermittent administration of the drug
is required. Chloromycetin should not be used
indiscriminately or for minor infections." It would
be desirable for the labels on all antibiotic prod-
ucts to carry a statement warning against indis-
criminate use.

Summary. — Chloramphenicol is a crystalline
nitrobenzene derivative that is endowed with
broad antibiotic activity against rickettsias, gram-
positive and gram-negative bacteria, some larger
viruses, and some spirochetes. It is especially
useful in typhus and other rickettsial infections
and in typhoid and related enteric diseases. The
drug is available in several dosage forms under
the trademark Chloromycetin (Parke, Davis).

Being soluble and readily absorbed from the
gastrointestinal tract, Chloromycetin generally is
administered orally. It has, however, been used
successfully via the intramuscular, intravenous,
intrathecal, intracisternal, and rectal routes. The
drug is rapidly distributed to all body tissues and
fluids and also to the fetus in pregnant women.
Chloromycetin is excreted in the urine and feces;
appreciable quantities appear in the urine within
30 minutes after an oral dose.

Gastrointestinal irritation is less frequent and
usually less intense following administration of
Chloromycetin than after dosage with Aureomycin
or Terramycin. However, aplastic anemia and
other blood dyscrasias have occasionally been re-
ported to follow prolonged or oft-repeated treat-
ment with Chloromycetin. Therefore, adequate
blood studies should be made when the drug is
used for more than 2 weeks. [YJ

Dose. — The usual dose by mouth is 50 mg.
per Kg. of body weight as a single initial dose,
with a range of 25 to 75 mg. per Kg., followed by
maintenance doses of 250 mg. every 2 to 3 hours,
with a range of 250 mg. every 6 hours to 500 mg.
every 3 hours. Under most 'circumstances, a dose
of 250 mg. every 6 hours by mouth, continued
for 48 to 72 hours after fever and symptoms have
subsided, is adequate. The U.S. P. gives the usual
dose as 3 Gm. daily, and the range of dose as 2 to
8 Gm. daily. Doses for children are in proportion
to weight. It may be administered by rectum in
the usual oral doses.

288 Chloramphenicol

Part I

The usual dose intravenously is 10 mg. per Kg.
every 6 to 12 hours, with a range of 5 to 20 mg.
per Kg. For an adult this will amount to 500 mg.
in a volume of 250 ml. of sterile isotonic sodium
chloride solution for injection or 5 per cent dex-
trose solution for injection. Solution is effected
with the aid of the special solvent (containing
N,N-dimethylacetamide) supplied with the ampul
of Chloromycetin. Usually, there is no need for
intravenous administration and this route is not
indicated when the patient is able to accept oral
medication.

Intrathecal injection of 1 mg. per Kg. of body
weight has been employed.

Various blood dyscrasias may be associated
with prolonged, repeated or unusually high doses
of Chloromycetin. To avoid serious consequences,
adequate blood studies should be made whenever
the drug is used for more than 2 weeks or when
treatment calls for reinstitution of Chloromycetin
therapy shortly after a previous course of ad-
ministration of the same drug.

For external use, a 1 per cent ointment or solu-
tion is used.

Chloromycetin Palmitate. — Chloromycetin
is extremely bitter, so that it is hardly suitable
for administration in liquid form in pediatric
practice or to adults who have difficulty in swal-
lowing capsules. To overcome this objection
Chloromycetin Palmitate, the monopalmitic acid
ester of Chloromycetin, has been introduced. It
is only very slightly soluble in water and is con-
veniently prepared in the form of a flavored sus-
pension which provides a palatable dosage form
when the antibiotic must be administered orally
in a liquid medium. Chloromycetin Palmitate,
which is a white, crystalline substance, is virtu-
ally devoid of antibacterial activity, but is readily
hydrolyzed in the duodenum with liberation of
free Chloromycetin which is available for absorp-
tion from the upper intestine and subsequent dis-
tribution to body fluids and tissues. The prep-
aration and pharmacology of this compound have
been described by Glazko et al. {Antibiotics and
Chemotherapy, 1952, 2, 234). The indications
for use of this ester are the same as for Chloro-
mycetin. As would be expected, blood levels rise
more slowly but extend over somewhat longer
periods of time when Chloromycetin is adminis-
tered as the ester than when given in alcohol
form. In adults a single dose of 4 teaspoonfuls
may give detectable blood levels of Chloromycetin
for 12 hours.

The ester is supplied as a suspension contain-
ing the equivalent of 125 mg. of Chloromycetin
in 4 ml. (1 teaspoonf ul) . The usual dosage is
1 teaspoonful of the suspension every 4 to 6
hours for infants under 20 pounds, or 1 to 2 tea-
spoonfuls for children over 20 pounds. Alter-
natively the dose for children, during severe in-
fection, may be calculated on the basis of 50 to
100 mg. of Chloromycetin per Kg. per day. For
adults, 4 teaspoonfuls (equivalent to 500 mg. of
Chloromycetin) may be given every 4 to 6 hours.

Storage. — Preserve "Chloroamphenicol in
tight, light-resistant containers." U.S.P.

CHLORAMPHENICOL CAPSULES.
U.S.P. (B.P.)

"Chloramphenicol Capsules contain not less than
85 per cent of the labeled amount of C11H12-
G2N2O5. Chloramphenicol Capsules conform to
the regulations of the federal Food and Drug Ad-
ministration concerning certification of antibiotic
drugs." U.S.P.

The B.P. specifies that Capsules of Chlor-
amphenicol are hard gelatin capsules containing
chloramphenicol mixed with not more than one-
fifth of its weight of lactose; the content of
chloramphenicol in each capsule of average weight
is not less than 92.5 per cent and not more than
107.5 per cent of the prescribed or stated amount
of chloramphenicol.

The U.S.P. assay for chloramphenicol is a
microbial one, while the B.P. assay specifies ex-
traction of an aqueous suspension of a portion of
the contents of the capsules with ether, evapora-
tion of the solvent from the latter solution, and
weighing of the residue of chloramphenicol after
drying at 105°.

Chloramphenicol in capsule form is supplied
as Chloromycetin Capsules (Parke, Davis) and,
in special hermetically sealed capsules, as Chloro-
mycetin Kapseals (Parke, Davis). The ordinary
capsules contain either 50 mg. or 100 mg. of the
antibiotic; Kapseals contain 250 mg. Both are
stable products that retain their full potency for
at least 5 years when protected from moisture and
stored under reasonably favorable conditions.

For simultaneous use of chloramphenicol and
streptomycin there are available Kapseals Chloro-
strep (Parke, Davis), each Kapseal containing
125 mg. of Chloromycetin and an amount of
dihydrostreptomycin sulfate equivalent to 125
mg. of dihydrostreptomycin base. Such a prep-
aration may be especially useful preoperatively
and postoperatively in elective surgery of the
colon. Boling (South. M. J., 1953, 47, 133) re-
ported complete elimination of coliform organ-
isms and of pathogenic streptococci from fecal
matter of patients given a mixture of these two
antibiotics. Although marked overgrowth of yeasts
occurred, no proctitis, pruritus ani, or diarrhea
was reported.

CHLORAMPHENICOL OPHTHALMIC
OINTMENT. U.S.P.

"Chloramphenicol Ophthalmic Ointment con-
tains not less than 85 per cent of the labeled
amount of C11H12CI2N2O5. The labeled amount
is not less than 1 mg. per Gm. Chloramphenicol
Ophthalmic Ointment conforms to the regula-
tions of the federal Food and Drug Administra-
tion concerning certification of antibiotic drugs."
U.S.P.

Chloromycetin Ophthalmic Ointment (Parke, Davis).

Chloromycetin is supplied for ophthalmologic
use in two application forms: a 1 per cent oint-
ment, and a dry powder mixed with borate buffer
for extemporaneous preparation of a solution.
Only the ointment is recognized officially. The
ointment retains its full potency for at least a

Part I

Chlorcyclizine Hydrochloride 289

year at room temperature; the dry ophthalmic
powder is stable for longer periods of time.

The powder, supplied under the name Chloro-
mycetin Ophthalmic (N.N.R.), is packaged in
vials containing 25 mg. of Chloromycetin with
sufficient of the borate to give a properly buffered
solution when sterile distilled water is added as
the solvent. Adding 5 ml. of water gives a 0.5 per
cent solution of Chloromycetin; 10 ml. gives a
0.25 per cent solution; 15 ml. gives a 0.16 per
cent solution. The pH of the solution ranges from
about 7.3 for the most concentrated one to about
7.8 for the least concentrated one.

Either the ointment or the solution may be
used therapeutically in infections or prophy-
lactically in cases of trauma. The wide anti-
microbial spectrum of Chloromycetin, combined
with its general freedom from irritation, makes
these ophthalmic preparations useful against
ocular invasion by bacteria or by viruses, notably
those responsible for trachoma and herpetic
conditions.

The ointment is applied to the eyelids or con-
junctivas as necessary. The solution generally is
applied every 3 hours, 2 or 3 drops at a time, for
48 hours and then is continued on the same
schedule, but omitting night time instillations, for
at least 48 hours after the eyes appear to be re-
stored to their normal condition.

Local use of antibiotic preparations should not
be considered as supplanting general measures
used in treating severe ocular infections accom-
panied by keratitis, iritis, dacryocystitis, etc. The
local therapy, while important, is complementary
and should be accompanied by systemic anti-
biotic treatment and other general measures.

Storage. — Preserve "in collapsible tubes."
U.S.P.

CHLORCYCLIZINE
HYDROCHLORIDE. U.S.P.

Chlorcyclizinium Chloride, l-(p-Chlorobenzhydryl)-
4-methylpiperazine Hydrochloride

t,At"

CI"

"Chlorcyclizine Hydrochloride, dried at 120°
for 3 hours, contains not less than 98 per cent of
C18H21CIN2.HCI." U.S.P.

N-Methyl-N-(4-chlorobenzhydryl)piperazine Hydrochloride.
Di-Paralene Hydrochloride (Abbott). Perazil (Burroughs
Wellcome) .

Chlorcyclizine belongs to the class of methyl-
piperazine antihistaminic drugs, and is apparently
the most active and least toxic member of that
class. Synthesis of chlorcyclizine base, as de-
scribed by Baltzly et al. (J. Org. Chem., 1949, 14,
775), involves interaction of />-chlorobenzhydryl
chloride with methylpiperazine (see also Hamlin,
J.A.C.S., 1949, 71, 2731, 2734).

Description. — "Chlorcyclizine Hydrochloride

occurs as a white, odorless, or almost odorless,
crystalline powder. Its solutions are acid to litmus.
One Gm. of Chlorcyclizine Hydrochloride dis-
solves in about 2 ml. of water, in 11 ml. of
alcohol, and in about 4 ml. of chloroform. It is
practically insoluble in ether and in benzene.
Chlorcyclizine Hydrochloride melts between 222°
and 227°." U.S.P.

Standards and Tests. — Identification. — (1)
A brilliant yellow color is produced when 25 mg.
of chlorcyclizine hydrochloride is dissolved in 5
ml. of sulfuric acid, the color disappearing when
the solution is diluted with 20 ml. of water, leav-
ing a clear solution. (2) A 1 in 100,000 solution
in alcohol exhibits an ultraviolet absorbance maxi-
mum at 230 m\x, ± 1 m\i, and a minimum at 218
m\i ± 1 mn; the absorptivity (1%, 1 cm.), at
230 mji is between 425 and 445. (3) Chlorcyclizine
hydrochloride responds to tests for chloride. Loss
on drying. — Not over 2 per cent, when dried at
120° for 3 hours. Residue on ignition. — Not over
0.2 per cent. U.S.P.

Assay. — About 500 mg. of chlorcyclizine hy-
drochloride, dried at 120° for 3 hours, is assayed
by the nonaqueous titration method described
under Antazoline Hydrochloride. Chlorcyclizine
hydrochloride, however, is a diacidic base, releas-
ing two acetate ions to be titrated with perchloric
acid. Each ml. of 0.1 N perchloric acid represents
16.86 mg. of C18H21CIN2.HCI. U.S.P.

Uses. — Pharmacological studies (Castillo et al.,
J. Pharmacol., 1949, 96, 388; Roth et al., Arch,
internat. pharmacodyn. therap., 1949, 80, 378)
demonstrated this antihistaminic drug to be more
active and less toxic than diphenhydramine or
tripelennamine ; its action is more prolonged than
that of either of the other drugs. Chlorcyclizine
possesses slight antiacetylcholine and antispas-
modic action and it enhances the action of epi-
nephrine; like diphenhydramine it is a local
anesthetic.

Jaros et al. {Ann. Allergy, 1949, 7, 458, 466)
reported it to be clinically effective in allergic
disorders, and also observed that the benefit from
a single dose of 50 mg. often persisted for 24
hours. Brown et al. {ibid., 1950, 8, 32) treated
186 patients having allergic complaints and ob-
tained good results in the majority of cases. Good
symptomatic relief in hay fever, urticaria and
vasomotor rhinitis have been reported in hun-
dreds of patients (Cullic, South. M. J., 1950, 43,
643; Ehrlich and Kaplan, Ann. Allergy, 1950, 8,
682; Feinberg, Illinois M. J., 1950, 97, 324 and
others). An evaluation {J. Allergy, 1950, 21,
255), by a committee of the American Academy
of Allergy, of results obtained from use of the
drug in 588 patients showed it to be effective in
55.5 per cent of cases of seasonal allergic rhinitis,
in 38.4 per cent of cases of perennial allergic
rhinitis, in 12.8 per cent of cases of bronchial
asthma, in 68 per cent of cases of urticaria, and
in 47 per cent of cases of atopic dermatitis;
neither of two patients with contact dermatitis
was improved. The drug was effective within 30
minutes in most patients, and its useful action
persisted for 12 hours on the average.

Scant absorption and lack of toxicity of a 1 per

290 Chlorcyclizine Hydrochloride

Part I

cent cream was observed in animals (Light and
Tornaben, Ann. Allergy, 1951, 9, 607). The clini-
cal efficacy of the cream in localized neuro-
dermatitis, anogenital pruritus and nuchal eczema
was demonstrated by Ayres and Ayres (Arch.
Dermat. Syph., 1951, 64, 207); the failure of a
placebo cream confirmed the activity.

In seasickness Chinn et al. (Am. J. Med., 1952,
12, 433) observed equal protection from chlor-
cyclizine, promethazine, prophenpyridamine, and
diphenhydramine alone or with scopolamine.

Side effects from use of the drug have been
insignificant; drowsiness, headache, dry mouth,
blurred vision and insomnia have been reported.
The incidence of side effects encountered in the
study of the American Academy of Allergy was
12 per cent.

Dose. — The usual dose of this antihistamine
is 50 mg. (approximately }£ grain) one to four
times daily by mouth, with a range of 25 to 100
mg. The maximum safe dose is 100 mg., and the
total dose in 24 hours should generally not ex-
ceed 400 mg.

Storage. — Preserve in "tight, light-resistant
containers." US.P.

CHLORCYCLIZINE HYDRO-
CHLORIDE TABLETS. U.S.P.

"Chlorcyclizine Hydrochloride Tablets contain
not less than 93 per cent and not more than 107
per cent of the labeled amount of C18H21CIX2.-
HC1." U.S.P.

Assay. — The basic procedure described under
Antazoline Hydrochloride Tablets is employed,
the appropriate constants for chlorcyclizine hy-
drochloride being substituted.

Usual Size. — 50 mg.

CHLOROAZODIN. N.F.

a,a'-Azo-bis(chloroformamidine), [Chloroazodinum]

/NH2

H2NN

CIN

jp_N=N-

NCI

"Chloroazodin contains not less than 97 per
cent and not more than 102 per cent of C2H4-
CbNe." N.F.

N,N'-Dichloroazodicarbonamidine ; a,a'-Azobis-chlorof onna-
midine. Azochloramid (.Wallace & Tiernan). Sp. Cloroazo-
dina.

Chloroazodin may be prepared by treating
guanidine nitrate in an aqueous solution of acetic
acid, buffered with sodium acetate and cooled to
0°, with sodium hypochlorite solution.

Description. — "Chloroazodin occurs as bright
yellow needles or flakes. It has a faint odor sug-
gestive of chlorine, and a slightly burning taste.
Solutions of Chloroazodin in glycerin and in alco-
hol decompose rapidly on warming, and all solu-
tions of Chloroazodin decompose on exposure to
light. Chloroazodin decomposes explosively at
about 155°. Its decomposition is accelerated by
contact with metals. Chloroazodin is very slightly
soluble in water. It is sparingly soluble in alcohol,
slightly soluble in glycerin and in glyceryl tri-
acetate, and very slightly soluble in chloroform."

Standards and Tests. — Identification. — (1)
A brick red precipitate, soluble in an excess of
ammonia T.S., is produced on adding 0.25 ml.
of silver ammonium nitrate T.S. to 5 ml. of a
saturated solution of chloroazodin. (2) On add-
ing 2 ml. of potassium iodide T.S. and 0.5 ml. of
chloroform to 5 ml. of a saturated solution of
chloroazodin the chloroform layer is colorless or
only faintly colored; on adding 0.1 ml. of diluted
hydrochloric acid to the mixture, and shaking, a
deep violet color appears in the chloroform layer.
(3) The solution obtained on adding sulfurous
acid T.S. dropwise to 5 ml. of a saturated solu-
tion of chloroazodin until the yellow color is just
discharged responds, when acidified with diluted
nitric acid, to tests for chloride. Residue on igni-
tion.— Not over 0.1 per cent, after preliminary
heating with hydrochloric acid, followed by evapo-
ration in the presence of diluted sulfuric acid and
finally ignition to constant weight. Chloride. — The
limit is 0.7 per cent. N.F.

Assay. — About 120 mg. of chloroazodin is dis-
solved in glacial acetic acid, potassium iodide is
added and the liberated iodine is titrated with
0.1 N sodium thiosulfate, using starch T.S. as in-
dicator. Each ml. of 0.1 AT sodium thiosulfate
represents 3.050 mg. of C2H4CI2N6. In this assay
each molecule of chloroazodin liberates three
molecules of iodine; two molecules are liberated
by the reduction of each atom of chlorine from
a valence number of +1 to —1, and one mole-
cule of iodine is released by reduction of the
— N=N — group to — HN — NH — . Accordingly,
the hydrogen equivalent of the molecule of
chloroazodin is six. N.F.

Uses. — In general, chlorine antiseptics have
such a strong affinity for proteins that their effec-
tiveness is materially reduced by contact with
body tissue. Azochloramid apparently has less
affinity for organic matter than have other chlorine
compounds, but still possesses strong bactericidal
properties. Schmelkes and Horning (/. Bad.,
1935, 29, 323) found that in solutions of equiva-
lent chlorine content, chloroazodin was slightly
slower in its bactericidal effect than chloramine
when there was no organic matter, but in the
presence of 50 per cent blood serum chloroazodin
was 15 or 20 times as actively germicidal as
chloramine. A solution containing chloroazodin
equivalent to 50 parts per million killed all vege-
tative bacteria within one hour in the presence of
50 per cent serum.

A synergistic effect of this antiseptic on the
action of sulfonamides was reported by Schmelkes
and Wyss (Proc. S. Exp. Biol. Med., 1942, 49,
263) who suggested it was due to inactivation of
the sulfonamide inhibitor ^-aminobenzoic acid.
Skelton (/. Bad., 1944, 47, 273) confirmed this
synergism in vitro but both he and Lamberti
et al. (J. Bad., 1944, 48, 612) found no evidence
of any potentiation in vivo with streptococcal
infections. Grubaugh and Starin (Am. J. Med.
Sc, 1943, 205, 709 and 712) reported beneficial
effects on infections with the anaerobic bacteria
CI. perfringens, CI. septicum, CI. tetani, CI. botu-
linum, etc., and found that it inactivated the
toxins produced by these organisms.

Chloroazodin is used as a surgical antiseptic.

Part I

Chlorobutanol

291

According to Sutton and Van Duyn (N. Y. State
J. Med., 1936, 36, 1835) it is especially useful in
deep wounds and pus pockets, but is also serv-
iceable in superficial suppurating wounds. Salle
(Proc. S. Exp. Biol. Med., 1944, 56, 141) com-
pared the concentrations required to kill the chick
embryo with those required to kill different bac-
teria in the presence of organic matter using the
1:3300 aqueous solution of chloroazodin with
1 : 1000 concentration of the wetting agent sodium
tetradecyl sulfate. A concentration of 1:18,000
or higher killed the chick embryo while dilutions
up to 1 : 70,000 were lethal to Staphylococcus
aureus and 1:108,000 to E. typhosa. Of the fre-
quently employed antiseptics only iodine showed
an equal margin of safety according to these
criteria.

Chloroazodin is available commercially in a
number of application forms. A 1:500 solution
(see Chloroazodin Solution) in glyceryl triacetate
may be used undiluted in open traumatic wounds,
infected and contaminated postoperative wounds
and fractures, chronic ulcers and sinuses, and on
burns; gauze impregnated with this semi-oily
solution does not dry or sick to a wound. A 1 :3300
saline solution of chloroazodin, prepared by add-
ing available tablets or powder to wa:er, is used
for warm irrigations, wet dressings for cellulitis,
and for "Dakinization" of traumatic or infected
wounds. This Powder Saline Mixture of Azo-
chloramid (N.N.R.) contains 3.17 per cent of
chloroazodin, 89.56 per cent of sodium chloride,
0.95 per cent of monopotassium phosphate, and
6.32 per cent of anhydrous sodium phosphate. A
surface-active saline mixture of Azochloramid,
in powder form, is available for preparing a
1:3300 solution of chloroazodin which is isotonic
and contains 1 : 1000 of the wetting agent sodium
tetradecyl sulfate. Such a solution may be used
like the preceding one, but finds special utility as
an irrigating agent in deep wounds or infections,
such as empyema, where the low surface tension
and high dispersing power combine to make it
very effective in liquefying and dispersing pus for
removal by lavage. A 1:1000 ointment is used
topically on the skin or on gauze dressings. A
1:2000 solution of chloroazodin in vegetable oil
is used in the vagina. During prolonged use of
aqueous solutions of chloroazodin the edge of
healthy skin in wound areas should be protected
with petrolatum or zinc oxide ointment from
action of the antiseptic by application.

Storage. — Preserve "in well-closed, light-re-
sistant containers, preferably in a cold place."
N.F.

CHLOROAZODIN SOLUTION. N.F.

[Liquor Chloroazodini]

"Chloroazodin Solution contains, in each 100
ml., not less than 240 mg. and not more than 280
mg. of C2H4CI2N6. Caution. — Chloroazodin Solu-
tion should not come in contact with metal." N.F.

Sp. Solucidn de Cloroazodina.

Place a sufficient quantity of glyceryl triacetate
to make 1000 ml. of solution in a carefully dried
vessel of glass or other vitreous material which

can be tightly closed and in which the solution
can be stirred with a minimum of exposure to air.
Add to it 2.6 Gm. of chloroazodin, and stir until
dissolved, avoiding all unnecessary exposure to
air and to light. Close the vessel tightly, and set it
aside for at least 30 days, avoiding exposure to
light. Filter, with the aid of suction, through filter
paper or a glass or stoneware filter, and package
immediately in tight containers. N.F.

Description. — "Chloroazodin Solution is a
clear, yellow, somewhat oily liquid, having a slight
fatty odor and a bitter taste." U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 1.154 and not more than 1.158.
Identification. — A brick red precipitate, soluble
in an excess of ammonia T.S., is produced on add-
ing a few drops of silver ammonium nitrate T.S.
to a mixture of 5 ml. of chloroazodin solution and
5 ml. of distilled water. Moisture. — Not more
than 0.3 ml. of water is present in 150 ml. of
chloroazodin solution, when determined as di-
rected under Moisture Method by Toluene Dis-
tillation. N.F.

Uses. — This is the 1:500 solution of chloro-
azodin mentioned in the preceding article as being
commercially available. The apparent discrepancy
in concentration between that solution and the
one described in this monograph is because the
designation 1:500 is on a weight-in- weight basis;
since the specific gravity of glyceryl triacetate is
about 1.156, the two strengths are identical. For
uses see under Chloroazodin.

Storage. — Preserve in "tight, light-resistant
containers." N.F.

CHLOROBUTANOL. U.S. P. (B.P.) LP.

Chlorobutanol, Chlorbutol, [Chlorobutanol]

C13C.C(CH3)2.0H

"Chlorobutanol is anhydrous or contains not
more than one-half molecule of water of hydra-
tion. Anhydrous Chlorobutanol contains not less
than 99 per cent of C4H7CI3O. Hydrated Chloro-
butanol contains not less than 94.5 per cent of
C4H7CI3O." U.S. P. The B.P. name for this sub-
stance is Chlorbulol; it is defined as trichloro-
tert.-butyl alcohol, with a variable amount of
water of crystallization, containing not less than
93.0 per cent of C4H7OCI3. The I. P. requires not
less than 96.8 per cent and not more than 100 per
cent of C4H7OCI3 for the anhydrous substance,
recognized as Chlorobutanol, and not less than
94.4 per cent and not more than 101.5 per cent
of C4H70Cl3.^2H20 for Chlorobutanol Hydrate.

B.P. Chlorbutol. Acetone-chloroform; Chlorctone; Tri-
chloro-ter/-butyl Alcohol; Trichloromethyldimethylcarbinol;
Acetonum-chloroformium. Fr. Alcool butylique tertiaire
trichlore ; Chloretone. It. Acetoncloroformio ; Cloretone.
Sp. Clorbutol; Clorobntanol.

The formula of chlorobutanol indicates that it
represents the addition of a molecule of acetone to
one of chloroform, with rearrangement to produce
trichloro-^er^ary-butyl alcohol. Chlorobutanol is
prepared, in commercial quantities, by the inter-
action of acetone and chloroform in the presence
of potassium hydroxide.

Description. — "Chlorobutanol occurs as color-
less to white crystals, having a characteristic,

292

Chlorobutanol

Part I

somewhat camphoraceous odor and taste. One
Gm. of Chlorobutanol dissolves in 125 ml. of
water, in about 1 ml. of alcohol, and in about
10 ml. of glycerin. It is readily soluble in ether,
in chloroform, and in volatile oils. Anhydrous
Chlorobutanol melts at a temperature not lower
than 95°. Hydrous Chlorobutanol melts at a
temperature not lower than 76°." U.S.P. The I. P.
gives the melting point of anhydrous chlorobuta-
nol as between 96° and 97°, and that of the
hemihydrate as between 77° and 78°.

Standards and Tests. — Identification. — (1)
A yellow precipitate of iodoform is produced
when 3 ml. of iodine T.S. is slowly added to a
mixture of 5 ml. of a freshly prepared 1 in 200
solution of chlorobutanol and 1 ml. of sodium
hydroxide T.S. (2) The disagreeable odor of
phenylisocyanide is noticeable on gently warming
a mixture of 100 mg. of chlorobutanol, 5 ml. of
sodium hydroxide T.S. and 3 or 4 drops of
aniline. Acidity. — The solution prepared by shak-
ing 500 mg. of chlorobutanol with 25 ml. of water
is neutral to litmus paper. Residue on ignition. —
Not over 0.1 per cent. Chloride. — The limit is
700 parts per million.

Assay. — About 200 mg. of chlorobutanol is
reacted with an alcohol solution of potassium hy-
droxide and the chloride thereby released is de-
termined by the Volhard method. Each ml. of
0.1 N silver nitrate represents 5.925 mg. of
C4H7CI3O. In this assay the chlorobutanol is de-
composed by alkali with release of 3 chloride
ions, and a molecule each of acetone and carbon
monoxide.

Incompatibilities. — Only the anhydrous prod-
uct will form a clear solution in liquid petrolatum.
It is decomposed by alkalies; ephedrine has been
reported to react with it to produce ephedrine
hydrochloride which precipitates from a liquid
petrolatum solution. Triturated with menthol,
phenol, antipyrine. or certain other substances it
produces a soft mass.

Uses. — Chlorobutanol was introduced by Abel
in 1894 as a hypnotic but it is seldom used for
this purpose. It is used chiefly as a preservative
in multiple-dose vials of sterile solutions for
parenteral injection and to a decreasing extent in
topical preparations for the skin and mucous
membranes.

Hypnotic. — Its physiological actions are simi-
lar to those of chloral hydrate (Rowe. /. Phar-
macol., 1916. 9, 107). As an internal remedy
chlorobutanol has been used as a somnifacient,
general nerve sedative and anticonvulsant but it
has no advantage over chloral hydrate. Wynter
(Lancet, December 14. 1929) found it useful for
relief of seasickness and in the treatment of
whooping cough.

Topical. — Chlorobutanol is locally anesthetic,
actively antiseptic, and. according to Rowe (/. A.
Ph. A., 1924, 13, 22). causes a relaxation of in-
voluntary muscles. According to Hamilton chloro-
butanol has a phenol coefficient of 1.2. The satu-
rated aqueous solution (containing about 0.8 per
cent) is a complete bacteriostatic and will destroy
the Bacillus typhosus in two minutes' exposure
(Taub and Luckey. /. A. Ph. A., 1943. 32, 28).
In 0.5 per cent concentration it is bacteriostatic

for non-spore forming organisms (Briggs and
Callow, Quart. J. P., 1941, 14, 127). As a local
remedy its slight solubility in water interferes
with its usefulness. A dusting powder con-
taining 1 to 2 per cent has been found a service-
able application in painful ulcerations (Fioca,
Presse med., 1917, p. 460), as in the dysphagia
of laryngeal tuberculosis. Chlorobutanol has been
employed with rather indifferent results in the
treatment of gastralgia and vomiting. Supposi-
tories containing 300 mg. have been used for
hemorrhoids. A 1 per cent solution, with menthol
and camphor, in liquid petrolatum, was formerly
popular for use as a spray in inflamed states of
the nasal mucosa. A 2.5 per cent solution in clove
oil (N.F. Toothache Drops) is used for producing
local dental anesthesia. A 1 per cent solution, in
liquid petrolatum, has been used in the ear in
otitis media, [v]

Preservative. — In 0.5 per cent concentration
chlorobutanol is used as a preservative in a variety
of solutions, particularly those for parenteral ad-
ministration. While when thus used it is efficient
as a bacteriostatic (but not bactericidal) agent,
Gershenfeld (Am. J. Pharm., 1952, 124, 363)
found that heating of the solution destroyed the
bacteriostatic effect of chlorobutanol through de-
composition of the chemical as evidenced by a
decrease in the pH of heated solutions.

Toxicology. — The untoward effects of chloro-
butanol resemble those of chloral hydrate (q.v.).

The usual dose of chlorobutanol, as given by
U.S.P. XIV. is 600 mg. (approximately 10 grains).
The B.P. gives the dose range as 300 mg. to 1.2
Gm. (approximately 5 to 20 grains).

Labeling. — "The label indicates whether the
Chlorobutanol is anhydrous or hydrous." U.S.P.

Storage. — Preserve "in tight containers."
U.S.P.

CHLOROCRESOL. B.P., LP.

Parachlorometacresol

CH3.C6H3(C1).0H

Chlorocresol is defined as 2-chloro-5-hydroxy-
toluene; the B.P. indicates it may be prepared by
chlorinating metacresol. The LP. defines it as 6-
chloro-3-hydroxytoluene.

Chlorcresol, Chloroxymethyl Benzene.

Description and Tests. — Chlorocresol occurs
in colorless or faintly colored crystals with a char-
acteristic phenolic odor. It is soluble in 260 parts
of water, and in 0.4 part of alcohol; it is also
soluble in ether, in terpenes. in fixed oils, and in
solutions of sodium hydroxide. Chlorocresol melts
between 64° and 66°.

Its saturated aqueous solution gives a bluish
color with test solution of ferric chloride. When
ignited with anhydrous sodium carbonate, and the
residue dissolved in water and nitric acid, it yields
a white precipitate with silver nitrate. When
heated on a water bath it volatilizes and leaves no
more than 0.1 per cent of residue.

Uses. — It is well known that the introduction
of a chlorine atom into the molecule of phenolic
antiseptics increases their antibacterial powers.
Although there is considerable difference in the

Part I

Chloroform

293

disinfectant power of the various chlorocresol
isomers they are apparently all stronger than ordi-
nary cresol. Klarman and co-workers (/. Bad.,
1929, 17, 423) found that parachlorometacresol
is about 10 times as actively bactericidal as meta-
cresol; it has a phenol coefficient of 30 against the
B. typhosus and 19.5 against staphylococcus. Al-
though the presence of organic matter decidedly
lessens its efficiency it is still much stronger than
cresol. Berry and co-workers {Quart. J. P., 1938,
11, 728) studied the activity of chlorocresol
against spores of Bacillus subtilis at different tem-
peratures; at a temperature of 60°, an 0.3 per cent
solution killed in three hours, and at a tempera-
ture of 98°, 0.1 per cent killed in 1*4 hours.

Chlorocresol has been used to a limited extent
as a surgical antiseptic. Konrad (Arch. Gyndk.,
1910, 91, 243) recommended especially a solu-
tion in alcohol-acetone for disinfecting the sur-
geon's hands.

Chlorocresol is one of the two "bactericides"
permitted to be used in the B.P. process for
sterilizing parenteral injections by heating with a
bactericide. In this process the injection is made
by dissolving or suspending the medicament in a
0.2 per cent w/v solution of chlorocresol in water
for injection, or in a 0.002 per cent w/v solution
of phenylmercuric nitrate in water for injection;
the preparation is distributed in the final con-
tainers, and these are sealed. When the volume
in each container does not exceed 30 ml., the
containers are heated at 98° to 100° for 30 min-
utes; when the volume exceeds 30 ml., the con-
tainers are heated for a sufficient time to ensure
that the solution or suspension in each container
is maintained at 98° to 100° for 30 minutes.
Davison (/. Pharm. Pharmacol., 1951, 3, 734)
found, however, that in his experiments even rela-
tively low concentrations of bacterial spores sur-
vived when either chlorocresol or phenylmercuric
nitrate was used according to the official direc-
tions; in the discussion of Davison's findings
other investigators reported having found the
procedure effective. Chlorocresol is a required
bacteriostatic ingredient of several B.P. injections.

Wien (Quart. J. P., 1939, 12, 212) tested the
toxicity of chlorocresol on mice and on rats; he
found that the LD50 for mice was 0.25 Gm. per
kilo hypodermically, and 0.12 Gm. intravenously.
He also injected hypodermically into rabbits 5 ml.
of an 0.25 per cent solution daily for 4 weeks,
with no apparent disturbance of the animals'
health nor post-mortem evidence of injurious
effects.

Off. Prep. — Injection of Bismuth; Injection
of Bismuth Oxychloride; Injection of Procaine
and Adrenaline, B.P .

CHLOROFORM. U.S.P., B.P. (I.P.)

[Chloroformum]

"Chloroform contains not less than 99 per cent
and not more than 99.5 per cent of CHCI3, the
remainder consisting of alcohol. Caution — Care
should be taken not to vaporize Chloroform in
the presence of a naked flame, because of the pro-
duction of noxious gases." U.S. P. The B.P. defines
chloroform as trichloromethane to which 1 to 2

per cent by volume of ethyl alcohol has been
added. The I.P. recognizes the same product, but
under the title Anaesthetic Chloroform.

I.P. Anaesthetic Chloroform; Chloroformium Anaes-
thesicum. Methenyl Trichloride; Trichloromethane. Formy-
lum Trichloratum; Chloroformium pro Narcosi. Fr. Chloro-
forme anesthesique ; Chloroforme officinal; Formene
trichlore. Ger. Chloroform; Methinchlorid. It. Cloroformio
per anestesia. Sp. Cloroformo.

Chloroform was discovered by Samuel Guthrie
of Sackett's Harbor, N. Y., in 1831, and at about
the same time by Soubeiran in France, and Liebig
in Germany. Guthrie obtained it by distilling a
mixture of chlorinated lime and alcohol. Chloro-
form was used internally in asthma and other con-
ditions as early as 1832 by Ives of New Haven,
but it was not until November, 1847, that Sir
James Y. Simpson of Edinburgh brought it for-
ward as a general anesthetic.

Chloroform may be prepared by several dif-
ferent methods. Being trichloromethane, it may
be made by the reaction of chlorine and methane,
but this process is not commercially practicable.

It is easily and economically prepared by the
haloform reaction, in which a suspension of chlo-
rinated lime or solution of sodium hypochlorite
is reacted with acetone or alcohol. With acetone
the first stage of the reaction with the halogen
compound yields trichloroacetone, which under-
goes alkaline cleavage to produce chloroform and
an acetate of the base of the halogen compound.
When alcohol is employed, the hypochlorite first
oxidizes it to acetaldehyde, which forms trichloro-
acetaldehyde and then undergoes alkaline cleavage
with formation of chloroform and a formate. The
chloroform is removed from the products of reac-
tion by distillation.

Chloroform may be prepared industrially also
by the reduction of carbon tetrachloride by means
of iron and water in the presence of a suitable
catalyst.

On exposure to air and sunlight, chloroform
undergoes oxidation with formation of the highly
toxic substance phosgene (COCI2). Squibb showed,
in 1857, that a more stable product is obtained
by adding a small amount of alcohol. The exact
mechanism of the action of alcohol remains un-
certain. From 1 to 2 per cent, by volume, of
alcohol is commonly added to chloroform; this
protects it under average conditions of storage
and use but on prolonged exposure to air and sun-
light decomposition of chloroform will eventually
occur. Amy and associates (/. A. Ph. A., 1931,
20, 1153) found that chloroform in amber or
green glass containers is stable for one year when
exposed to direct sunlight. They also found that
in diffused light all glass containers afforded
protection.

Description. — "Chloroform is a clear, color-
less, mobile liquid, having a characteristic, ethe-
real odor, and a burning, sweet taste. It is not
flammable, but its heated vapor burns with a green
flame. It boils at about 61°. It is affected by light.
Chloroform dissolves in 210 volumes of water.
It is miscible with alcohol, with ether, with ben-
zene, with petroleum benzin, and with fixed and
volatile oils. The specific gravity of chloroform is
not less than 1.474 and not more than 1.478, indi-

294

Chloroform

Part I

eating not less than 99 per cent and not more than
99.5 per cent of CHCla." U.S.P.

Chloroform has extensive solvent power for
camphor, caoutchouc, gutta-percha, mastic, elemi,
tolu, benzoin, and copal. It also dissolves iodine,
bromine, many alkaloids, the fixed and volatile
oils, most resins, and fats. Amber, sandarac, lac,
and wax are only partially soluble. It dissolves
sulfur and phosphorus sparingly. As a general
solvent, it has the advantages over ether of not
being flammable, and of dissolving much less
water than does ether.

Standards and Tests. — Non-volatile residue.
— Not over 1 mg. of residue, dried at 105° for
1 hour, is obtained from 50 ml. of chloroform.
Acidity, chloride ion and chlorine. — The aqueous
layer from a mixture of 10 ml. of chloroform and
25 ml. of water is neutral to litmus paper and
separate portions are not affected by a few drops
of silver nitrate T.S. or colored blue by a few
drops each of potassium iodide T.S. and starch
T.S. Readily car6onizable substances. — 40 ml. of
chloroform is shaken vigorously with sulfuric
acid for 5 minutes; the chloroform layer is color-
less, and the acid has no more color than matching
fluid A. Odorous and chlorinated decomposition
products. — A 2 -ml. portion of acid from the pre-
ceding test, when diluted with 5 ml. of water,
remains colorless and clear and emits only a faint
vinous or ethereal odor (odorous decomposition
products). When the mixture is further diluted
with 10 ml. of water it remains clear and does
not produce any reaction with 3 drops of silver
nitrate T.S. within 1 minute (chlorinated de-
composition products). Acid and phosgene. — A
20-ml. portion of chloroform, shaken with 10 ml.
of water previously made slightly alkaline to
phenolphthalein T.S., requires not more than 0.20
ml. of 0.01 N sodium hydroxide to produce the
same intensity of color which persists for 15 min-
utes; comparison of the color is made with an-
other portion of water made similarly alkaline to
phenolphthalein T.S. Aldehyde and ketone. — No
turbidity or precipitate develops within 1 minute
when 5 ml. of the aqueous extract obtained from
a mixture of 3 ml. of chloroform and 10 ml. of
ammonia-free water is mixed with 40 ml. of
ammonia-free water and 5 ml. of alkaline mercuric
potassium iodide T.S. Foreign odor. — No foreign
odor is perceptible as the last portions of 20 ml.
of chloroform evaporate from clean, odorless filter
paper placed on a warmed glass plate, and the
paper remains colorless. U.S.P.

Uses. — Chloroform has been employed as an
inhalation anesthetic, an irritant on the skin, an
antitussive in cough syrups, a carminative and a
flavoring.

Topical Action. — Locally chloroform is ac-
tively irritant and somewhat anesthetic. When
applied to the skin it produces pain and redness
and if evaporation be prevented will frequently
blister. The pain is followed by a sensation of
numbness. Chloroform is actively antiseptic and
even germicidal. A one per cent solution is suffi-
cient to kill most non-sporulating bacteria if the
contact be sufficiently prolonged; but against
spore-forming organisms it is of little avail. It has
some preservative action in aqueous extracts.

Brown (Laryng., 1945, 55, 371) effectively treated
screw-worm (larval stage of Cochliomyia Ameri-
cana or macellaria) infestation of the upper re-
spiratory tract with irrigations of 50 per cent
chloroform in a light vegetable oil.

Action After Oral Ingestion. — Taken into
the stomach in doses of about 0.3 ml. (approxi-
mately 5 minims), it induces only gastric symp-
toms, chiefly due to its irritant properties; but
when there is excessive flatulence, colic, or gas-
tralgia, it not only causes increased peristalsis
and expulsion of any flatus present, but also has
a distinct local narcotic influence through its
lessening of pain and spasm. Chloroform has been
employed as an anthelmintic but it has been super-
seded by the less toxic carbon tetrachloride and
tetrachloroethylene. The official chloroform water
is useful as a vehicle for salts (though in formu-
lations where "salting-out" of chloroform occurs
sufficient water, or alcohol, must be added to dis-
solve the chloroform). In doses of 4 to 8 ml.
chloroform produces a narcotism similar to that
occurring when it is administered by inhalation
which, however, develops much more slowly and
is of longer duration. Chloroform has been added
to cough-mixtures as a respiratory sedative, but
its action is too fleeting to be of any great value.

Inhalation Anesthetic. — Chloroform is a
general anesthetic which produces all stages of
surgical anesthesia (see under Ether for general
discussion). Its potency, speed of induction of
anesthesia, and rate of recovery of consciousness
are all superior to those of ether, but it is more
toxic to visceral organs than is ether. November,
1947, marked the centennial anniversary of the
use of chloroform as an inhalation anesthetic by
J. Y. Simpson (see Chloroform: A Study After
100 Years, by R. M. Waters, 1951, University
of Wisconsin Press).

Only about one-third as much chloroform as
ether is required for the several stages of surgical
anesthesia. For induction and maintenance of
stage III, plane 1, anesthesia about 1.5 volumes
per cent of chloroform is needed in the inspired
air, in contrast to about 5 to 7 volumes per cent
of ether. Because of the lesser concentrations re-
quired, chloroform is less irritating to the mucosa
of the respiratory tract. Likewise, the concentra-
tion of chloroform in the blood in deep anesthesia
is about 30 to 40 mg. per cent, in contrast to 130
to 140 mg. per cent for ether. Deep anesthesia
may be obtained rapidly — in 2 to 5 minutes — but
such rapid induction must be avoided. With high
initial concentrations of chloroform in the in-
spired air, reflex breath-holding may occur, fol-
lowed by a deep inspiration, resulting in a sudden
high concentration in the heart and serious ar-
rhythmia before unconsciousness develops. Equi-
librium of the concentrations of chloroform in
the blood and brain occurs in about 10 minutes,
while in the case of ether about 30 minutes is
required. Secher (Acta Pharmacol. Toxicol., 1951,
7, 231) described blocking of nerve impulse
transmission at the motor end-plate with anes-
thetic concentrations of chloroform and ether.

Chloroform is largely eliminated through the
lungs. When inhalation is discontinued the con-
centration in the blood decreases about 50 per

Part I

Chloroform 295

cent within 5 minutes, and only traces remain
after 30 minutes. However, traces still remain at
2 hours, with some chloroform being excreted in
the urine, sweat and milk.

Analgesic Uses. — Because of its rapidity of
action chloroform is an effective agent for ob-
stetrical analgesia (Lenahan and Babbage, N. Y.
State J. Med., 1950, 50, 1717). Light and inter-
mittent chloroform anesthesia, sufficient to relieve
labor pains, has little effect on uterine contrac-
tions and does not delay delivery. In the absence
of a trained assistant, almost anyone, even the
patient, may administer chloroform by inhalation
at the onset of the labor-pain. About 2 ml. of
chloroform is placed on cotton in a glass or cup
and the patient inhales the vapors; when anes-
thesia develops the patient's arm drops and the
cup and its vapors are removed from the face.
There is little clanger of hepatic or renal damage
from this procedure but anesthesia may become
sufficiently deep to present the risk of ventricular
fibrillation, and this procedure cannot be recom-
mended (Lancet, 1936, 1, 283) in spite of its
effectiveness. Chloroform has also been used by
inhalation for the relief of other types of severe
pain. Chloroform is an easily transported anes-
thetic for use in emergency conditions. Glass
ampules containing 1.2 ml., for crushing in a
handkerchief, are convenient. It will control con-
vulsions and relieve asthmatic seizures.

External Use. — Chloroform is widely em-
ployed as a counterirritant for myalgic, neuralgic
and arthralgic pain, especially in the form of the
liniment; an ointment has also been used. A chlo-
roform ointment has been prepared by incor-
porating twenty parts of chloroform in a mixture
of ten parts of white wax and ninety parts of lard.
Gelatinized chloroform may be prepared by agi-
tating a mixture of equal parts of chloroform and
egg white; about three hours are required for
gelatinization. A mixture of four parts of chloro-
form and one of egg white gels in a few minutes
at 60°. Such a product may be applied to the
skin with friction or spread on cloth.

Chloroform is sometimes prescribed in aque-
ous mixtures wherein it is insoluble. The use of
an equivalent amount of the spirit may overcome
the difficulty or it may be convenient to use a
more concentrated alcoholic solution of chlo-
roform, [v]

Toxicology. — The margin of safety between
the concentration of chloroform required for deep
anesthesia and that producing a fatal result is
very narrow (Buckmaster and Gardner, Proc.
Roy. Soc. London, 1907, 79, 309). A concentra-
tion of only 2 volumes per cent in the inspired
air stops respiration, with the blood concentra-
tion being but slightly more than the 40 mg. per
cent required for deep surgical anesthesia. Anes-
thetic concentrations of chloroform depress the
circulation to a dangerous degree during the
course of the first hour of anesthesia (Blalock,
Surg. Gynec. Obst., 1928, 46, 72). With third
stage anesthesia the blood pressure falls pro-
gressively; the myocardium is depressed and
cardiac output decreases (Fisher et al., Anesth.,
1951, 12, 19); the vasomotor center is depressed
and the muscle of the peripheral vessels is also

dilated by direct action. The skin is pale, rather
than pink as with ether.

During the induction of anesthesia, ventricular
fibrillation with sudden death occurs with suffi-
cient frequency to make this an undesirable
anesthetic. The myocardium is sensitized by
chloroform to factors which stimulate abnormal
ventricular rhythms (ventricular tachycardia, ex-
trasystole and fibrillation), such as reflex stimula-
tion from the respiratory tract or sites of trauma,
increased amounts of epinephrine arising from
pain or fear, and increased tension of carbon
dioxide in the blood resulting from irregular
breathing. Depression of carotid sinus reflexes
results in failure to respond to hypotension. The
refractory phase of the cardiac cycle is shortened
and the myocardium is more irritable. In cardiac
standstill or serious arrhythmia, the chloroform
should be discontinued; oxygen inhalation, cardiac
massage or antifibrillatory drugs (such as pro-
caine hydrochloride) as indicated — and prayer —
are recommended. Adequate preoperative seda-
tion decreases the incidence of these untoward
cardiac effects. Even with no obvious arrhythmia,
the electrocardiogram shows the multiple focus
type of ventricular tachycardia during the induc-
tion period of anesthesia (Hill, Edinburgh M. J.,
1932, 39, 533; Lancet, 1932, 1, 1139), this dis-
appearing during stage III. Ether has less tend-
ency to cause such changes but ethyl chloride
behaves like chloroform.

Chloroform causes more renal tubular damage
than ether (Mousel and Lundy, Anesth., 1940, 1,
40) and hyperglycemia is greater with chloroform
(Ravdin et al, J. Pharmacol, 1938, 64, 111).
Chloroform causes acute fatty infiltration of the
liver in doses representing about 15 minutes of
surgical anesthesia (Rosenthal and Bourne,
J.A.M.A., 1928, 90, 377). After 1 hour of surgical
anesthesia, central necrosis of the liver due to a
direct toxic action is common. About 1 to 3 days
later, so-called delayed poisoning may occur,
manifested by prostration, nausea, vomiting,
jaundice, hypoprothrombinemia and other results
of liver failure, coma and death on the fourth
or fifth day with central necrosis of the liver or
slow recovery from the severe hepatic damage.

A high-protein (methionine) and carbohydrate
and low-fat diet in the preoperative period, and
adequate oxygen during anesthesia, tend to pro-
tect the liver from damage by chloroform (Gold-
schmidt et al, J. Clin. Inv., 1939, 18, 277; Miller
and Whipple, Am. J. Med. Sc, 1940, 199, 204).
Chloroform is contraindicated in patients with
cardiac, renal or hepatic disease. Anoxia aggra-
vates the deleterious effect of chloroform and
severe anemia, which increases anoxia, is also a
contraindication. In the blood more chloroform is
found in erythrocytes than when ether is em-
ployed; moreover, it is detectable in the red cells,
although only in traces, for many hours longer.

Although chloroform has the advantages over
ether of more rapid induction of anesthesia, less
excitement and pulmonary irritation, less post-
operative nausea and vomiting, better muscle re-
laxation and non-flammability, these virutes are
offset by the greater cardiac, renal and hepatic
hazards of chloroform anesthesia and the higher

296

Chloroform

Part I

incidence of fatalities due to anesthesia. It has
remained in favor in hot climates where the vola-
tility of ether is too great for the use of the open
drop-method of administration, but a simple,
semi-open method of administering ether has been
described (see Ether).

Poisoning. — If an overdose of chloroform is
taken by mouth, the stomach should be emptied
by the pump or siphon tube and treatment insti-
tuted as for serious narcosis from inhalation. S

Dose. — The usual dose by inhalation as an
anesthetic is regulated according to the response
of the patient. The oral dose is 0.3 to 1 ml. (ap-
proximately 5 to 15 minims).

Storage. — Preserve "in tight, light-resistant
containers, preferably at a temperature not above
30°. If cork stoppers are used, they should be
covered with tin foil or other suitable material."
U.S.P.

Off. Prep. — Chrysarobin Ointment. U.S. P.;
Chloroform Spirit; Chloroform Water. N.F., B.P.;
Chloroform Liniment. N.F.; Compound White
Pine Syrup. N.F.; Emulsion of Chloroform;
Emulsion of Cod Liver Oil. B.P.

EMULSION OF CHLOROFORM.

Emulsio Chloroformi

B.P.

This contains 5 per cent of chloroform dis-
persed in water, emulsified by means of 0.1 per
cent of liquid extract of quillaja and 5 per cent
of mucilage of tragacanth. It is equivalent in
chloroform content to the B.P. Spirit of Chloro-
form and is used for the same purposes.

Dose, from 0.3 to 2 ml. (approximately 5 to
30 minims).

CHLOROFORM LINIMENT. N.F.

[Linimentum Chloroformi]

"Chloroform Liniment contains in each 100 ml.,
not less than 27 ml. and not more than 30.5 ml.
of CHCla." N.F.

Liniment of Chloroform. Sp. Linimento de Cloroformo.

Mix 300 ml. of chloroform with 700 ml. of
camphor and soap liniment. N.F.

Alcohol Content. — From 43 to 47 per cent,
by volume, of C2H5OH. N.F.

Uses. — Chloroform liniment is an active rube-
facient but, because of the volatility of its chief
ingredient, its effects are of very short duration
and it is not efficient for any serious inflammation.
It is frequently employed, however, for the relief
of minor forms of myalgias, neuralgias, and simi-
lar conditions.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 30°." N.F.

CHLOROFORM SPIRIT. X.F. (B.P.)

[Spiritus Chloroformi]

"Chloroform Spirit, contains, in each 100 ml.,
not less than 5.55 ml. and not more than 6.30 ml.
of CHCls." N.F.

B.P. Spirit of Chloroform.

Mix 60 ml. of chloroform with sufficient alcohol
to make the product measure 1000 ml. N.F.
The B.P. Spirit of Chloroform is prepared by

mixing 50 ml. of chloroform with sufficient 90
per cent alcohol to make 1000 ml.

Alcohol Content. — From 85 to 91 per cent,
by volume, of C2H3OH. N.F.

Uses. — Chloroform spirit is used for internal
administration of chloroform, as in cases of
gastrointestinal spasm or pain, or as a carmina-
tive, when it acts locally. The spirit may be
advantageously dispensed in a vehicle of aromatic
elixir.

Dose, from 0.6 to 4 ml. (approximately 10 to
60 minims).

Storage. — Preserve "in tight, fight-resistant
containers." N.F.

CHLOROFORM WATER. N.F., B.P.

Aqua Chloroformi

Aqua Chloroformiata; Solutio Chloroformii. Fr. Eau
chloroformee ; Solute de chloroforme. Ger. Chloroform-
wasser. It. Acqua cloroformizzata. Sp. Agua cloro-
formica ; Agua de cloroformo.

To a convenient quantity of purified water
in a dark amber-colored bottle, add sufficient
chloroform to have a slight excess present after
the mixture has been repeatedly and thoroughly
shaken. To dispense chloroform water, decant
the required quantity of the supernatant aqueous
solution. N.F. The chloroform water of the
B.P. is made by dissolving 0.25 per cent of
chloroform in distilled water. The B.P. prepara-
tion is only about half-saturated; a fully saturated
water contains about 0.5 per cent of chloroform.

Chloroform water is used as a carminative and
as a vehicle for administering active remedies.
By virtue of its antiseptic properties, mixtures
containing it resist decomposition longer than
those made with ordinary water.

Dose, 15 ml. (approximately 4 fluidrachms) .
The B.P. preparation may be given in up to twice
this dose, since it contains but half the amount of
chloroform as the N.F. water.

Storage. — Preserve "in tight, light-resistant
containers." N.F. If chloroform water is ex-
posed to light and air the chloroform may
undergo oxidation to phosgene (COCb) and
hydrochloric acid.

Off. Prep. — Mucilage of Acacia; Mucilage of
Tragacanth, B.P.

CHLOROPHENOTHANE.
U.S.P. (B.P.) (LP.)

Dicophane, l,l,l-Trichloro-2.2-bis(p-chlorophenyl-ethane,
[Chlorophenothanum]

The B.P. recognizes as Dicophane a grade of
the substance of lesser purity, containing not less
than 75.0 per cent of 1 :1 :1 :-trichloro-2 :2-di-
(/>-chlorophenyl) ethane, with varying quantities
of an isomer as well as the carbinol resulting
from the condensation of one molecular propor-
tion of chlorobenzene with chloral hydrate, the
reactants from which dicophane is made by
action of sulfuric acid. The B.P. also requires
not less than 9.5 per cent and not more than

Part I

Chlorophenothane 297

11.5 per cent of hydrolyzable chlorine. The LP.
likewise recognizes a product of lower purity
than that of the U.S. P., under the name Technical
Chlorophenothane, requiring it to contain not less
than 70.0 per cent of the principal constituent.

B.P. Dicophane; Dicophanum. LP., Technical Chloro-
phenothane; Chlorophenothanum Technicum. DDT.
Gesarol. Neocid. GNB.

In 1874 Zeidler, working on his doctorate
thesis at the University of Strasbourg, condensed
chloral with monochlorobenzene to obtain as the
chief constituent l-trichloro-2,2-bis(£-chloro-
phenyl)ethane. It was not until about 1936 or
later than the insecticidal properties of this
reaction product were discovered by the Swiss
chemist Miiller in the course of studies on the
development of new mothproofing agents. Several
publications concerning the effectiveness of the
substance against agricultural insect pests ap-
peared in the foreign literature, and in the sum-
mer of 1942 samples of the material exported to
this country from Switzerland were brought to
the attention of the Bureau of Entomology and
Plant Quarantine of the U. S. Department of
Agriculture. Results of tests by the Bureau against
cabbage aphid, thrips, younger larvae of whiteflies,
active forms of mealybugs, carpet beetles, Ger-
man roaches, and houseflies were highly promis-
ing and in May 1943 a DDT louse powder was
adopted by the armed services.

Several syntheses of DDT have been reported,
all of which, including the commercial process,
involve condensation of 2 moles of monochloro-
benzene with 1 mole of chloral in the presence of
a condensing agent, which is sulfuric acid in the
commercial method. Three grades of DDT have
been recognized: (1) Technical DDT, which con-
tains between 65 and 73 per cent of 1-trichloro-
2,2-bis(/>-chlorophenyl)ethane (commonly re-
ferred to as p,p'-Dt)T) and 19 to 21 per cent
of l-trichloro-2-0-chlorophenyl-2-p-chlorophenyl-
ethane (referred to as o/-DDT), with from
0.007 to 4 per cent of minor constituents; (2)
purified or aerosol DDT, which is a partially
refined grade and contains larger amounts of the
p,p' -DDT than does the technical grade; (3) pure
DDT, essentially the p,p'-DDT, melting between
108.5° and 109°, and used as a standard of com-
parison for special physiological and pharmaco-
logical studies. The o,p'-DT>T is not as effective
an insecticide as is the p,p'-DDT.

Description. — "Chlorophenothane occurs as
colorless or white crystals or as a white to
slightly off-white powder. It is odorless or has
a slight, aromatic odor. It is stable in air and is
but slowly affected by light. Chlorophenothane
is insoluble in water. One Gm. dissolves in 40
to 60 ml. of alcohol and in 5 to 7 ml. of boiling
alcohol: the greater the purity of the Chloro-
phenothane the lower is its solubility in alcohol.
One Gm. dissolves in about 2.5 ml. of acetone,
in 3.5 ml. of chloroform, and in about 4 ml. of
ether. Chlorophenothane congeals at a tempera-
ture not lower than 89°. U.S. P. The B.P. specifies
for dicophane a setting point of not less than 92°;
the LP. congealing temperature is not less
than 89°.

Standards and Tests. — Identification. — (1)
The pale green color of a mixture of chloropheno-
thane, potassium hydroxide and a solution of
xanthydrol in anhydrous pyridine changes to a
reddish orange on boiling under a reflux con-
denser. (2) The solution obtained on refluxing
chlorophenothane with alcoholic potassium hy-
droxide T.S., then adding water and neutralizing
with nitric acid, responds to tests for chloride.
Residue on ignition. — Not over 0.5 per cent.
Water extractives. — Not over 1 per cent. Chlo-
ride.— The limit is 140 parts per million. Sulfate.
— No turbidity is produced in 1 minute on adding
diluted hydrochloric acid and barium chloride
T.S. to a saturated aqueous solution of chloro-
phenothane. Chloral hydrate. — Not over 0.025 per
cent. Organically-combined chlorine. — Not less
than 48 per cent and not more than 51 per cent
of CI, determined as chloride by the Volhard
method following reduction of chlorine with metal-
lic sodium. U.S. P. The B.P. allows up to 1.0 per
cent of sulfated ash.

Assay. — For 1 :1 :l-trichloro-2:2-di-(p-chloro-
phenyl) ethane. — About 10 Gm. of dicophane is
dissolved, with the aid of heat, in 50 ml. of
dehydrated alcohol previously saturated at 17.5°
to 18.5° with pure 1 :1 :l-trichloro-2 :2-di-(£-
chlorophenyl) ethane (hereafter called pure
DDT). The solution is allowed to cool slowly
to permit crystallization of pure DDT, with
equilibrium being finally established at 17.5°
to 18.5°, after which the crystals are filtered
through a tared Gooch crucible, washed with 20
ml. of the saturated solution of pure DDT, and
finally dried to constant weight at 80°. It is
assumed in this assay that the other components
of dicophane dissolve in the saturated alcohol
solution of the pure DDT. B.P., I. P. For hydro-
lyzable chlorine. — About 500 mg. of dicophane
is boiled with 0.5 A7 alcoholic potassium hydrox-
ide, and the chloride thus produced is determined
by the Volhard titrimetric method, using nitro-
benzene to coat the particles of silver chloride
prior to titration with 0.1 A7 ammonium thio-
cyanate. Each ml. of 0.1 N silver nitrate required
represents 3.546 mg. of hydrolyzable chlorine.
B.P.

Cristol and Haller {Chem. Eng. News, 1945,
23, 2070), in a review of the chemistry of DDT,
give many important data concerning the manu-
facture, composition, physical properties, stabil-
ity, and methods of analysis of DDT. They point
out that in the use of DDT as an insecticide the
following points should be kept in mind: (1)
DDT should not be mixed with alkaline diluents,
nor with salts of the type represented by ferric
and aluminum chloride; (2) contamination with
iron, steel, or rust should be minimized; (3)
compatibility with diluent or with other insecti-
cides, fungicides, or fertilizers must be consid-
ered; (4) solvents containing chlorine or nitro
groups should be avoided; (5) high temperatures
and sunlight should be avoided (see also Haller,
Ind. Eng. Chem., 1947, 39, 467).

Action. — In insects, DDT acts as both contact
and stomach poison. Ordinarily it is absorbed
through the feet, antenna and mouth parts of the
insect. Attacking the nervous system, DDT pro-

298 Chlorophenothane

Part I

duces hyperactivity and uncoordinated move-
ments, followed by progressive paralysis and
death. It is slow acting, and may take from ten
minutes to several hours to cause death, depend-
ing on the insect species.

In man and higher animals DDT acts pri-
marily on the central nervous system, as con-
trasted with its apparent peripheral action in
insects. The cerebellum and higher motor cortex
appear to be the chief sites of action; no action
on the spinal cord, myoneural junctions or mus-
cles has been demonstrated. The principal
systemic effects are hyperexcitability, generalized
tremors, spastic or flaccid paralysis and convul-
sions. DDT also sensitizes the myocardium to
the extent that ventricular fibrillation may be
induced. For a detailed discussion of the pharma-
cology of DDT see J.A.M.A., 1951, 145, 728.

Uses. — Chlorophenothane is an insecticide and
larvicide against a wide variety of insect species,
including head and body lice, fleas, ticks, mos-
quitoes, flies, roaches, bedbugs, and beetles; also
against species attacking fruit, shade and forest
trees, ornamental plants, vegetables, and field
and grain crops.

In therapeutics the medicinal grade of chloro-
phenothane, which is official in the U.S. P., is used
as a pediculicide and scauicide, particularly when
prepared in an ointment or emulsion form, espe-
cially the latter. Various formulations for such
application have been proposed and used. Morris
(New Eng. J. Med., 1949, 241, 742) used a
wettable form of DDT, containing 55 per cent
of active ingredient with a suitable surface-active
agent, for treatment of various forms of pedicu-
losis. He directed patients with pediculosis capitis
or pediculosis pubis to apply the DDT prepara-
tion, in the form of a lather, to affected hairy
parts previously wet with water; after 15 minutes
the medication is washed off with water. One
treatment killed all lice, but did not affect nits
or ova that contained unhatched lice which re-
quired repetition of the treatment once weekly
for three weeks. If wettable DDT is not available
a paste prepared from 55 per cent regular DDT
and a synthetic non-soap detergent could be used
similarly. Approximately 15 Gm. of wettable
powder sufficed for one treatment of the average
male scalp, while 60 Gm. was used for the average
female scalp. For treating clothing, in pedicu-
losis corporis, about 120 Gm. of powder to a
tubful of clothing was sufficient; the laundered
clothing was subsequently ironed with a hot iron.
Frazer (Brit. M. J., 1946, 2, 263) treated pa-
tients with the pediculosis capitis with an aqueous
emulsion containing 2 per cent of DDT, 15
per cent of naphtha, and 5 per cent of an emulsi-
fying agent.

For treatment of scabies Goldberg (Arch.
Dermat. Syph., 1947, 56, 871) used successfully
a lotion containing 7 per cent of DDT in equal
parts of xylol, ether and liquid petrolatum, apply-
ing it once daily for 3 days. A 6 per cent oint-
ment was used similarly by Gamier (Presse
med., 1948, 56, 458).

A combination of benzyl benzoate, ethyl amino-
benzoate, and chlorophenothane utilizes the desir-
able effects of all three substances for treatment

of pediculosis and scabies; its formulation and
virtues are discussed in the monograph on Benzyl
Benzoate, under Uses.

Chlorophenothane, variously applied as a 2 to
10 per cent dusting powder both to the skin and
clothing of infested people, has been credited
with aborting typhus epidemics; murine typhus
in the southeastern states of this country has
been effectively controlled through use of a dust
mixture containing 10 per cent of DDT and
90 per cent of pyrophyllite in rat runs, burrows
and harborages (Williams, Mil. Surg., 1949, 104,
163).

DDT is widely used on livestock and other
domesticated animals to control many insect
pests. Dairy cattle or animals to be used as food
should not be treated with DDT, for it has been
demonstrated that the substance may accumulate
in the milk and tissues of treated animals. Food
crops require particularly careful treatment to
keep residues of DDT at harvest time within a
safe minimum.

While use of various preparations of DDT as
an insecticide has been notably successful, in
recent years an alarming degree of resistance
to the chemical has developed in houseflies and
some strains of mosquitoes and body lice.

Technical DDT is formulated in many differ-
ent ways including (1) oil solutions in petroleum
or other suitable organic solvents, (2) emulsion
concentrates which are diluted with water before
use, (3) powders in which the DDT is diluted
with pyrophyllite (aluminum silicate mineral),
various talcs, clays or soapstone, with or without
wetting agents, (4) aerosols of various types, (5)
in paints, polishes, waxes, etc. Concentrations of
DDT in various preparations on the market vary
from 1 to 75 per cent. |Y]

Toxicology. — While DDT has a wide margin
of safety, the substance is by no means harmless
to man and a large number of cases of poisoning,
some terminating fatally, have been attributed to
it or to ingredients combined with it in various
formulations (see J. A.M. A., 1952, 145, 728).

Acute poisoning from absorption of crystalline
DDT, either through the skin or the respiratory
tract, is unlikely and since the fatal oral dose ap-
pears to be of the order of 500 mg. per Kg. of
body weight only large doses could be toxic when
taken orally. In solvents which also dissolve lipids,
however, the tendency for absorption of DDT
through the skin, and the gastrointestinal tract, is
sufficient to be dangerous. Inhalation of DDT
powder is not hazardous, but emulsions and cer-
tain oil solutions of the substance may be ab-
sorbed from the lungs after inhalation. The stand-
ard DDT aerosol, containing 3 per cent of DDT,
will not produce symptoms of poisoning even with
frequent application because appreciable concen-
trations of the insecticide do not stay long in the
atmosphere.

Symptoms of acute poisoning begin with twitch-
ing of the eyelids, which progresses until severe
generalized tremors occur, these being particu-
larly severe in the extremities. The convulsive
seizures are similar to those encountered with
strychnine poisoning. Death usually results from
respiratory failure, though heart failure may in-

Part I

Chloroquine Phosphate 299

tervene. Chronic intoxication may result in loss
of weight, anorexia, mild anemia, muscular weak-
ness and tremors that terminate in convulsive
seizures, coma and death.

Treatment of acute poisoning requires removal
of DDT from the alimentary tract, employing
gastric lavage if the chemical has been ingested,
followed by a saline cathartic. Oil cathartics or
dietary fats should be avoided, since these pro-
mote absorption of DDT. Phenobarbital should
be administered to control tremors or other ner-
vous symptoms. In chronic poisoning symptomatic
therapeutic measures employed for hepatotoxic
substances may be employed if these are indicated
by liver function tests. |v]

Chlorophenothane is applied topically to the
skin in concentrations of 5 to 10 per cent, being
diluted with various inert bases (see above).

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S.P.

CHLOROQUINE PHOSPHATE.

U.S.P. (LP.)

Chloroquinium Diphosphate, 7-Chloro-4-(4-diethylamino-
l-methylbutylamino)quinoline Diphosphate

N+H-CH(CH2)3N(C2H5)2
H

2 H2P04~

"Chloroquine Phosphate, dried at 105° for 2
hours, contains not less than 98 per cent of
C18H26CIN3.2H3PO4." U.S.P. The LP. defines
Chloroquin Diphosphate as 7-chloro-4- (^-diethyl-
amino- 1 -methylbutylamino ) quinoline diphosphate,
occurring in two forms differentiated by their
melting ranges; not less than 11.80 per cent and
not more than 12.25 per cent of P, and not less
than 60.76 per cent and not more than 63.25 per
cent of C18H26N3CI is required.

LP., Chloroquin Diphosphate; Chloroquini Diphosphas.
Aralen Diphosphate (Winthrop-Stcarns). SN 7618.

Chloroquine phosphate is an antimalarial of the
4-aminoquinoline type. The base may be pre-
pared in an overall yield of 20 per cent from
w-chloroaniline and diethyl oxalacetate (see Sur-
rey and Hammer, J.A.C.S., 1946, 68, 113). An
alternate synthesis utilizing ra-chloroaniline and
diethyl(ethoxymethylene)malonate, and provid-
ing an overall yield of more than 40 per cent, was
developed in several universities under contract
by the Office of Scientific Research and Develop-
ment to study and develop synthetic antimalarials.
For further information concerning manufacture
of chloroquine see Ind. Eng. Chem., 1949, 41, 654.

Description. — "Chloroquine Phosphate occurs
as a white, crystalline powder. It is odorless, has
a bitter taste, and slowly discolors on exposure to
light. Its solutions are acid to litmus, having a pH
of about 4.5. Chloroquine Phosphate is freely solu-
ble in water. It is almost insoluble in alcohol, in
chloroform, and in ether. Chloroquine Phosphate
exists in two forms ; the usual form melts between

193° and 195°; the other form melts between
215° and 218°." U.S.P.

Standards and Tests. — Identification. — (1)
A yellow precipitate is produced on adding tri-
nitrophenol T.S. to an aqueous solution of chloro-
quine phosphate. The precipitate of chloroquine
picrate, washed with water and dried over sulfuric
acid, melts between 205° and 210°. (2) A yellow
precipitate forms when silver nitrate T.S. is added
to a solution of chloroquine phosphate neutralized
with ammonia T.S. Loss on drying. — Not over 2
per cent, when dried at 105° for 2 hours. U.S.P.

Assay. — From about 300 mg. of chloroquine
phosphate, previously dried at 105° for 2 hours,
chloroquine base is liberated with ammonia and
extracted with several portions of ether. After
washing the ether solution with water, the ether
is evaporated and the residue of chloroquine is
dried at 105° for 1 hour and weighed. The weight
of chloroquine multiplied by 1.613 represents the
equivalent of C18H26CIN3.2H3PO4. U.S.P. The
LP. assays for chloroquine by this same pro-
cedure; the assay for phosphorus involves pre-
cipitation of bismuth phosphate, which is deter-
mined gravimetrically.

Uses. — Currently chloroquine is the most
effective, least toxic and most convenient drug for
the suppressive treatment of malaria during ex-
posure to infestation and for hepatic amebiasis.
Malaria is probably the most prevalent infectious
disease in the world and one of the most impor-
tant causes of death and disability. Management
in humans concerns two types of situations: (1)
inhabitants of a malarious area repeatedly exposed
to the same strain and type of parasite, and
(2) immigrants without previous exposure who
will be exposed for a few months or years. In the
former the object is to prevent death, serious dis-
ability and impaired growth and development
while the individual is acquiring some immunity.
For the latter group, the aim is to prevent or
treat, as the case may be, the acute malarial
paroxysm and eventually to eliminate the exo-
erythrocytic stage of the parasite. There are three
common types of malarial parasite in the human
and one infrequent one (P. ovale) and strains of
variable susceptibility to the available drugs in
each of the four types of parasite. Theoretically,
a drug which would destroy the gametocytes
(sexual forms in the blood) in man would pre-
vent involvement of the mosquito host and vector
but so far no clinically satisfactory drug is avail-
able for this purpose. Where weather, geographic
conditions and economics are favorable, consider-
able success in eliminating malaria by destroying
all the mosquitoes in the area has been attained
(see under Chlorophenothane). In the absence
of a true causal preventive drug for malaria, the
available ones may be considered as: (1) sup-
pressive or (2) curative. The former eliminate
the asexual trophozoite stage in the red blood cells
of man which cause the symptoms; the patient
has the infection but is asymptomatic as long as
the drug is used. Such a drug, being used for long
periods of time, must be non-toxic for most
people. Among these are quinine and related
cinchona principles, quinacrine, chloroquine and
chloroguanide. The curative drugs for use when

300 Chloroquine Phosphate

Part I

exposure has ceased eliminate the exo-erythro-
cytic (tissue) stage of the parasite and are neces-
sary to prevent symptoms when the suppressive
drug is discontinued in the immigrant group of
humans. Among the drugs used for this purpose
are pamaquine, pentaquine and primaquine of
which only the last-named appears to be suffi-
ciently non-toxic in effective doses for general
use.

Action. — Chloroquine is absorbed rather com-
pletely and rapidly from the gastrointestinal tract.
As compared with quinacrine the same dose pro-
duces a blood plasma concentration ten to twenty
times greater; for example, a dose of 0.3 Gm.
results in 176 micrograms per liter in blood plasma
(Berliner et al., J. Clin. Invest., 1948, 27, Suppl.,
98). Very little drug can be recovered from the
feces. The concentration in the erythrocytes is
10 to 25 times that in plasma, in which it is
largely bound to non-diffusible components. In-
creasing concentrations are found in red blood
cells, brain, muscle, heart, kidney, lung and liver.
In the liver the concentration is about 300 times
that in the plasma, which is less than is found
with quinacrine, but it is more persistent. Five
days after the last dose of chloroquine the blood
plasma concentration remains at 53 per cent of
the level present 3 hours after the last dose. This
was the most persistent of the several 4-amino-
quinoline compounds studied by Berliner's group.
Only 10 to 25 per cent of the dose is excreted in
the urine. This rate of excretion is increased by
acidosis and decreased by alkalosis (Jailer et al.,
J. Pharmacol, 1948, 92, 345). Degradation prod-
ucts have been studied by Craig et al. {Anal.
Chem:, 1948, 20, 134). The persistence of this
compound in the body suggests its use at intervals
greater than the daily or twice weekly interval
required with quinacrine for the suppression of
malaria.

For parenteral administration, the hydrochlo-
ride has been given intramuscularly, dissolved in
distilled water, in a dose equivalent to 0.2 Gm.
of the base, once or twice daily with an interval
of at least 4 hours between doses (Culwell et al.,
J. Nat. Malaria Soc, 1948. 7, 311); therapeutic
concentrations in the blood were observed within
1 hour of the injection, and no local or systemic
reactions were produced in 16 cases thus treated.
Spicknall et al. (Am. J. Med. Sc, 1949. 218, 374)
confirmed the safety and efficacy of this pro-
cedure in the treatment of malaria. Intravenous
administration was performed by Scott (Am. J.
Trop. Med., 1950. 30, 503). With doses up to
0.4 Gm. of the base in the form of the hydrochlo-
ride salt dissolved in 500 ml. of physiological salt
solution and injected slowly over a period of
1 hour, there were no untoward effects. More
rapid injection of more concentrated solutions
caused hypotension, dizziness, drowsiness, nausea
and blurred vision.

Antimalarial Therapy. — Chloroquine has
been found to be an effective suppressive agent
against all types of malarial parasites in all parts
of the world bv many observers. It was adopted
by the U. S. Army (Bull. U. S. Army M. Dept.,
1947, 7, 835) for the treatment and suppression

of P. vivax, P. malariae and P. falciparum. In
the treatment of vivax malaria Most et al.
(J.A.M.A., 1946, 131, 963) reported relief of
fever within 24 hours in 98 per cent of patients,
and disappearance of parasites from the blood
films at 48 hours in 86 per cent and at 72 hours
in 96 per cent of cases. A blood plasma concen-
tration of 10 micrograms per liter was effective.
On this basis it is about 3 times as active in
malaria as is quinacrine. It is effective for
P. malariae and Loeb et al. (J.A.M.A., 1946, 130,
1069) reported good results with P. falciparum.
Lucena (Rev. brasil. Med., 1948, 5, 269) re-
ported the order of increasing susceptibility to be :
P. falciparum, P. malariae, P. vivax. Its efficacy
in the relapsing P. vivax malaria in Korea was
reported by Aquilena and Paparella (J. A.M. A.,
1952, 149, 834). As with quinacrine it is able to
cure P. falciparum with its short exo-erythrocytic
stage but not P. vivax, the tissue phase of which
persists for many months or even years (Berberian
and Dennis, Am. J. Trop. Med., 1948, 28, 755).
In the treatment of the malarial paroxysm, it is
reported to be more rapidly effective than chloro-
guanide in P. falciparum (Canet, Bull. Soc. Path,
exot., 1948, 41, 661, 690; Schneider and Mechali,
ibid., 274) and equally effective in P. vivax (Loeb
et al., loc. cit.; Pullman et al., J. Clin. Invest.,
1948. 27, Suppl., 46); Smith et al., Acta med.
Philipp., 1948, 5, No. 2, 1). Relapses are slower
in appearing after treatment with chloroquine,
partly at least because of the persistence of this
drug in the tissues of the body, but this delay is
seldom of practical importance. In a continually
exposed population, Berberian and Dennis (Am.
J. Trop. Med., 1949, 29, 463) reported a decrease
in splenomegaly when chloroquine was used as a
suppressive. As a suppressive drug, it has the
great advantage over others of being effective in
a single dose once a week. Packer (J. Nat. Malaria
Soc, 1947. 6, 147) found that 0.25 Gm. weekly
was insufficient for P. falciparum. Wallace (/.
Trap.. Med. Hyg., 1949, 52, 93) reported that
0.3 Gm. once or twice weekly was effective
against P. vivax and Chaudhuri (Brit. M. I., 1952,
1, 568) found 0.4 Gm. weekly to be superior to
0.3 Gm. of chloroguanide. Nelson and Conlin
(Pediatrics. 1950, 5, 224) advised a therapeutic
dose for infants of 0.375 Gm. initially followed
at 8. 24 and 48 hours with 0.25 Gm.; for children
over 8 years of age. they used 1 Gm. initially
followed at 8. 24 and 48 hours by 0.5 Gm. Poin-
dexter (I. Pediat., 1951. 38, 169) used 0.3 Gm.
weekly successfully as a suppressive in children
2 to 18 years old but reported some side effects
in 46 per cent of cases.

For hepatic amebiasis, chloroquine is preferred
to emetine. Conan (Am. J. Med., 1949. 6, 309)
concluded from the treatment of 7 cases that it
was as effective as emetine and less toxic. A dose
of 0.25 Gm. was given four times daily for 2 days
then twice daily for 14 to 21 days. Alone it is
inadequate for intestinal amebiasis. It was effec-
tive in the pulmonary complications of amebic
abscess of the liver (Conan, et al., Trans. Roy.
Soc. Trop. Med. Hyg., 1950. 43, 659). Efficacy
in hepatic amebiasis has been confirmed by Harris

Part I

Chlorothen Citrate

301

and Wise (Am. Pract. & Dig. Treat., 1952, 3,
128), by Sodeman et al. (Ann. Int. Med., 1951,
35, 331), and others.

In leishmaniasis. Puello Garcia (Rev. facultad.
med., 1949, 17, 338) reported cure with cicatriza-
tion in 10 of 21 cases and improvement in 9 cases.
on a dosage of 0.75 Gm. twice the first day and
0.5 Gm. twice the second and third days and then
0.5 Gm. every 5th to 7th day until healed. lYl

Toxicology. — Only minor untoward effects
during therapeutic or suppressive use of chloro-
quine have been reported, these including pru-
ritus, anorexia, dizziness, diarrhea (Bull. U. S.
Army M. Dept., 1947, 7, 834). Alving et al. (J.
Clin. Invest., 1948, 27, Suppl., 60) studied the
effect of larger doses than are needed in therapeu-
tics in volunteers, administering 0.3 Gm. (as base)
daily for 77 days and then 0.5 Gm. weekly for
the remainder of a year. On this large dose visual
disturbances, headache and changes in the T wave
of the electrocardiogram were observed, these
disappearing when the drug was discontinued.
Berliner et al. (ibid., 98) also reported blurred
vision in volunteers on large doses. Craige et al.
(ibid., 56) described 2 instances of lichen planus
at the 8th and 12th month when using 0.5 Gm.
weekly. This lesion has not proven to be a prob-
lem in widespread use, as was the case with quina-
crine (q.v.). In a comparative study of several
antimalarial drugs, the group receiving chloro-
quine made no more complaints than those re-
ceiving a placebo. Some reports have mentioned
nausea at the beginning of use, and erythema of
the palms after prolonged use has been reported.
Chinn et al. (J. Aviation Med., 1949, 20, 161)
found that it had no deleterious effect on the
tolerance of aviators to hypoxia. Unlike quina-
crine, it does not stain the skin.

Dose. — The dose in the treatment of malaria
is 1 Gm. (approximately 15 grains) initially fol-
lowed by 0.5 Gm. at 6, 24 and 48 hours; for the
suppression of malaria it is 0.5 Gm. weekly on
the same day of the week. The dose for amebic
hepatitis is 0.5 Gm. three times daily for 2 weeks,
then 0.75 Gm. twice weekly for several months.
If vomiting prevents oral administration, the
equivalent of 0.2 Gm. of chloroquine base in the
form of the hydrochloride salt dissolved in 5 ml.
of distilled water is given intramuscularly once or
at the most twice, with an interval of at least 4
hours between doses; the usual dosage is then
continued by mouth.

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S.P.

CHLOROQUINE PHOSPHATE
TABLETS. U.S.P. (LP.)

"Chloroquine Phosphate Tablets contain not
less than 93 per cent and not more than 107 per
cent of the labeled amount of C18H26CIN3.2H3-
PO4." U.S.P. The LP. limits are the same.

I. P. Tablets of Chloroquin Diphosphate; Compressi
Chloroquini Diphosphatis.

Usual Size. — 250 mg. (approximately 4
grains).

CHLOROTHEN CITRATE. U.S.P.

Chloromethapyrilene Citrate, Chlorothenium Citrate,

N,N-Dimethyl-N'-(2-pyridyl)-N'-(5-chloro-2-thenyl)-

ethylenediamine Citrate

CI^/S\^CH2— NCH2CH2N (CH3)2

ion

H2C6HS07

"Chlorothen Citrate, dried in a vacuum desic-
cator over phosphorus pentoxide for 5 hours,
contains not less than 98 per cent of C14H18CIN3-
S.CeHsOi." U.S.P.

Tagathen Citrate (Lederle).

The base of this antihistaminic compound may
be synthesized by condensation of a-chloropyri-
dine with 3-dimethylaminoethylamine, followed
by treatment with 5-chloro-2-thenyl chloride; de-
tails of the synthesis have been published by
Clapp et al., J.A.C.S., 1947, 69, 1549. The base
is a chlorine derivative of methapyrilene, the
hydrochloride of which is official.

Description. — "Chlorothen Citrate occurs as
a white, crystalline powder, usually having a faint
odor. Its solutions are acid to litmus. One Gm. of
Chlorothen Citrate dissolves in about 35 ml. of
water. It is slightly soluble in alcohol, and prac-
tically insoluble in chloroform, in ether and in
benzene. Chlorothen Citrate melts between 112°
and 116°. On further heating it gradually solidifies
and remelts between 125° and 140° with decom-
position." U.S.P.

Standards and Tests. — Identification. — (1)
A dark red color results when 2 5 mg. of chlorothen
citrate is dissolved in 5 ml. of sulfuric acid; on
dilution with 20 ml. of water the color disappears
and a brown precipitate forms. (2) A 1 in 100,000
solution exhibits an ultraviolet absorbance maxi-
mum at 240 mn ± 1 m^i, and a minimum at 277
ran ± 2 m\i; the absorptivity (1%, 1 cm.) at
240 mn is between 390 and 410. (3) The salt re-
sponds to tests for citrate after separating chloro-
then base. Loss on drying. — Not over 0.5 per cent,
when dried in a vacuum desiccator over phos-
phorus pentoxide for 5 hours. Residue on ignition.
■ — Not over 0.1 per cent. U.S.P.

Assay. — About 600 mg. of chlorothen citrate,
previously dried in a vacuum desiccator over
phosphorus pentoxide for 5 hours, is assayed by
the nonaqueous titration method described under
Antazoline Hydrochloride, omitting the treatment
with mercuric acetate. Chlorothen citrate reacts,
in the acetic acid medium, as a diacidic base. Each
ml. of 0.1 N perchloric acid represents 24.40 mg.
of C^HisClNsS.CeHsOi. U.S.P.

Uses. — Pharmacological studies of this com-
pound, as well as of its bromine analog Bromo-
then (Lederle), by Litchfield et al. (Bull. Johns
Hopkins Hospital, 1947, 81, 55), have demon-
strated the compounds to have greater antihis-
taminic activity and less toxicity than tripelenna-
mine, although chloromethapyrilene ranked ninth
in order of effectiveness of 13 antihistaminic
agents tested by Sternberg et al. (J. A.M. A., 1950,

302

Chlorothen Citrate

Part I

142, 969) for ability to raise the histamine wheal-
ing threshold in man. Clinical trials bv Feinberg
(Quart. Bull. Northwest, f. Med. Sch'. 1948. 22,
27) indicated it to be effective as an antihis-
tamine; it appeared to have slightly more seda-
tive effect than has tripelennamine. Taub et al.
(Am. Pract., 1949. 3, 5S6) confirmed Feinberg's
report. In the management of parkinsonism, no
benefit with doses up to 100 mg. four times daily
was observed bv Effron (GP, 1951. 4, 61).
Hoagland et al. '{J.A.M.A.. 1951, 146, 612) re-
ported obtaining symptomatic relief in Rhus der-
matitis by the use of a solution (Rhulitol, Lederle)
containing 2 per cent of chlorthen citrate and 5
per cent of tannic acid, with chlorobutanol. phenol,
camphor, ammonium alum, glycerin and 37 per
cent of isopropyl alcohol.

Caubren Compound OYhittier) is a tablet con-
taining 25 mg. of chlorothen citrate. 320 mg. of
acetophenetidin. and 32 mg. of caffeine ; it is used
in the treatment of the "common cold" (see
Phillips and Fishbein. Ind. Med.. 1950. 19, 201).
See also the general discussion of Antiliistaminic
Drugs in Part II.

The dose of chlorothen citrate is 25 mg. (ap-
proximately }i grain) one to four times daily by
mouth, with a range of 25 to 50 mg. The maxi-
mum safe dose is 50 mg.. and the total dose in
24 hours should not exceed 200 mg.

Storage. — Preserve 'in tight, light-resistant
containers." U.S.P.

CHLOROTHEN CITRATE TABLETS.
U.S.P.

"Chlorothen Citrate Tablets contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of C^HisOXsS.CfiH^Oi."
U.S.P.

Assay. — The spectrophotometry procedure de-
scribed under Antazoline Hydrochloride Tablets
is employed, the appropriate constants for chloro-
then citrate being substituted.

Usual Size. — 25 mg.

CHLOROTHYMOL. X.F.

Monochlorothymol. [Chlorothymol]
CH3

CH3CHCH3
Chlorthymol : Monochlorthymol.

Chlorothymol is 6-chloro-4-isopropyl-l-methyl-
3-phenol. It may be obtained by the action of
sulfuryl chloride on a solution of thymol in carbon
tetrachloride.

Description. — "Chlorothymol occurs as white
crystals, or as a crystalline, granular powder,
possessing a characteristic odor, and an aromatic,
very pungent taste. It usually becomes discolored
with age, acquiring a yellowish or brownish color,
and is affected by light. One Gm. of Chlorothymol
dissolves in about 0.5 ml. of alcohol, in about
2 ml. of benzene, in about 2 ml. of chloroform,
in about 1.5 ml. of ether, and in about 10 ml. of

petroleum benzin. One hundred mg. of Chloro-
thymol dissolves completely in 100 ml. of a mix-
ture of 1 volume of alcohol and 3 volumes of
water. It is soluble in dilute aqueous solutions of
sodium hydroxide, but is almost insoluble in
water. Chlorothvmol melts between 59= and 61°."
X.F.

Standards and Tests. — Identification. — (1)
A pink color, gradually becoming red or brown-
ish red, is produced on adding 0.5 ml. of chloro-
form to a solution of 1 Gm. of chlorothymol in
5 ml. of a 1 in 10 solution of sodium hydroxide
which has been boiled for 1 minute, then cooled
to about 50°. (2) A white precipitate, soluble
in ammonia T.S.. is produced when the residue
from the fusion of 200 mg. of chlorothymol with
anhydrous sodium carbonate is extracted with
water, the solution acidulated with nitric acid
and filtered, and silver nitrate T.S. added. Re-
action.— 500 mg. of chlorothymol agitated with
10 ml. of hot distilled water leaves the liquid
neutral to litmus paper. Residue on ignition. —
Not over 0.05 per cent. N.F.

Uses. — According to Klarmann et al. (J. Bact..
192 7. 17, 423) chlorothymol is a powerful germi-
cide: its phenol coefficient is. in the absence of
organic matter, 61 against the typhoid bacillus,
and 15S against the staphylococcus; in the pres-
ence of organic matter the coefficients are. re-
spectively. 22 and 57. It is an ingredient of the
X.F. Antiseptic Solution. It is so intensely irri-
tant, however, that by itself it is all but impossi-
ble to use it in the mouth in sufficient concentra-
tion to be of any practical value. Chlorothymol
is also fungicidal and may be useful in parasitic
skin diseases.

Storage. — Preserve "in well-closed, light-re-
sistant containers, and avoid continuous excessive
heat." X.F.

Off. Prep. — X.F. Antiseptic Solution. X.F.

CHLOROXYLENOL. B.P.

Para chloromefaxylenol

C6H2(CH3)2(C1)(0H) (1.3,2,5)

The B.P. defines Chloroxylenol as 4-chloro-
3:5-xylenol. stating it may be prepared by the
interaction of xylenol and sulfuryl chloride.

Description and Tests. — Chloroxylenol con-
sists of white to creamy-white crystals or a crys-
talline powder with a characteristic odor. It is
soluble in about 3000 parts of water, more soluble
in hot water; also soluble in alcohol, ether, ben-
zene, terpenes. fixed oils and solutions of alkali
hydroxides. It is volatile in steam and melts be-
tween 114c and 115.5°.

The addition of 1 drop of ferric chloride solu-
tion to a saturated solution causes no blue color
(distinction from chlorocresol >. The product of
its ignition with 10 parts of anhydrous sodium
carbonate, if dissolved in water and acidified with
nitric acid, yields a white precipitate on the addi-
tion of silver nitrate solution.

Uses. — There have been in common use in
Great Britain for the past decade several pro-
prietary antiseptics — of which dettol is probably
the most popular — whose action depends largely
on the presence of a chlorinated xylenol.

Part I

Chlorpheniramine Maleate 303

While chloroxylenol solutions are acknowledged
not to be as valuable general antiseptics as are
cresol solutions, the advantage claimed for the
former over the latter is the lack of irritant prop-
erties. Colebrook (/. Obst. Gyn. Br. Emp., 1933,
40, 966) rubbed undiluted dettol into the skin of
several volunteers daily, for two weeks, with no
sign of irritating effect.

Chloroxylenol is effective against streptococci,
considerably less so against staphylococci, and is
almost devoid of activity against gram-negative
organisms, including Pseudomonas pyocyanea and
Bacillus proteus. Lockemann and Kunzman
(Angewandte Chem., 1933, 46, 296) found that
there is considerable difference in the efficiency
of the various isomers, depending chiefly on the
position of the methyl radicals. As chloroxylenol
is only very slightly soluble in water, it must be
emulsified when used in an aqueous vehicle; the
B.P. Solution of Chloroxylenol provides a prep-
aration that forms an emulsion when mixed with
water. Rapps (/. Chem. Ind., 1933, 52, 175T)
reported that, when solubilized by a castor oil
soap, chloroxylenol has a phenol coefficient of 62,
but with sodium hydroxide its coefficient was
only 5.7.

Although chloroxylenol has been used chiefly as
an external antiseptic, Zondek (/. Urol., 1942, 48,
747) recommended it also as a urinary antiseptic.
He stated that it can be absorbed through the
skin and suggested daily inunction with a 33 per
cent ointment accompanied by intramuscular in-
jections of a 10 per cent solution in olive oil (the
latter are quite painful and there should be added
an oil-soluble local anesthetic such as benzocaine)
in the treatment of pyelitis.

SOLUTION OF CHLOROXYLENOL.
B.P.

Roxenol, Liquor Chloroxylenolis

This solution contains 5 per cent w/v of chlor-
oxylenol and 10 per cent w/v of terpineol, along
with a soap prepared from castor oil and oleic
acid by saponification with potassium hydroxide,
in a 20 per cent solution of alcohol in water.

The solution is a yellow to amber-colored
liquid; when diluted with 19 volumes of water it
gives a white emulsion from which oily globules
or crystals do not separate after standing for
24 hours.

For application to wounds and abrasions the
solution is diluted 1 to 64 with water; as a
vaginal douche it is employed in 1 to 32 dilution;
as a gargle it is diluted with from 125 to 400
volumes of water.

CHLORPHENIRAMINE MALEATE.
U.S.P.

2-[p-Chloro-a-(2-dimethylaminoethyl)benzyl]pyridine

Maleate, Chlorpheniraminium Maleate, Chlorpro-

phenpyridamine Maleate

xs— CHCH2CH2N (CH3)2

HC4H20<

"Chlorpheniramine Maleate, dried at 105° for

3 hours, contains not less than 98 per cent of
C16H19CIN2.C4H4O4." U.S.P.

Chlor-Trimeton Maleate (Scheriny) .

Chlorpheniramine is the />-chloro derivative of
pheniramine, which is official in N.F. as Phenir-
amine Maleate and under which title the chemis-
try of chlorpheniramine is also discussed.

Description. — "Chlorpheniramine Maleate oc-
curs as a white, odorless, crystalline powder. Its
solutions are acid to litmus, having a pH between

4 and 5. One Gm. of Chlorpheniramine Maleate
dissolves in about 4 ml. of water, in 10 ml. of
alcohol, and in about 10 ml. of chloroform. It is
slightly soluble in ether and in benzene. Chlor-
pheniramine Maleate melts between 130° and
135°." U.S.P.

Standards and Tests. — Identification. — (1)
A 1 in 25,000 solution exhibits an ultraviolet ab-
sorbance maximum at 261 m\x ± 1 mix, and a
minimum at 244 m^i ± 1 mu-; the absorptivity
(1%, 1 cm.) at 261 m\i is between 140 and 150.
(2) Maleic acid separated from the salt melts
between 128° and 133°. Loss on drying. — Not
over 0.5 per cent, when dried at 105° for 3 hours.
Residue on ignition. — Not over 0.15 per cent.
Other antihistamine substances. — A solution of
25 mg. of chlorpheniramine maleate in 5 ml. of
sulfuric acid is colorless. U.S.P.

Assay. — About 500 mg. of chlorpheniramine
maleate, previously dried at 105° for 3 hours, is
assayed by the nonaqueous titration method de-
scribed under Antazoline Hydrochloride, omitting
the treatment with mercuric acetate. Chlor-
pheniramine maleate reacts, in the acetic acid
medium, as a diacidic base. Each ml. of 0.1 N
perchloric acid represents 19.54 mg. of C16H19-
CIN2.C4H4O4. U.S.P.

Uses. — This is probably the most active anti-
histaminic drug which has been developed. Oral
administration of as little as 4 mg. is thera-
peutically effective. By animal assay, it is twenty
times as active as prophenpyridamine (Tislow
et al, Fed. Proc, 1949, 8, 338). Chronic toxicity
studies in animals at a daily dose of 25 mg. per
kilogram of body weight showed no pathological
changes. The therapeutic index (LD50/ED50)
is 1500 (Margolin and Tislow, Ann. Allergy, 1950,
8, 515). In humans the wheal produced by the
intracutaneous injection of 3 micrograms of his-
tamine was reduced by one-third by the oral
administration of 8 mg.; a similar inhibition was
produced by 16 mg. of promethazine, 38 mg. of
chlorcyclizine, 105 mg. of pyrilamine, 230 mg. of
antazoline, or 330 mg. of thonzylamine (Bain,
Analyst, 1951, 76, 573). Monash (/. Invest.
Dermat., 1950, 15, 1) reported that tolerance
develops on continued use of chlorpheniramine
and other antihistaminic agents as measured by
the inhibition of the histamine wheal in the skin.
Studies of the effect on the mammalian capillary
bed by Haley and Andem (/. Pharmacol., 1950,
100, 393) showed that it was a potent vasocon-
strictor; leukocytes tend to stick to the walls of
the blood vessels in the slow-moving current of
blood. Boyd {Can. Med. Assoc. J., 1952, 67, 289)
found no increase in the secretion of fluid by the

304 Chlorpheniramine Maleate

Part I

mucous membrane of the respiratory tract of his
animals after chlorpheniramine; he concluded that
it had no expectorant action and that it was not
indicated in the treatment of cough except on an
allergic basis. Seneca (Science, 1952, 115, 48)
reported that it had fungistatic action.

Clinical experience has confirmed the phar-
macological promise of activity for this antihis-
taminic drug. In hay fever, satisfactory sympto-
matic relief has been reported for about 85 per
cent of cases (Vickers and Barrett, /. Maine
M. A., 1949, 40, 356; Eisenstadt, J. -Lancet, 1950,
70, 26; Reicher and Schwartz, N. Y. State J.
Med., 1950, 50, 1383; Silbert, New Eng. J. Med.,

1950, 242, 931; Allison and Robinson, /. South
Carolina M. A., 1949, 45, 344). Usually improve-
ment appears within 10 to 30 minutes of inges-
tion. In acute or chronic urticaria or angioneu-
rotic edema, similar good results were reported.
Even in bronchial asthma, Silbert (loc. cit.) found
oral administration useful and Gaillard (Ann.
Allergy, 1950, 8,' 318) reported relief in 35 per
cent and improvement in 41 per cent of his cases.
A prolonged-action tablet containing 4 mg. in an
outside layer and 4 mg. in an enteric-coated core
was effective when given every 12 hours in 50 per
cent of cases of pollen asthma and 75 per cent of
cases of hay fever (Wittich, Ann. Allergy, 1951,
9, 491). In the management of colds, Coricidin
(Schering) tablets, containing 2 mg. chlorphenira-
mine, 230 mg. acetylsalicylic acid. 150 mg. aceto-
phenetidin. and 30 mg. caffeine, were tested by
Kovaleff (N. Y. State J. Med., 1950. 50, 2955);
results were better than with a placebo or with
the "APC" combination without the antihistamine.
Some cases of atopic dermatitis, allergic eczema
and pruritus vulvae were improved by oral ad-
ministration. Adams and Sacca (Ann. Allergy,

1951, 9, 224) reported a gratifying recovery in a
case of allergic purpura.

In the prophvlaxis of air sickness, Chinn et al.
(Texas Rep. Biol. Med., 1950, 8, 320) found
chlorpheniramine ineffective. In cases of refrac-
tory peptic ulcer a dose of 8 mg. four times daily,
after meals and at bed-time, with an unrestricted
diet, relieved symptoms in about 48 hours, and
resulted in a decrease in hydrochloric acid in the
stomach both in the fasting state and after test
meals and the injection of histamine subcu-
taneously (Isaacson et al., Med. Ann. District
Columbia, 1951, 20, 63); symptoms recurred
when the antihistamine was discontinued. Ziperyn
(Ann. West. Med. Surg., 1950, 4, 612) treated a
few cases effectively using 2 mg. every 4 hours.

Injection. — In severe cases of asthma, Jenkins
(Ann. Allergy, 1953, 11, 96) relieved the upper
respiratory symptoms and the cough quickly with
5 mg. in cases of seasonal asthma and 20 mg. in
instances of perennial asthma. A dose of 30 mg.
intramuscularly aggravated the dyspnea. In urti-
caria, a dose of 5 mg. intramuscularly once or
twice daily gave good relief. Bernstein and Klotz
(ibid., 1952, 10, 479) mixed the chlorpheniramine
directly in the syringe with calcium gluconate and
felt that the therapeutic effect was potentiated.
In severe cases of poison ivy dermatitis, Jenkins
gave 10 mg. subcutaneously daily for 3 days with
satisfactory control of symptoms and reported

that intravenous injection of 5 mg. slowly gave
immediate relief. In allergic eczema, intravenous
administration gave immediate relief and cessa-
tion of "weeping." The addition of 10 mg. to 500
ml. of citrated blood for transfusion prevented
transfusion reactions (Frankel and Weidner, ibid.,
1953, 11, 204); blood containing chlorpheniramine
remains satisfactory for use in the blood bank for
3 weeks. In combination with aqueous penicillin
in the same syringe, it has prevented allergic
reactions in sensitive cases (Simon, ibid., 1952,
10, 187; Maslansky and Sanger, Antibiot. Chemo-
ther., 1952, 2, 385) and in large groups of indi-
viduals among whom some susceptible individuals
would have been expected. A dose of 10 to 20 mg.
may be used with doses of penicillin of 300,000
to 600,000 units, according to the degree of sensi-
tivity of the patient at the time. It has been em-
ployed to minimize untoward effects of opiates,
meperidine or tetracaine (Bernstein and Klotz,
loc. cit.) and many other injections, such as
tetanus antitoxin or toxoid, contrast media for
roentgen examinations, insulin, liver extract and
vitamin B-complex injections. Chlorpheniramine
maleate injections are available in concentrations
of 2, 10, and 100 mg. per ml.

Allergenic Extracts. — Since antihistaminic drugs
inhibit the undesirable physiological effects of any
histamine released in an antigen-antibody reac-
tion, but do not alter the antigen-antibody mech-
anism in any known manner, an obvious thera-
peutic application is in the prevention of untoward
responses during the hyposensitization program
with pollen and other allergens. Jenkins (loc. cit.),
Bernstein and Klotz (loc. cit.), and others have
mixed 5 to 20 mg. of chlorpheniramine with the
specific allergenic extract in the same syringe in
over 1000 injections in several hundred patients
with allergic rhinitis or dermatitis with benefit.
Higher concentrations of the allergen can be in-
jected, and the dose increased more rapidly, with
a resulting quicker accomplishment of adequate
hyposensitization of the patient to the environ-
mental substance to which he is hypersensitive.
Chlorpheniramine lends itself to this use better
than any other antihistaminic drug because the
small effective dose can be contained in a small
enough volume of solution to be practical for
subcutaneous injection, e.g., 5 mg. in 0.1 ml. The
solution must be protected from light during
storage.

A nasal solution of 0.25 per cent strength was
used by Schaffer and Seidman (Ann. Allergy, 1952,
10, 194); in 48 of 61 cases of allergic rhinitis, it
produced adequate shrinkage of the swollen
mucosa without subsequent rebound swelling.

Toxicology. — The drug is well tolerated. On
oral administration of doses effective in allergic
disorders, the incidence of side effects in several
reports on a total of 412 cases was 3.1 per cent.
From parenteral use, an incidence of 4 per cent
is reported. Symptoms include drowsiness, jitteri-
ness and dry mouth.

Dose. — The usual dose is 4 mg. (about ^is
grain) up to 4 times daily by mouth, with a range
of 2 to 8 mg. The maximum safe dose is 8 mg. and
the total dose in 24 hours should not exceed 32
mg. For parenteral use, the average dose is 2 to

Part I

Chlortetracycline Hydrochloride 305

4 mg. (approximately Ho to Hs grain) for intra-
muscular, subcutaneous or intravenous injection.
After tolerance to a dose of 2 mg. has been demon-
onstrated, up to 10 mg. may be used if indicated.
Storage. — Preserve "in tight, light-resistant
containers." U.S. P.

CHLORPHENIRAMINE MALEATE
TABLETS. U.S.P.

"Chlorpheniramine Maleate Tablets contain not
less than 93 per cent and not more than 107 per
cent of the labeled amount of Ci«Hii)ClN2.C4-
H4O4." U.S.P.

Assay. — The spectrophotometric procedure de-
scribed under Antazoline Hydrochloride Tablets
is employed, the appropriate constants for chlor-
pheniramine maleate being substituted.

Usual Sizes. — 4 and 8 mg.

CHLORTETRACYCLINE HYDRO-
CHLORIDE. U.S.P. (BR, LP.)

Aureomycin Hydrochloride (U.S.P. XIV)

N(CH3)2

CONH,

"Chlortetracycline Hydrochloride contains not
less than 90 per cent of C22H23CIN2O8.HCI.
Chlortetracycline Hydrochloride conforms to the
regulations of the federal Food and Drug Admin-
istration concerning certification of antibiotic
drugs. Chlortetracycline Hydrochloride not in-
tended for parenteral use is exempt from the re-
quirements of the tests for Pyrogen and Sterility."
U.S.P.

The B.P. defines Aureomycin Hydrochloride
as a mixture of the hydrochlorides of the several
antimicrobial substances produced by the growth
of Streptomyces aureofaciens, or the hydrochlo-
ride of any of the same substances produced by
any other means. It contains not less than 900
Units per mg. The LP. definition and rubric are
substantially identical with those of the B.P.

B.P., J. P. Aureomycin Hydrochloride. Aureomycin.

History. — Chlortetracycline hydrochloride is
a broad-spectrum antibiotic separated from the
metabolic products of the actinomycete Strepto-
myes aureofaciens. Isolation of the actinomycete
and discovery of the antibiotic properties of
Aureomycin were end results of a program of
research undertaken by Professor Duggar who,
after retirement from an active university career,
accepted employment in industry (see Duggar,
Ann. N. Y. Acad. Sc, 1948, 51, 177). Aureomycin
(this term will be used synonymously with Aureo-
mycin hydrochloride and chlortetracycline hydro-
chloride in this monograph) was the second
broad-spectrum antibiotic to become available —
Chloromycetin was the first — and its discovery
marked a notable advance in antibiotic therapy.
Jt is paradoxical that Aureomycin was nearly

passed over in the early phases of the screening
program in the search for antibiotic substances
because of its relatively poor in vitro perform-
ance. It has since been demonstrated many times
that, due probably to its instability in solution
under usual conditions of in vitro antibacterial
testing, Aureomycin often is much more effective
in treatment of bacterial infections than would
be anticipated from in vitro assays. The anti-
biotic, first referred to merely as A-377 and origi-
nally marketed under the trade-mark Duomycin
(Lederle), was later called Aureomycin, and the
species of Streptomyces which elaborates it was
designated aureofaciens, in allusion to the golden
yellow pigment that it produces.

Biosynthesis. — Numerous mutant strains of
Streptomyces aureofaciens have been induced by
ultraviolet irradiation and one of these has been
selected for industrial biosynthesis of Aureomycin
because of the superior yields obtained in sub-
merged cultures. In appropriate media, this strain
produces as much as 1300 micrograms of Aureo-
mycin per ml. Extraction of the antibiotic from
the fermentation broth proceeds in numerous
steps. The basic procedures depend on the am-
photeric character of the antibiotic and the dif-
ferential solubility of the free compound and its
salts in polar and in nonpolar solvents, and on the
differential adsorption of the free compound and
its salts on various types of ion exchange resins.
Production and extraction methods have been re-
viewed and summarized by Van Dyke {Anti-
biotics and Chemotherapy, 1952, 2, 184).

Structure. — Aureomycin (chlorotetracycline)
and Terramycin (oxytetracycline) are closely re-
lated compounds which, as their generic names
indicate, are derivatives of tetracycline, itself an
antibiotic of great promise (see Tetracycline
Hydrochloride). Chlortetracycline is the 7-chloro
derivative of tetracycline which, in turn, is con-
sidered a derivative of naphthacenecarboxamide.
Following the Chemical Abstracts system of
nomenclature the chemical name of chlortetra-
cycline is 7-chloro-4-dimethylamino-l,4,4a,5,5a,6,-
ll,12a-octahydro-3,6,10,12,12a-pentahydroxy-6-
methyl- 1 , 1 l-dioxo-2-naphthacenecarboxamide.

Chlortetracycline embodies two ionizable hy-
droxyl groups and a tertiary amino group, thereby
rendering the compound amphoteric. It readily
forms salts with acids and with bases. Because of
superior pharmacologic properties and greater
stability the salts with acids generally have been
preferred for systemic therapy, with the hydro-
chloride being commonly employed. More re-
cently, however, a suspension of the calcium salt
has been made available commercially and has
been well received. The borate is supplied for
local medication in ocular infections.

Description. — "Chlortetracycline Hydrochlo-
ride is a yellow, crystalline powder. It is odorless
and has a bitter taste. It is stable in air but is
. slowly affected by light. Its 1 in 200 solution has
a pH between 2.3 and 3.3. One Gm. of Chlortetra-
cycline Hydrochloride dissolves in about 75 ml.
of water, and in about 560 ml. of alcohol. It is
soluble in solutions of alkali hydroxides and car-
bonates. It is practically insoluble in acetone, in
chloroform, in dioxane, and in ether." U.S.P.

306 Chlortetracycline Hydrochloride

Part I

Chlortetracycline hydrochloride is somewhat
more soluble in a 5 per cent aqueous solution of
dextrose than it is in water (Schoenbach et al.,
Ann. N. Y. Acad. Sc, 1948, 51, 267); it is stated
that a 4 per cent solution of the antibiotic salt
may be prepared in this vehicle. Chlortetracycline
hydrochloride is also more soluble in aqueous
solutions of methylcellulose than it is in water;
solutions of the antibiotic, containing methyl-
cellulose, have been recommended for topical use
to prevent scarring in varicella (Kalz et al., Can.
Med. Assoc. J., 1949, 61, 171).

Aqueous solutions of chlortetracycline hydro-
chloride (20 micrograms per ml.) in distilled
water or in isotonic sodium chloride solution have
a pH of 2.5 to 2.9 and are irritating to tissues
and cause pain when injected intramuscularly.
Usually they can be injected intravenously with-
out deleterious consequences, although occasion-
ally phlebitis develops due to the irritating prop-
erty of the drug or perhaps to the high acidity of
the solution or to both factors. These undesirable
effects are minimized by buffering the antibiotic
solution with appropriate salts of suitable amino
acids, of which sodium glycinate appears to be
one of the most satisfactory.

Stability. — Dry crystalline chlortetracycline
hydrochloride, when stored in tight containers
and protected from light and moisture, is stable
at ordinary temperature for many months. Aque-
ous solutions, however, are affected markedly by
pH and by temperature.

Solutions containing 20 micrograms of the hy-
drochloride per ml. and having a pH of 2.5 are
stable for several hours at room temperature, but
at 37° they lose 15 per cent of their antibiotic
activity in 5 hours and 50 per cent in 24 hours.
Neutral or alkaline solutions are very unstable
and deteriorate rapidly even at room temperature.
A solution at pH 8.5 loses about 12 per cent of
its activity in 30 minutes at 25°, about 20 per
cent in one hour, and about 40 per cent in 2 hours
(Harned et al., Ami. N. Y. Acad. Sc, 1948, 51,
182).

Dry Aureomycin borate is quite stable, but a
0.5 per cent solution in isotonic sodium chloride
solution having a pH of 7.5 to 7.8 is antibac-
terially inert after 24 hours at room temperature
(Braley and Sanders, Ann. N. Y. Acad. Sc, 1948,
51, 280). Deterioration is more rapid in more
alkaline solutions. This has practical significance
because the pH of solutions of Aureomycin borate
as dispensed for treatment of ocular infections
may have a pH of 7.5 to 8.5. Solutions should,
therefore, be freshly prepared from the dry salt
immediately before dispensing, and the patient
should be told to keep the solution refrigerated
when it is not in use. A 0.5 per cent solution re-
tains its activity for several days at 4°.

Womak et al. (Proc S. Exp. Biol. Med., 1949,
72, 706; /. Lab. Clin. Med., 1950, 36, 655) re-
ported that egg yolk contains a heat-stable factor
that partially protects Aureomycin against de-
terioration in solution.

Standards and Tests. — Identification. — (1)
A brown color with a greenish tinge results on
addition of an alcoholic solution of ferric chloride
to a dilute solution of chlortetracycline hydro-

chloride. (2) A blue color, quickly changing to
green and finally to dark olive-green, results when
sulfuric acid is added to chlortetracycline hydro-
chloride (oxytetracycline hydrochloride gives a
red color). (3) Chlortetracycline hydrochloride
responds to tests for chloride. Loss on drying. —
Not over 2 per cent, when dried in vacuum at 60°
for 3 hours. Pyrogen. — Chlortetracycline hydro-
chloride, used in a test dose of 1 ml. of a solution
(containing 5 mg. per ml.) per Kg., meets the
requirements of the test. Safety. — Chlortetracy-
cline hydrochloride, used in a test dose of 0.5 ml.
of a solution containing 2 mg. of the antibiotic
salt in each ml., meets the requirements of the
test. Sterility. — Chlortetracycline hydrochloride is
required to be free of bacteria, molds and yeasts.
U.S.P.

Assay. — Chlortetracycline hydrochloride is
assayed by the official microbial assay. U.S.P. For
description of a nonaqueous titration method in
which a glacial acetic acid solution of the anti-
biotic is titrated with a solution of perchloric
acid, which method is under certain conditions
suitable for chemical control, see Sideri and Osol
(/. A. Ph. A., 1953, 42, 688).

Action. — No entirely satisfactory chemical
tests for assaying Aureomycin in the blood and
other body fluids have been developed. There-
fore, studies of absorption, distribution, and ex-
cretion have had to rely on bioassay technics.
With Aureomycin, however, such technics yield
relative values only, because the antibiotic de-
teriorates rapidly in solution, especially at incu-
bator temperatures. For example, when human
serum or tryptose phosphate broth-thioglycollate
medium containing 1 microgram or less of Aureo-
mycin per ml. is incubated at 37° from 94 to 97
per cent of the initial activity is lost in 8 hours
(Dowling et al., Ann. N. Y. Acad. Sc, 1948, 51,
241). Despite these difficulties, a considerable
amount of information regarding uptake, distri-
bution, and elimination of the drug has been
acquired.

Absorption. — Aureomycin is rapidly absorbed
from the gastrointestinal tract following oral ad-
ministration and is rapidly distributed to most
tissues, organs, and body fluids. It is more effec-
tive clinically than would be predicted from re-
sults of in vitro tests. A single oral dose of 250
to 500 mg. of Aureomycin yields maximum plasma
concentrations in from two to eight hours and
usually the antibiotic can be detected in the blood
for as long as 12 hours and sometimes for as long
as 24 hours.

When multiple doses of chlortetracycline hy-
drochloride are given (0.25 to 1 Gm. every six
hours) maximum concentrations of the drug in
the blood range from about 2.5 to about 6 micro-
grams per ml. Increasing the dose (on either
single or multiple schedule) does not increase
commensurately the maximum concentration at-
tained in the plasma, but it does prolong some-
what the time during which the plasma level re-
mains above any given submaximal value.

Following intravenous injection of Aureomycin,
maximum concentrations in the blood may be
reached in five minutes, and detectable amounts
may be present for as long as twelve hours after

Part I

Chlortetracyciine Hydrochloride 307

a single dose of 250 mg. Small intravenous doses,
as low as 25 mg., often produce satisfactory and
therapeutically effective blood levels.

Welch made a comprehensive comparison of
absorption, blood levels, distribution, and excre-
tion of Chloromycetin, Aureomycin, and Terra-
mycin (Ann. N. Y. Acad. Sc, 1950, 53, 253),
and found that, following any given oral dosage
schedule, blood levels achieved with Aureomycin
and Terramycin were similar in magnitude and
in maintenance pattern. Neither drug attained
such high concentrations in the blood as Chloro-
mycetin.

Distribution. — Aureomycin has been found in
various organs (liver, kidney, spleen, lungs, etc.)
of patients who have died while undergoing
Aureomycin therapy. Therefore, it is thought that
the antibiotic diffuses into the intracellular fluids.
In view of the remarkable efficacy of Aureomycin
in rickettsial infections, it seems reasonable to
assume that the drug penetrates endothelial cells.
Aureomycin diffuses into the cerebrospinal fluid
and also passes the placental barrier.

Aureomycin, like Terramycin, tends to reach
relatively high concentrations in the liver and in
the bile ; the titer in the bile may be several times
that in the blood. The relatively high levels at-
tained in the liver and bile undoubtedly are re-
sponsible for the superiority of these drugs in
liver and biliary infections (see below).

Excretion. — Excretion of Aureomycin is
effected via the urine and the feces. Much of
it is excreted in a biologically active form. Welch
(loc. cit.) observed that concentrations of Aureo-
mycin in urine and in feces were considerably
below those of Terramycin, following similar
doses. Some of the difference may be only appar-
ent, being due to the somewhat greater difficulty
in satisfactorily assaying Aureomycin in body
tissues and fluids, but it seems unlikely that this
is the sole explanation. It has been suggested that
less Aureomycin than Terramycin is found in
total 24-hour urine collections following adminis-
tration of the respective drugs because intra-
cellular penetration by Aureomycin is greater
than by Terramycin. At present, there is no ex-
perimental evidence to support this view.

When single oral doses ranging from 0.5 to 2
Gm. were given, total urinary excretion in 24
hours varied from about 9 per cent to about 15
per cent of the administered dose. Somewhat
higher percentages of the total dose can be re-
covered from the urine following multiple doses.
Approximately 17.5 to 25 per cent of the total
dose is excreted in biologically active form when
Aureomycin is given in four equal doses of 0.25
to 1 Gm. at intervals of six hours. Maximum and
average concentrations of Aureomycin demon-
strable in the urine and concentrations in the
feces and the skin are lower than those of Terra-
mycin. But Aureomycin may reach higher con-
centrations than Terramycin in the spleen, bile,
and lungs.

Uses. — Aureomycin, like its close chemical
relative, Terramycin, provides effective medica-
tion in a wide variety of infections due to bacteria
(both gram-positive and gram-negative), rick-
ettsias, some large viruses, and some protozoa.

It is ineffective against the smaller viruses, such
as those causing rabies, poliomyelitis, vaccinia,
and encephalitis and also is ineffective against
fungi. General articles that indicate the scope of
usefulness of Aureomycin in treatment of various
types of infections are as follows: blood stream
and heart (Herrell, J.A.M.A., 1952, 150, 1450);
respiratory tract (Romansky and Kelser, ibid.,
1447) ; gastrointestinal tract (Hughes, ibid., 1456) ;
genitourinary tract (Nesbit and Baum, ibid.,
1459); skeletal system (Altemeier and Largen,
ibid., 1462); viral and related infections (Finland,
New Eng. J. Med., 1952, 247, 317; ibid., 557);
tropical diseases (Ann. N. Y. Acad. Sc, 1952, 55,
969 to 1284 and Killough, Proc. Roy. Soc. Med.,
1952, 45, 109). An amply documented review of
the varied infectious conditions in which Aureo-
mycin has been employed in treating patients,
from the time of its first clinical trial up to 1952,
has been published in book form by the Lederle
Laboratories (The Fifth Year of Aureomycin) .
See also the tables in the article on Antibiotics,
in Part II.

Aureomycin, if used according to the principles
suggested by Meyer and Eddie (Antibiotics An-
nual, 1954-55, p. 544), can have an important
role in the control of psittacosis and ornithosis.
Their proposals, if adopted, would eliminate a
major source of infection by controlling the dis-
ease in avian carriers.

Resistance of organisms to Aureomycin may
be increased several fold in the laboratory, but
generally acquired resistance is not a clinically
significant problem with Aureomycin or, for that
matter, with other broad-spectrum antibiotics.
For exception, see discussion of staphylococcosis
during intensive treatment with oxytetracycline.
However, if organisms acquire resistance to
Aureomycin, frequently they evidence increased
resistance to Terramycin also and vice versa.
(For discussion of resistance and cross-resistance
among antibiotics, see Pratt and Dufrenoy, Anti-
biotics, 2nd ed., 1953, Lippincott.)

Rickettsial Infections. — Aureomycin is in-
dicated for all rickettsial infections — Rocky
Mountain spotted fever, typhus, scrub typhus,
murine typhus, Brill's disease, and Q fever. The
current attitude toward Q fever was summed up
by Melolesi (Wien. klin. Wchnschr., 1951, 63, 5),
who stated that therapy of Q fever has become
simple and effective with the introduction of
Aureomycin, which influences the course of the
disease in a decisive manner in 3 days. This is a
common experience in Q fever treated with
Aureomycin. However, other reports indicate that
Aureomycin is not always uniformly effective in
Q fever, although it is a logical choice for ther-
apy. Clark et al. (Arch. hit. Med., 1951, 87,
204), summarizing 45 cases treated with Aureo-
mycin, reported that 71 per cent became afebrile
in 5 days or less, 20 per cent did not become com-
pletely afebrile in this period but had decided
decrease in fever and marked subjective improve-
ment. The remaining 9 per cent showed either
no or very slight improvement. Q fever is a dis-
ease which often is accompanied by complica-
tions: thrombo-phlebitis, pulmonary embolism,
encephalitis, pancreatitis, lymphocytotic meningi-

308 Chlortetracycline Hydrochloride

Part I

tis and other sequelae. Moeschlin and Koszcwski
{Schwa*, med. Wcknschr., 1950. 80, 929) and
Gsell (Helv. Med. Acta. 1950, 17, 279) have com-
mented on the lower incidence of such complica-
tions when Aureomycin therapy is started early
in the course of the infection. Q fever may call
for somewhat higher doses of drug than bacterial
infections. Fellers {i'. S. A. F. Med. J., 1952. 3,
665) recommended a total of 9 to 11 Gm. orally
over a period of 5 days.

Rocky Mountain spotted fever is a severe
rickettsial infection that appears to be spreading
over the Northern Hemisphere. Formerly marked
by approximately 50 per cent mortality, today
prompt recovery almost always follows adminis-
tration of therapeutically effective doses of Aureo-
mycin. Review of the many reports indicating
improvement in one to two days after the first
dose of Aureomycin and the start of convalescence
in a few days is given in The Fifth Year of Aureo-
mycin (1952. Lederle).

The favorable results obtained with Aureomycin
in treatment of Q fever and Rocky Mountain
spotted fever have been repeated so often with
typhus (endemic, scrub, exanthematous. and re-
crudescent), tick-bite fever, and other rickettsial
infections as to have become almost routine. This
is not meant to minimize the seriousness of these
diseases. In all of them a long period of con-
valescence (several weeks) is indicated in order
to avoid complications. The marked diminution
in subjective, and even clinical, evidence of infec-
tion should not be permitted to lull the patient
or the physician into a false sense of security.
Constant vigil must be maintained against relapse,
at the first indication of which the antibiotic treat-
ment should be renewed.

Immunity. — It is important to bear in mind
that, at the concentrations generally prevailing in
the blood during treatment with Aureomycin. the
drug is primarily ■"static"* rather than "cidal" and
that, therefore, ultimate recover}' without relapse
depends on the immune status of the host. In
most bacterial infections, host resistance mech-
anisms are mobilized relatively rapidly. But in
rickettsial infections and in Brucella infections
immune reactions are slow in onset and develop
relatively slowly. Subsidence of subjective mani-
festations of disease does not necessarily indicate
cure. The organisms may merely be held in abey-
ance and may flare up. causing relapse or develop-
ment of chronic disease, if the antibiotic is
withdrawn before the natural host mechanisms of
defense are adequate to continue the inhibitory
action of the drug. It has been claimed that
Aureomycin therapy early in the course of Q
fever interferes little, if at all, with antibody
formation (Brawley and Modern. Arch. Int. Med.,
1949. 84, 917). Perhaps this is true in Q fever. If
so. the disease appears to be an exception to the
rule. In the same year, Smadel was among the
first to point out that early treatment of rick-
ettsial infections with Aureomycin (or other
broad-spectrum antibiotics) may seriously inter-
fere with development of an immune response
{Trans. Am. Clin. & Climatol., 1949. 61, 152).
Similar observations have been made in rickettsial-

pox (Rose et al., Am. J. Med., 1950, 9, 300)
and more recently by Ley and Smadel (loc. cit.)
in scrub typhus. Until more conclusive evidence
to the contrary is available it seems wise in most
rickettsial infections and in brucellosis to follow
the line of caution and to assume that there may
be interference with antibody formation. Although
deliberate withholding of antibiotic therapy once
a clear-cut diagnosis has been made is not advised
or even suggested, in order to prevent relapse,
administration may need to be continued for a
longer time when therapy is started early in the
course of such infections than when it is started
later. According to Siegert et al. (Ztschr. Tropen-
med. u. Parasitol., 1950. 2, 1), Aureomycin is
particularly valuable in Q fever when employed
early, even before there has been time for definite
serologic diagnosis. This has led to the suggestion
that the antibiotic should be given merely on the
suspicion of Q fever. Whether or not this is good
medicine remains to be proved.

Use of any antibiotic early in the course of an
infection may so alter the morphology and the
biochemical reactions of an invading pathogen
that subsequent identification of the organism
becomes extremely difficult, and accurate diag-
nosis of the infection may be seriously delayed.
In coping with ill-defined infections it is impor-
tant, when antibiotic therapy seems to be indi-
cated, to obtain a specimen of blood, sputum,
urine, mucus, or other material, depending on the
infection, before the first administration of the
drug so that the etiologic agent can be isolated
for identification in an unaltered condition. This
may be more important in bacterial infections
than in those due to rickettsias.

Brucellosis. — Brucellosis responds favorably
to Aureomycin. especially when antibiotic therapy
is supported by use of the specific antigen.
Aureomycin is effective in both the acute and
chronic forms of the disease as well as in its
complications. It is the opinion of Knight (.4mm.
N. Y. Acad. Sc, 1950. 53, 332), shared by others,
that the more severely ill the patient, the better
his response to Aureomycin. The brucellae are
intracellular obligate parasites. Aureomycin. which
readily passes cell membranes, can. therefore,
track the enemy down in its lair, as it were, and
is a drug of choice in treating this infection. Con-
comitant administration of Aureomycin. strepto-
mycin, sulfadiazine, and antigen may be more
effective than any one of these agents alone. For
the rationale for joint use of antigen and anti-
biotics in brucellosis see discussion under Oxy-
tetracycline Hydrochloride. Brucellosis is a world-
wide problem and, as such, has had the attention
of the Food and Agricultural Organization and
the World Health Organization, both of the
United Nations. In a joint report (World Health
Organ. Tech. Rep. Series, 1951, No. 37, 5) com-
mittees of these U. N. agencies have recommended
2 to 4 Gm. of Aureomycin daily, in divided doses
at six-hour intervals for 14 to 21 days. Cortisone
will control toxemia in severe cases of brucellosis
(Magill et al., Am. J. Med., 1954, 16, 810).

Liver and Biliary Tract. — Aureomycin is one
of the most effective chemotherapeutic drugs for

Part I

Chlortetracycline Hydrochloride 309

many infections of the liver and of the biliary
tract. In fact, it has been claimed that Aureo-
mycin exerts some protective action in the liver —
that it prevents or delays hepatic necrosis in ani-
mals fed a necrogenic diet (Abel and Beveridge,
Arch. Path., 1951, 52, 428). This report, based
on experimental studies with rats, seems at vari-
ance with the clinical observations of fatty de-
generation of the liver in patients on high dosages
of Aureomycin (see below and Rutenberg and
Pinkes, New Eng. J. Med., 1952, 247, 797). In
any event, it is clear that the antibiotic reaches
relatively high levels in the liver, and this prob-
ably accounts for its extreme effectiveness in
treating infections of that organ. The drug is
useful in chronic residua of acute hepatitis, in
acute hepatic coma, and in fulminating acute
hepatitis. When evaluating existence of liver dam-
age or distinguishing between obstructive and
nonobstructive jaundice in a patient on Aureo-
mycin therapy, it must be remembered that
urobilinogen disappears more or less completely
from the urine during administration of the anti-
biotic. Therefore, this liver function test, if indi-
cated, should be performed before the start of
Aureomycin therapy.

The number of reports of successful use of
Aureomycin in different liver infections ranging
from mild to severe and acute to chronic is over-
whelming. These are reviewed in The Fifth Year
of Aureomycin (Lederle), but there have also
been failures. Kalmansohn et al. (J. Philippine
M. A., 1951, 27, 549) and Shaffer et al. (Am. J.
Med. Sc, 1950, 220, 1) observed no significant
effect when Aureomycin was used in acute viral
hepatitis with jaundice. Rissel (Helv. Med. Acta,
1950, 17, 404), following study of 45 patients,
pointed out that Aureomycin is most effective in
early jaundice and that if the condition has lasted
for two weeks or more there may be little benefit
from Aureomycin. This may be because of the
irreversible liver damage that may occur rapidly
in jaundice due to infectious hepatitis. The value
of Aureomycin in infectious hepatitis, especially
when used early in the course of infection, was
demonstrated on a large scale in Egypt during an
epidemic outbreak in 1951 (Rizkalla, /. Roy.
Egyptian M. A., 1951, 34, 153).

Bacterial Infections. — Most infections caused
by gram-positive bacteria (as Staphylococcus and
Pneumococcus) and by gram-negative bacteria
(as E. colt) respond favorably and rapidly to
Aureomycin. Penicillin, because it can be given
virtually ad libitum and because of its low tox-
icity and absence of gastrointestinal distress, is
the antibiotic of choice for all sensitive organ-
isms. But Aureomycin is extremely valuable in
treating infection due to gram-positive penicillin-
resistant pathogens or most gram-negative or-
ganisms. Breese (/. Pediatr., 1952, 40, 85) found
Aureomycin effective in controlling an epidemic
outbreak of beta hemolytic streptococcal infec-
tions; doses were 5 mg. per Kg. per day for 2 to
5 days, followed by 2.5 mg. per Kg. per day for a
total of 4 to 12 days. Acute otitis media or
mastoiditis often responds well. It is not indi-

cated for systemic Proteus vulgaris or Pseudo-
monas aeruginosa infections.

In acute anthrax Aureomycin is indicated.

Whooping Cough. — Higher doses may be re-
quired for pertussis. Hasselmann-Kahlert (Anti-
biotics & Chemotherapy, 1952, 2, 159) found the
best dosage during an epidemic of whooping
cough to be 25 mg. per Kg. per day for 2 to 12
days. Best results, as indicated by incidence of
relapse, were obtained with the longer period of
therapy.

Subacute Bacterial Endocarditis.— This con-
dition sometimes responds to Aureomycin given
alone or with other antibiotics when it fails to
respond to penicillin. Each case seems to be a
specific entity and to need special consideration.
However, joint penicillin-streptomycin therapy
usually is indicated as first choice. When this
treatment fails, Aureomycin or some other broad-
spectrum antibiotic may be effective, either alone
or jointly with penicillin or streptomycin.

Urinary Tract Infections. — Metzger et al.
(J. Urol., 1952, 67, 374) reported on a series of
113 patients with urinary tract infections treated
with Aureomycin, the average dose being 250 mg.
four times daily. The cases were about equally
divided between acute and chronic conditions.
All but one of the acute cases showed definite
reduction or elimination of all clinical symptoms,
usually within 48 hours, and in 58 per cent of the
patients the urine was sterilized. The chronic
cases generally were more complex, but 88 per
cent of them either improved or were clinically
cured and in '1 7 per cent the urine was sterilized.
Treatment for the chronic group lasted 2 weeks.
Infections with E. coli, A. aerogenes, staphylococci
and streptococci usually respond readily. Species
of Pseudomonas and of Proteus are among the
most resistant gram-negative bacteria and some-
times emerge as resistant persisters following
Aureomycin therapy of urinary tract infections.
Control of these organisms may call for use of
polymyxin. (See discussion of Oxy tetracycline
Hydrochloride for further consideration of use of
Aureomycin in urinary tract infections.)

Meningitis.— In a series of 18 children, aged
3 to 51 months, with Hemophilus influenza men-
ingitis, intravenous injection of 3 to 10 mg. of
Aureomycin per Kg. was given every 6 to 12
hours for 3 to 4 days, followed by 40 to 60 mg.
per Kg. orally in divided doses every 4 to 6 hours
for 14 days (Schoenbach et al., Am. J. Med.,
1952, 12, 263). Results were indifferent; 3 pa-
tients died. In another trial (Ainley-Walker and
Bosanquet, Lancet, 1952. 262, 433), intrathecal
administration of Aureomycin in leucine buffer
to maintain a concentration of 50 micrograms per
ml. in the cavity was effective in curing menin-
gitis caused by Bacterium aerogenes. Five to 40
mg. Aureomycin can be given intrathecally 2 to 3
times daily without inducing serious untoward
reactions, according to these authors. For men-
ingococcus or pneumococcus meningitis, sulfa-
diazine or penicillin is usually preferred.

Virus Infections. — Among the virus diseases,
primary atypical pneumonia and psittacosis are
efficiently treated with Aureomycin. Finland has

310 Chlortetracycline Hydrochloride

Part I

reviewed the extensive literature on Aureomycin
treatment for viral pneumonia (New Eng. J.
Med., 1952, 247, 317) and concluded that until
more definite information is available, Aureomycin
and Terramycin should be considered effective
for antibiotic treatment of this condition. Finland
(ibid., 1952, 247, 557) also pointed out that there
is no justification for use of Aureomycin or
Terramycin in influenza except as a means of
treating (or perhaps preventing) serious com-
plicating bacterial infections. Aureomycin is
useful in acute laryngotracheobronchitis, acute
infectious (non-diphtheritic) croup, and some
cases of acute bronchitis.

None of the antibiotics currently available is
effective in treating the common cold, but large
quantities continue to be used for this purpose on
the assumption that they will prevent or minimize
secondary- complications. However, a controlled
study of 159 children (ages less than 1 year to
15 years) with 55 of them serving as controls,
has shown that "immediate treatment with anti-
biotic or chemotherapeutic agents does not
shorten the recovery period from complications"
nor substantially reduce incidence of complica-
tions in upper respiratory infections (Hardy,
Quart. Bull. Northwestern U. Med. School, 1954,
28, 263). The different treatments consisted, re-
spectively, of aspirin plus a placebo, aspirin plus
Gantrisin, aspirin plus oral penicillin, or aspirin
plus Aureomycin. In the control group, 50 per
cent recovered in one week, 40 per cent in two
weeks, and 10 per cent required more than two
weeks. Among the treated individuals, only 39 per
cent recovered in one week and 13 per cent re-
quired more than two weeks for recovery. All
groups received the same supportive treatment:
among the controls 16.3 per cent required addi-
tional treatment for recovery, among the treated
groups 12.3 per cent. About 2 7 per cent of com-
plications occurred after five days of study in the
control group, but in the treated groups 62.5 per
cent of complications developed after 5 days of
treatment. Complications included otitis media,
persistent fever, cervical adenitis, tonsillitis, pneu-
monia, pyuria, and paratonsillar abscess.

Reports on measles are inconclusive; some in-
vestigators have reported favorable response, pre-
vention of complicating sequelae, or even cure,
while others reported no effect on the course of
the disease or on subsequent complications. One
of the most extensive surveys in measles was re-
ported by El-Din (/. Roy. Egyptian M. A., 1951,
34, 340). During an epidemic in Egypt, he noted
that Aureomycin did not prevent appearance of
the rash, but that, if given early, it reduced the
intensity of the rash. When Aureomycin was
given before development of the rash, fever
dropped rapidly and the catarrhal stage was
about one-half as long as when no Aureomycin
was given. Penicillin and sulfadiazine were about
as effective as Aureomycin in preventing com-
plications.

Mumps is in about the same category as
measles with respect to Aureomycin — some re-
ports claim favorable effects, some no effect.
Deming (Rhode Island M. J., 1951, 34, 537)

advocated joint use of Aureomycin and female
sex hormone given daily for 5 days as soon as
mumps is diagnosed in the adult male. The hor-
mone is claimed to reduce markedly the compli-
cations of orchitis. If orchitis is already present,
the treatment is of little value.

Venereal Diseases. — Aureomycin is effective
in syphilis, gonorrhea, lymphogranuloma inguinale
and in other venereal diseases. For syphilis, yaws
and gonorrhea, however, penicillin remains the
antibiotic of choice, but Aureomycin may be use-
ful when penicillin is contraindicated or in pre-
venting some of the complications of gonorrhea.
For lymphogranuloma inguinale, generally Aureo-
mycin or Terramycin is indicated. The two anti-
biotics are about equally effective. Doses usually
are 2 Gm. daily divided into equal portions given
at 4 to 6 hour intervals for from 10 days to 2
months, depending on the severity and previous
duration of the infection.

Amebiasis. — In amebiasis, Aureomycin and
Terramycin, used alone in doses of 1 Gm. daily
for 20 days or with Chloroquine (500 mg.) have
yielded better than 90 per cent cures (Armstrong,
South African Med. J., 1953, 27, 42). An earlier
long-term evaluation of Aureomycin in amebiasis
was made by McVay (South. M. J., 1952, 45,
183) who found 500 mg. Aureomycin orally 4
times daily for one week effective in rendering
80 patients asymptomatic. No relapse occurred in
22 patients observed for 15 months. In others,
when relapse occurred, doses of 3 Gm. per day
generally effected remission.

Actinomycosis. — This disease is another indi-
cation for Aureomycin.

Topical Use. — Clinical indications for topical
use of Aureomycin in dermatology and ophthal-
mology are essentially the same as for Terra-
mycin. For specific conditions calling for Aureo-
mycin and reports of clinical trials see discussion
under Oxy tetracycline Hydrochloride and also
The Fifth Year of Aureomycin (Lederle). Aureo-
mycin borate, used alone in the eye or supple-
mented by systemic administration of the hydro-
chloride, is a useful drug in ophthalmology. For
precautions necessary in storage of the borate,
see discussion under Stability.

Toxicology. — Toxicity is not a major prob-
lem in therapy with chlortetracycline hydrochlo-
ride. Early tests in animals were made by Harned
et al. (Ann. N. Y. Acad. Sc, 1948, 51, 182), who
reported the acute intravenous LD50 for mice,
following a single dose, to be 134 mg. per Kg. of
body weight and for rats 118 mg. per Kg. when
the drug was given in aqueous solution at pH 2.5.
At pH 8.5, the LD50 for mice was 102 mg. per
Kg. Orally administered, the drug was very well
tolerated; no deaths occurred when mice were
given 1500 mg. per Kg., there was one death
(among 20 animals) at 2000 mg. per Kg., and
seven deaths at a dose of 3000 mg. per Kg. There
were no deaths among rats (groups of 10 animals)
at the 3000 mg. per Kg. dose. Dogs readily toler-
ated intravenous doses of 50 mg. per Kg., given
at a rate of 10 mg. per Kg. per minute. There
was no evidence of serious subacute toxicity fol-
lowing multiple intravenous doses in dogs. Sub-

Part I

Chlortetracycline Hydrochloride 311

cutaneous, intramuscular, and intraperitoneal
doses at pH values of 2.5, 7.0, and 8.5 were uni-
formly irritating.

Chronic toxicity in mice, rats, and dogs, fol-
lowing oral doses of 100 to 200 mg. per Kg. daily
for twelve weeks, was low as judged by changes
in weight, hematology, liver function tests, kid-
ney function tests, blood pressure, and patholo-
gist's reports. (See, however, comments below on
liver damage and on antithyroid action.)

Coagulation. — There was evidence of slight
transient reduction in clotting time of some ani-
mals, an observation confirmed by Innerfield
et al. (Am. J. Physiol., 1951, 166, 578) who
noted that the effect was associated with more
than 100 per cent increase in Ac-globulin content.
Prothrombin time was unaffected. Observations
on humans have indicated transient but slight
reduction (Waisbren and Glick, Proc. S. Exp.
Biol. Med., 1950, 75, 476) or an increase (Shapse
and Wright, Angiology, 1950, 1, 306) in coagula-
tion time of blood. Blodgett and Schilling (Am. J.
Med. Sc, 1951, 221, 688) and later workers con-
cluded that there is no clinically significant effect
of Aureomycin on clotting time in normal human
patients.

Intestinal Flora. — The most prevalent and dis-
turbing side effects following Aureomycin therapy
in man are encountered in the gastrointestinal
tract. The symptoms are similar to those seen in
patients treated with oxytetracycline hydrochlo-
ride (which see), and undoubtedly have the same
origin, namely, profound alteration of the com-
position of the gastrointestinal microflora popu-
lations. They should not, therefore, be considered
toxic effects in the pharmacologic sense. Discon-
tinuing the drug generally is unnecessary. Reme-
dial measures are the same as those described
under oxytetracycline hydrochloride. Occasion-
ally the symptoms persist for several weeks after
therapy is completed. When this occurs, adminis-
tration of kaolin, pectin, or bismuth often is help-
ful in reducing diarrhea. These agents reduce
absorption of Aureomycin from the intestinal
tract and should not be administered concurrently
with the antibiotic. For the same reason aluminum
hydroxide gels are contraindicated. Gastrointesti-
nal effects following oral doses of Aureomycin
can be minimized by administering the drug in
milk (1 ml. per mg. of drug) or with cottage
cheese. Sodium carboxymethylcellulose also is
effective in controlling digestive disturbance with-
out impeding absorption of Aureomycin (Green-
span et al., Am. J. Digest. Dis., 1951, 18, 35) oi
exerting measurable effect on serum levels.

Some patients develop anorexia while on an
Aureomycin regimen; others develop powerful
desires for specific types of food and sometimes
a voracious appetite for any kind of food. Sto-
matitis, skin and mucous membrane eruptions,
and vaginitis sometimes occur, but generally are
not sufficiently severe to warrant withdrawal of
the drug. Sometimes the epidermal and mucosal
manifestations of reaction can be controlled by
use of antihistaminics (Finland and Weinstein,
New Eng. J. Med., 1953, 248, 220).

Aureomycin available today is a highly puri-

fied recrystallized salt. Incidence of untoward
reactions to the present-day products is much
less than to the less highly refined forms available
several years ago when the drug first appeared
on the market.

Moniliasis. — Attention was directed to the oc-
currence of superinfections during antibiotic ther-
apy as early as 1948 (Applebaum and Leff,
J. A.M. A., 1948, 138, 119). Since that time, there
has been growing concern over the apparent in-
creased incidence of moniliasis, thrush, and other
yeast and fungus infestations in man, especially
following the advent of widespread broad-spec-
trum antibiotic therapy. The discussion of this
problem under oxytetracycline hydrochloride
(which see) applies equally to chlortetracycline
hydrochloride.

Hepatic Effect. — Lepper (Arch. Int. Med.,
1951, 88, 284) reported jaundice and pathologic
changes in the liver, including fat vacuolization
of cellular cytoplasm, in mice and dogs receiving
relatively large amounts of Aureomycin or Terra-
mycin. Similar observations have been made on
human patients receiving high or prolonged doses
of Aureomycin or Terramycin for chronic hepatic
disease (Sborov et al., Gastroenterology, 1951,
18, 598). These effects generally are not observed
in patients receiving the usual oral therapeutic
doses of 1 to 2 Gm. daily for several days (Fin-
land and Weinstein, loc. cit., 1953). The un-
desirable hepatic effects seem to be less prominent
in experimental animals when the drugs are given
orally than when they are administered intra-
venously. Lepper (loc. cit.) has recommended
that to avoid or to minimize these effects no more
than 2 Gm. of Aureomycin or Terramycin should
be given daily by the intravenous route, and no
more than 1 Gm. if it is accompanied by oral
doses.

Heart. — Cardiac arrhythmia in frog and turtle
hearts perfused with Aureomycin followed by as
little as 1 microgram of epinephrine has been
reported by Harvey and Yang (Science, 1953,
118, 752). The degree of arrhythmia was roughly
proportional to the length of time the hearts
were treated with Aureomycin. Blockage was
relatively slight 20 minutes after treatment but
was often complete one hour later. The effect
could be abolished by perfusion with KC1 solu-
tion after the Aureomycin treatment. The authors
suggest that Aureomycin interferes with the
energy-liberating mechanism that causes myo-
cardial contraction. The clinical implications, if
any, of these observations are not clear at pres-
ent, but it is possible that they might have
significance when emergency surgery, which might
concurrently call for use of epinephrine or
epinephrine-like stimulants, is contemplated for
patients on a prolonged regimen of Aureomycin
therapy.

Antithyroid Action. — Calesnick et al. (Science,
1954, 119, 128), working with rats, found that
ingestion of small amounts of Aureomycin daily
for six weeks caused approximately a four-fold
enlargement of the thyroid (corrected for differ-
ence in size of experimental and control animals)
and nearly 80 per cent reduction in uptake of

312 Chlortetracyclinc Hydrochloride

Part I

radioactive iodine. Experimental animals received
1 mg. of Aureomycin per Kg. of food and were
permitted to eat ad libitum. Penicillin induced
qualitatively similar but quantitatively smaller
effects. The authors suggest that, under the con-
ditions of their experiments, these antibiotics
may have goitrogenic action. No similar effects
have been noted in human patients under usual
clinical conditions and dosage regimens.

Summary. — Chlortetracycline hydrochloride,
available in a variety of pharmaceutic forms
under the name Aureomycin Hydrochloride
(Lederle), is a broad-spectrum antibiotic that is
effective in most rickettsial infections, in many
bacterial infections, and in some infections due
to large viruses or to amebae.

The antibiotic soon appears in therapeutically
effective concentrations in most body tissues and
fluids following oral or intravenous administra-
tion. It should not be administered intramuscu-
larly. Higher concentrations are achieved in the
liver, bile, and urine than elsewhere, accounting
for the particular usefulness of the drug in
treating infections of the liver and of the biliary
or urinary tracts.

Chlortetracycline has relatively low toxicity but
may cause nausea, vomiting, diarrhea, or pruritus
ani in 15 to 35 per cent of patients and pruritus
vulvae in some females following oral doses.
The effects may be sufficiently severe in a small
percentage of patients to necessitate discontinu-
ance of systemic chlortetracycline hydrochloride
therapy. The incidence and severity of these
symptoms can be reduced considerably in oral
administration by giving the drug in milk or
other suitable fluid (see Dosage). If the symp-
toms persist after treatment is discontinued,
kaolin, pectin, bismuth, aluminum hydroxide
gels, etc., may give relief.

Superinfection by yeasts and fungi, especially
Candida albicans, is encountered occasionally.
(For hypotheses to account for such outbreaks
during systemic administration of broad-spectrum
antibiotics, see under Oxytetracycline Hydrochlo-
ride.) Other untoward reactions, seen less fre-
quently, are anorexia and stomatitis.

Acquired microbial resistance to chlortetracy-
cline is not a major clinical problem, although
occasionally strains of Proteus or of Pseudomonas
emerge as persisters following prolonged use of
this antibiotic in treatment of mixed genito-
urinary infections. Polymyxin usually is indicated
in such instances. When organisms do acquire
resistance to one broad-spectrum antibiotic,
generally resistance to others also increases
somewhat. Therefore, when one broad-spectrum
antibiotic fails in a bacterial infection, often
little is to be gained by switching to another. In
such circumstances, better results may be
achieved with joint use of penicillin and strepto-
mycin or polymyxin.

Chlortetracycline hydrochloride, like other
broad-spectrum antibiotics, may indirectly inter-
fere with antibody formation. Therefore, it is
important to watch carefully for symptoms of
relapse following apparent cure, especially when

treatment is started early in the course of sys-
temic infection. S

Dosage. — The usual dose is 250 mg. (approxi-
mately 4 grains) by mouth, 4 times daily, with a
range of 50 mg. to 1 Gm. The maximum safe
dose is usually 1 Gm. and the total dose in 24
hours is 6 Gm.. which is seldom indicated. The
usual recommended oral doses of Aureomycin
are based on a daily intake of 12.5 to 20 mg. of
antibiotic per Kg. of body weight, or 5 to 9 mg.
per pound. The total daily dose should be di-
vided into four equal portions given six hours
apart. For the average adult, the suggested mini-
mum daily dose is 1 Gm. divided into four doses
of 250 mg. each. Total doses for children are
reduced in proportion to body weight. The reduc-
tion is effected in each of the four doses — not
by giving the drug less frequently.

Each dose is best administered with, or imme-
diately after, a meal; or preferably with a bland
drink, such as milk. One ml. of fluid per mg. of
Aureomycin (approximately 1 oz. of liquid for
each 30 mg. of antibiotic) is indicated to mini-
mize the incidence of gastrointestinal irritation.
Increased fluid intake favors early solution of
Aureomycin and some of the other broad-
spectrum antibiotics that are relatively insoluble,
and thus facilitates absorption; it also tends to
reduce the local concentration of the drugs to
levels below the threshold that is irritating to
the intestinal mucosa and simultaneously helps
to satisfy the important need for increased fluids
during infection.

Individual oral doses of Aureomycin exceeding
250 mg. are not completely absorbed. Therefore,
if daily doses higher than those indicated above
are desired, the frequency of administration
should be increased rather than the size of the
individual doses. Increasing the total daily dose
of Aureomycin beyond 1 Gm. does not propor-
tionately increase the concentrations in the blood
nor necessarily improve the clinical result. Di-
vided doses of 250 mg. even' six hours give
blood levels almost as satisfactory as those fol-
lowing doses of 500 mg. to 1 Gm. even- six hours
(Welch et al., J. A. Ph. A., 1950, 39, 185) and
are much less likely to be followed by the gastro-
intestinal symptoms and other manifestations of
Aureomycin irritation described above.

Therapy generally should be continued for
from 1 to 3 days after apparent cure. If favor-
able clinical response with partial remission of
symptoms is not evident after 36 to 48 hours of
therapy, generally some other course of treatment
is indicated. (See general article on Antibiotics,
in Part II. for comments on sensitivity testing
as basis for antibiotic therapy and on importance
of obtaining a culture of the causal organism
before beginning antibiotic therapy in ill-defined
infections. ) In some diseases it may be safer to
continue dosage beyond the 1 to 3 days after
restoration of normal temperature. In staphylo-
coccus infections, brucellosis, or amebiasis, a
10- to 14-day course of therapy may be indicated.
In subacute bacterial endocarditis, therapy may
need to be continued for six weeks or longer.
Vitamin B complex should be prescribed for all

Part I

Chlortetracycline Hydrochloride, Ophthalmic 313

patients who receive Aureomycin for 7 days or
more.

Route of Administration. — For systemic
medication, chlortetracycline hydrochloride is
administered orally. In emergency it may be
given intravenously, but the intravenous route
should be employed only if the patient is in a
moribund condition or is unable to swallow. As
soon as the patient is able to accept oral medi-
cation, intravenous administration should be
discontinued in favor of the oral route. Chlortet-
racycline should never be given intramuscularly;
it produces severe irritation when so adminis-
tered. Topical application of the drug is indi-
cated for some ocular infections, and for some
pyogenic cutaneous conditions; it may also be
employed for some superficially localized and
confined infections. Frequently when topical ap-
plication seems in order, it is desirable to fortify
the patient by giving the drug orally also, espe-
cially if there is a possibility that the infection
may spread or may become generalized.

Storage. — Preserve "in tight containers, pro-
tected from light." U.S.P.

CHLORTETRACYCLINE HYDRO-
CHLORIDE CAPSULES. U.S.P.

"Chlortetracycline Hydrochloride Capsules
contain not less than 85 per cent of the labeled
amount of C22H23CIN2O8.HCL" U.S.P.

Chlortetracycline hydrochloride capsules are
the most widely used dosage form of the anti-
biotic; they contain the crystalline salt with an
appropriate dry diluent. The available capsules
contain 50 mg., 100 mg. or 250 mg. of Aureo-
mycin hydrochloride.

CHLORTETRACYCLINE HYDRO-
CHLORIDE FOR INJECTION. U.S.P.

"Chlortetracycline Hydrochloride for Injection
is a sterile, dry mixture of chlortetracycline
hydrochloride with a suitable buffer, the latter
usually consisting of an amino acid. It contains
not less than 85 per cent of the labeled amount
of C22H23CIN2O8.HCI." U.S.P.

Chlortetracycline hydrochloride for injection is
supplied in vials containing 100 mg. or 500 mg.
of the dry crystalline antibiotic, buffered with
sodium glycinate, also in vials containing 100 mg.
of chlortetracycline hydrochloride along with an
ampul containing a 1.95 per cent solution of
leucine. The function of the amino acid is to
reduce the natural acidity of the antibiotic salt
(see under Chlortetracycline Hydrochloride)
which would be irritating and, possibly, tend to
increase the chance of developing phlebitis.
Solutions are prepared immediately before use,
employing not less than 10 ml. of diluent for
each 100 mg. of antibiotic. Water for injection,
isotonic sodium chloride solution, and 5 per cent
dextrose injection are the only acceptable dilu-
ents. After addition of the diluent to the vial it
should be shaken vigorously for a minute to
ensure solution.

Uses. — Intravenous use of Aureomycin hydro-
chloride (it should not be given intramuscularly)

is indicated to provide almost immediate bacteri-
ostasis in blood or tissues of moribund or uncon-
scious patients with a susceptible infection; to
secure bacteriostasis when oral therapy is tem-
porarily contraindicated. as in peritonitis; and
to reinforce oral therapy in critically ill pa-
tients. It may also be useful in acute surgical
emergencies complicated by infection, in initial
treatment of subacute bacterial endocarditis, in
some tropical diseases, and in resistant brucel-
losis.

There is always some risk of thrombophlebitis
at the site of injection. Normally, therefore,
Aureomycin hydrochloride should be given intra-
venously only to hospitalized patients and only
when oral medication cannot be administered.

The usual adult dose is 500 mg. intravenously
every 12 hours, or 250 mg. every 6 hours. The
former schedule usually is therapeutically satis-
factory and disturbs the patient less. The dose
may be adjusted according to severity of infec-
tion; it may be as low as 25 mg. every 4 to 6
hours, but should seldom exceed 500 mg. in 6
hours. Approximately 5 minutes should be taken
for injecting each 10 ml. of solution.

OPHTHALMIC CHLORTETRA-
CYCLINE HYDROCHLORIDE. U.S.P.

"Ophthalmic Chlortetracycline Hydrochloride
is a sterile, dry mixture of chlortetracycline
hydrochloride with a suitable buffer. It contains
not less than 85 per cent of the labeled amount
of C22H23CIN2O8.HCI. It may contain suitable
bacteriostatic agents and diluents." U.S.P.

Ophthalmic chlortetracycline hydrochloride is
supplied, under the name Aureomycin Hydrochlo-
ride, Ophthalmic (Lederle), in a dropper vial
containing 25 mg. of Aureomycin hydrochloride,
62.5 mg. of sodium chloride, 25 mg. of sodium
borate, and a bacteriostatic agent. A solution is
prepared by adding 5 ml. of distilled water im-
mediately before dispensing. Patients should be
warned to keep the solution under refrigeration
when not in use, and not to use it after 4 days
even when refrigerated, as the solution will de-
teriorate.

Uses. — Ophthalmic Aureomycin hydrochloride
has been used successfully in trachoma, kerato-
conjunctivitis, dendritic conjunctivitis, and in
ocular infections caused by staphylococci, strep-
tococci, pneumococci, Hemophilus influenza,
Mrobacter cerogenes, Alcaligenes fcscalis, Pro-
teus sp., Pseudomonas ceruginosa, Friedlander's
bacillus, and other organisms.

Either the solution, or a 1 per cent ophthalmic
ointment (N.N.R.), may be freely applied topi-
cally to the infected eye. Often mild infections
respond in 48 hours when either preparation is
applied every 2 hours, but severe infections may
require more frequent treatment and for several
days. Bellows et al. (Am. J. Ophth., 1950, 33,
2 73) applied the drug every 30 minutes during
the first day of treatment of acute epidemic
keratoconjunctivitis. Severe infections may re-
quire oral therapy also. In general, the solution
is used for active treatment, the ointment as an

314 Chlortetracycline Hydrochloride, Ophthalmic

Part I

adjuvant to other treatment and for physical
protection of the conjunctiva and cornea.

Storage. — Preserve "in tight containers, so
closed that the sterility of the product will be
maintained until the package is opened for use."
U.S.P.

CHOLERA VACCINE. U.S.P., B.P.

"Cholera Vaccine is a sterile suspension, in
isotonic sodium chloride solution or other suitable
diluent, of killed cholera vibrios (Vibrio comma).
It is prepared from equal portions of suspensions
of cholera vibrios of the Inaba and Ogawa strains.
The Inaba strain used possesses an antigenic value
not less than that of N.I.H. Inaba strain 35-A-3,
and the Ogawa strain possesses an antigenic value
not less than that of N.I.H. Ogawa strain 41. At
the time of manufacture cholera vaccine contains,
in each ml., 8 billion cholera organisms. It may
contain not more than 0.5 per cent of phenol, or
not more than 0.4 per cent of cresol, as a pre-
servative." U.S.P. The B.P. provides that more
than one strain of Inaba and Ogawa may be used
for manufacture to provide other 0 antigens in
addition to those common to the two main sero-
logical types.

For information on vaccines in general and
methods for their preparation, see Vaccines, Part
II.

Cholera vaccines of various types have been
used for many years and the results of various
field studies have led to divergent opinions of
their usefulness. Much of this difficulty has
arisen because of differences in the types and
dosages of the vaccines which were used and be-
cause of lack of knowledge concerning the anti-
genic structure of the cholera vibrios. Much of
the basic information on cholera and the anti-
genic structure of cholera vaccine has been avail-
able since the second decade of this century, but
has not become widely disseminated because it
was in the Japanese literature. With the advent
of World War II, the interest in cholera in Amer-
ica increased considerably because of military
necessity.

It is now recognized that Vibrio comma carries
both heat-stable somatic 0 antigens which are
species-specific, and heat-labile flagellar H anti-
gens which are shared widely among a variety of
vibrios in addition to V. comma. The 0 antigens
of the cholera organisms are not completely iden-
tical in all strains and although a single serum
will cause agglutination of all classical cholera
strains, agglutinin absorption studies reveal at
least two sub-types within the species; these were
designated as the Inaba (original) and the Ogawa
(variant) types by the Japanese and are the desig-
nations which are now widely used (Burrows,
J. Infect. Dis., 1953, 92, 152). The vaccines which
are currently employed contain both the Inaba
and Ogawa types. For a more detailed discussion
of the clinical background of cholera vaccine and
the antigenic structure of V. comma, see Burrows
et al., ibid., 1946, 79, 159, 168.

V. comma organisms used in the preparation of
cholera vaccine are usually grown on a tryptic
digest beef infusion agar at a pH of approxi-

mately 7 for 18 hours at 37°. They are then
washed from the surface of the agar with isotonic
sodium chloride solution containing 0.5 per cent
phenol. The bacterial suspension is adjusted im-
mediately to a density of 8000 million organisms
per ml., and held at room temperature for 24
hours, after which it is tested for sterility; if it
is satisfactory, it is tested for antigenicity.

Description. — "Cholera Vaccine is a turbid,
whitish liquid, nearly odorless or having a faint
odor due to the preservative." U.S.P.

Assay. — A test for potency is required by the
National Institutes of Health. Four-week-old
mice are immunized by an intraperitoneal injec-
tion of 0.25 ml. of a 1:10 dilution of the vaccine.
Two weeks later they are divided into groups and
the several groups are infected intraperitoneally
with mucin suspensions of virulent cholera or-
ganisms. These suspensions are prepared by grow-
ing V. comma for 5 hours at 37° and diluting the
suspension in 10-fold steps with a 5 per cent hog
gastric mucin medium. At the same time non-
immunized mice are also infected intraperitoneally
with graded doses of the same suspension to de-
termine the minimum lethal dose of the suspen-
sion. It is required that 50 per cent of the im-
munized mice receiving 100 MLD of V. comma
suspension must survive for at least 72 hours.
This immunization test is carried out on each lot
of vaccine, using both an Inaba and an Ogawa
strain of V. comma separately as the challenging
infection.

"Cholera Vaccine complies with the safety,
sterility, and antigenicity tests and other require-
ments of the National Institutes of Health of the
United States Public Health Service, including
the release of each lot individually before its dis-
tribution." U.S.P.

Uses. — Cholera vaccine is used for prophylactic
immunization against cholera. The duration of the
immunity which it produces is not known with
certainty, but is believed to be quite short (Dyer,
Ann. Int. Med., 1951, 35, 771). In areas where
cholera is endemic it has become the practice tc
re-immunize every 6 months with a "booster"
dose of 1 ml. Cholera vaccine is recommended for
travelers visiting or passing through most Asiatic
and Middle East countries. A certificate of vac-
cination is valid from the seventh day to the end
of the sixth month after vaccination; persons re-
turning to the United States within 5 days of
exposure in infected areas require a valid cer-
tificate to enter the country.

Cholera vaccine is usually given in three sub-
cutaneous doses of 0.5, 0.5 and 1 ml. at intervals of
7 to 10 days. Children are usually given one-half
or one-quarter these doses, depending upon body
weight and age. No severe reactions following use
of cholera vaccine have been reported; malaise
and fever may occur.

Labeling. — "The package label bears the name
Cholera Vaccine; the bacterial count at the time
of manufacture; the lot number; the expiration
date, which is not more than 18 months after date
of manufacture or date of issue; the manufac-
turer's name, license number, and address; and
the statement. 'Keep at 2° to 10° C. (35.6° to
50° F.).'" U.S.P.

Part I

Cholesterol

315

CHOLESTEROL. U.S.P.

Cholesterin, [Cholesterol]

CH3

CH-(CH2)3-CH(CH3)2

3 (Cis)-hydroxy-5-cholestene. Cholesten-(5 :6)-ol-3.
Colesterol.

Sp.

The principal animal sterol (see Sterids, Part
II) is cholesterol. Originally (1788) found in
gallstones, in which it is often present to the
extent of 90 per cent, cholesterol occurs in all
tissues of the animal body, but particularly in
the brain tissue and nerve sheaths; it exists both
free and esterified with fatty acids. The concen-
tration of it in normal tissues varies from a few
hundredths of a per cent to 4 or 5 per cent; blood
contains ISO to 200 mg. of cholesterol per 100 ml.
Cholesterol is synthesized in the body and while
the mechanism of its formation is still unknown,
from the experiments of Bloch and Rittenberg
(/. Biol. Chem., 1942, 143, 297; 1944, 155, 243)
which led to the finding that following adminis-
tration of acetic acid labeled with heavy hydrogen
to mice and rats there is produced cholesterol con-
taining heavy hydrogen, it would appear that
the sterol is synthesized from small molecules
and that acetic acid is a specific precursor of it.
It is altogether possible that cholesterol is the
substance from which the animal body synthe-
sizes the various sterid hormones and other sub-
stances of similar structure.

Foods contain varying amounts of cholesterol;
of these egg yolk is the richest source, containing
about 1.7 per cent of the sterol.

Cholesterol is obtained commercially from the
spinal cord of cattle by alkaline saponification
followed by extraction of the non-saponifiable
portion with suitable solvents. Wool fat is also
used for the production of cholesterol, but the
product must be treated to separate other type
alcohols from it. For certain details of its produc-
tion see Lower, Drug Costnet. Ind., 1953, 73,
758.

Cholesterol has been synthesized by Woodward
et al. (J.A.C.S., 1951, 73, 3547), starting with
2-methyl- 5-methoxy- 1 ,4-benzoquinone.

Though cholesterol has been known for many
decades its structure as a derivative of the cyclo-
pentanoperhydrophenanthrene nucleus was not
established until 1932, after more than thirty
years of study by Windaus and his colleagues,
and others. Cholesterol is a secondary alcohol
and it contains eight asymmetric carbon atoms,
permitting of numerous isomerides, some of which
are known.

Description. — "Cholesterol occurs as white
or faintly yellow, almost odorless, pearly leaflets
or granules. It usually acquires a yellow to pale
tan color on prolonged exposure to light. Choles-

terol is insoluble in water. One Gm. slowly dis-
solves in 100 ml. of alcohol, and in about 50 ml.
of dehydrated alcohol. It is soluble in acetone,
in hot alcohol, in chloroform, in ether, in ethyl
acetate, in petroleum benzin, and in vegetable
oils. Cholesterol melts between 147° and 150°."
U.S.P.

Lower (Drug Cosmet. Ind., 1953, 73, 758),
who records extensive solubility data for choles-
terol, states that clear aqueous solutions of
cholesterol may be prepared with the aid of
polyethylene glycol ethers of fatty alcohols or
fatty esters.

Standards and Tests. — Identification. — (1)
To a solution of 10 mg. of cholesterol in 1 ml. of
chloroform add 1 ml. of sulfuric acid: the chloro-
form is colored blood-red and the sulfuric acid
exhibits a green fluorescence. (2) To a solution
of 5 mg. of cholesterol in 2 ml. of chloroform
add 1 ml. of acetic anhydride and 1 drop of sul-
furic acid: a pink color, rapidly changing through
red and blue, and finally to a brilliant green, is
produced. Specific rotation. — The specific rota-
tion of a dioxan solution containing 200 mg. of
cholesterol in 10 ml. is between —34° and —38°.
Loss on drying. — Not over 0.3 per cent, when
dried at 60° for 4 hours. Residue on ignition. —
Not over 0.1 per cent. Acidity. — A solution of
1 Gm. of cholesterol in 10 ml. of ether is heated
with 10 ml. of 0.1 N sodium hydroxide and the
excess of alkali titrated with 0.1 N sulfuric acid,
using phenolphthalein T.S. as indicator. After
making any necessary correction by conducting a
blank test on the reagents, not less than 9.7 ml. of
0.1 iV sulfuric acid should be required. Solubility
in alcohol. — No deposit or turbidity results when
a solution of 500 mg. of cholesterol in 50 ml. of
warm alcohol is allowed to stand 2 hours. U.S.P.

Cholesterol and Arteriosclerosis. — Cho-
lesterol occupies a position of great interest in
medicine because of its alleged relationship to
arteriosclerosis, hence to vascular disease and
thereby to the most frequent cause of morbidity
and mortality in occidental populations of in-
creasing average age. Wilens (Arch. Int. Med.,
1947, 79, 129) indicated an incidence of arterio-
sclerosis of 50 per cent by the age of 50 years.
It is more frequent in the obese than in the
spare individual (Heyer, South. M. I., 1952, 45,
428). At age 18 years the average blood serum
cholesterol concentration was found to be 168 mg.
per 100 ml. in the study by Keys et al. (I. Clin.
Inv., 1950, 29, 1347) of the "healthy" popula-
tion in Minnesota, whereas at age 55 years it
was 256 mg. per 100 ml. Even though analyses
of non-atheromatous arteries show an increasing
cholesterol concentration with increasing age, it
is a natural hope that arteriosclerosis is not a
necessary concomitant of aging, but rather a
correctable abnormality of lipid metabolism. The
relationship of lipids to vascular disease has
been studied since Virchow described the fatty
lesions in 1856, Aschoff (Verhandl. deutsch. path.
Gesellsch., 1907, 10, 106) identified cholesterol
esters in the atheroma on the arteries, and
Marchand (Verhandl. Kongr. inn. Med., 1904,
21, 23) introduced the term atherosclerosis.
Anitschkow and Chalatow (Centralbl. allg. Path.,

316

Cholesterol

Part I

1913, 24, 1) produced atheromatosis in rabbits
by feeding egg yolk or cholesterol in oil; the
study of cholesterol metabolism has been vig-
orous, although rather unrewarding, ever since.
The predisposition to atherosclerosis of patients
with diseases characterized by hypercholesterol-
emia— diabetes mellitus, nephrosis, xanthomatosis
— has continued to stimulate the search for an
abnormality of cholesterol metabolism in patients
with cardiovascular disease. In the rabbit, which
is unable to excrete a large intake of cholesterol,
a high concentration in the diet results only in
cholesterosis of the arteries and other tissues
but in the dog or the chicken lesions identical
with those found in the human disease are pro-
duced in the coronary, cerebral and other arteries.
In man no definite evidence incriminating
cholesterol in the diet has been developed (Barr,
Am. J. Med., 1952, 13, 665). Keys (Fed. Proc,
1954, 13, 449) believes that hypercholesterol-
emia and atherosclerosis are correlated with an
excess of calories' as fat in the diet rather than
with dietary intake of cholesterol. This is of
course compatible with the rising incidence of
atherosclorotic disease in the generally over-
weight American public and the lower incidence
in non-fat-eating or malnourished populations.

Stroma Theory. — Aschoff {Lectures in Path-
ology, New York, P. B. Hoeber. 1924) cham-
pioned the "imbibition'" theory which held that
the deposit of cholesterol was secondary to tissue
damage rather than the primary abnormality.
In the second quarter of this century. Leary
(Arch. Path., 1949. 47, 1) was the sponsor in
the United States of the etiologic role of choles-
terol in atherosclerosis while Winternitz (with
Thomas and LeCompte, The Biology of Arterio-
sclerosis, 1938) was the proponent of the theory
that lipids and calcium were deposited in an area
of tissue destruction. His studies demonstrated
hemorrhage and thrombotic occlusion of the nu-
trient vessels (vaso vasorum) in the media of
atherosclerotic vessels.

Hypercholesterolemia. — Near the half cen-
tury mark, increased use of the clinical laboratory
had focused attention on the frequency of hyper-
cholesterolemia in patients who had experienced
acute myocardial infarction (Gertler et al., Circu-
lation, 1950, 2, 205; and others), which is fre-
quently associated with arteriosclerotic narrowing
of the coronary arteries. The report of Morrison
(J. A.M. A., 1951, 145, 1232) that the long-term
survival of coronary occlusion patients was
greatly improved by lipotropic therapy (choline,
etc.) resulted in a monstrous wave of anti-lipid
therapy in the United States, although his report
was subsequently criticized because of the lack
of an adequate, concurrent, comparable series of
untreated cases. The refined physical measure-
ments of Gofman and his associates {Science,
1950, 111, 166) and others, which demon-
strated a correlation between clinical vascular
disease and the presence of an increased con-
centration of large, low-density lipoprotein mole-
cules of certain flotation characteristics in the
ultracentrifuge. stimulated further tremendous
interest. Keys (J.A.M.A., 1951. 147, 1514),
however, claimed that an increased concentration

of cholesterol in the blood serum was more
closely correlated with vascular disease than were
these lipoprotein complexes which were imprac-
tical of measurement in ordinary laboratories.
The average physician depending upon the aver-
age clinical laboratory can only envy the ac-
curacy of the analytical procedure available to
Keys. For example, Moses and his associates
(Katz et al.. Am. J. Med. Sc, 1953, 225, 120)
found that the range in both normal and vascular
disease cases was so great and so overlapping
that single determinations of total serum choles-
terol, cholesterol-phospholipid ratio or concen-
tration of the Sf 12 to 20 flotation class of
lipoprotein molecules were of little diagnostic
value.

The theory of a primary lesion in the stroma
into which lipid and calcium are deposited as
they are in other destructive lesions, viz., tuber-
culous lesions in the lung, lymph nodes, etc..
continues to have strong advocates (Moon and
Rhinehart. Circulation, 1952, 6, 481; Duff. Arch.
Path., 1935. 20, 371; Willis, Can. Med. Assoc. J.,
1953, 69, 17, and see also under Ascorbic Acid).
In detailed studies of the human aorta, using
special stains and incubation with hyaluronidase.
Taylor (Am. J. Path., 1953, 29, 871) concluded
that the initial lesion was characterized by an
accumulation of chondroitin sulfate, degeneration
of elastic fibers and fibrosis. With certain excep-
tions (v.i.). the general failure to influence the
blood cholesterol concentration and perhaps over
a period of years the course of atherosclerotic
vascular disease with any feasible therapeutic
regimen has resulted in a critical attitude toward
the etiologic significance of lipid metabolism in
atherosclerosis. Furthermore, in this decade of
general interest in and incomplete understanding
of stress (Groen et al., J. Gerontology, 1951. 6,
95) as conceived by Selye (see under Cortico-
tropin), augmented by the general availability
of cortisone and corticotropin for therapeutic
use, the demonstration of lesions in the intima
of arteries of young soldiers in combat has called
attention to the impression of some clinicians
that the hypercholesterolemia after acute myo-
cardial infarction is secondary to the severe
injury rather than primary to the atherosclerosis.

Mechanical Factors. — The obvious role of
mechanical factors, at least in determining sites
and accelerating development of atherosclerosis,
must be considered. Such factors included hyper-
tension; local turbulence of blood flow, as at
the branching of arteries, the arch of the aorta,
etc.; impaired elasticity of the artery as a result
of external fixation by adjacent disease or by
intrinsic disease of the media. Medial sclerosis
of arteries, which is common in old age without
the complications familiar with intimal athero-
sclerosis, must be distinguished in this connection.

In summary, the relationship of cholesterol to
atherosclerosis must remain subjudice in spite
of the observations and studies of nearly a
century.

Occurrence. — In the body, cholesterol exists
mostly esterified (at carbon atom number 3 in
ring A) with various fatty acids. It is not dis-
solved in extracellular fluid but exists rather as

Part I

Cholesterol

317

a suspension of large lipoprotein aggegrates; the
phospholipids, such as lecithin, and also some
neutral fats are likewise included in these com-
plexes. Electrophoresis studies show these aggre-
gates to exist as a- and P-lipoproteins (Luetscher,
Physiol. Rev., 1942, 27, 621); the former con-
tains more phospholipid, which seems to increase
the solubility or suspension stability of choles-
terol. Similar groups of complexes may be pre-
cipitated with alcohol, while the ultracentrifuge
may be utilized to separate the wide variety of
aggregates containing cholesterol, phospholipid,
neutral fat and protein (Gofman et al., Circula-
tion, 1952, 5, 119; Pratt, Fed. Proc, 1952, 11,
270).

Macromolecules. — At least ten distinct spe-
cies of lipoprotein molecule, differing in density
and rate of flotation, have been described (Lind-
gren et al., J. Phys. Colloid Chem., 1951, 55,
80). In investigations on atherosclerosis those
lipoproteins with a density of less than 1.063
have been studied. Such lipoproteins are separated
from blood serum by adding a concentrated solu-
tion of sodium chloride to produce a specific
gravity of 1.063 in the serum, which is then
centrifuged for 13 hours to bring the low density
lipoproteins to the surface, where they may be
removed by pipetting; they are then transferred
to an ultracentrifuge which revolves 52,640 times
a minute (providing a centrifugal force 200.000
to 250,000 times that of gravity). The migration
of lipoproteins in this field occurs at different
rates for the different species and may be re-
corded photographically through changes in the
refractive index of the suspension. The results
are finally expressed in terms of Sf units, where
a unit is the flotation rate corresponding to
1 X 10 _13 cm. per second per dyne per Gm.
Isolation of particular species, corresponding to
different Sf values, may be achieved by use of
suspension media of appropriate density, and
thus the components of a complex mixture may
be separated and studied. The content of protein
in these lipoproteins varies from 25 per cent in
those having an Sf value of 2, to 7 per cent in
those characterized by an Sf of 40,000, which
latter are the chylomicrons observed with the
dark-field microscope (see Gofman et al., J.
Gerontology, 1951, 6, 105). The content of
cholesterol and its esters ranges from 30 per cent
in lipoproteins with an Sf value of 4, to 5 per
cent in lipoproteins with an Sf of 40,000, with
less of the esters in the latter than in the former;
phospholipid is present in all the lipoproteins,
with less of it being found in the higher Sf com-
pounds. Neutral fat (glycerides) is prominent
in lipoproteins having an Sf value above 17, and
virtually absent in Sf 13 and lower compounds.
The proportion of lipoproteins of Sf 20 and
above is influenced by meals, but those below
Sf 20 are not thus affected so that fasting blood
specimens are not required for studies of the
latter group. In rabbits fed cholesterol and fat,
dogs fed cholesterol and thiouracil, and chickens
implanted with diethylstilbestrol, lipoproteins
having an Sf of 10 and less appeared early in
significant concentrations in those animals that
subsequently developed atherosclerosis. As noted

above, studies of humans with atherosclerosis
have demonstrated a significant correlation with
increase in the concentration of Sf 0 to 12, and
also Sf 12 to 400, lipoproteins, although the latter
are also acutely and variably influenced by meals.
An excess of Sf 10 to 20 lipoproteins is also
observed in myxedema, nephrosis and xanthoma
tuberosum, in which conditions atherosclerosis is
excessive.

Lipomicrons. — The presence of glittering par-
ticles in the blood serum, best seen with a dark-
field microscope, has provided another method
of studying the metabolism of lipids. In relation
to atherosclerosis, Zinn and Griffith (Am. J. Med.
Sc., 1950, 220, 597) reevaluated this phenomenon
with the method used by Moreton (Science, 1948,
107, 371). The total number of lipomicrons
(fatty particles) per cubic millimeter of blood
serum and the number of such particles with a
diameter greater than 0.3 micron is counted.
Following a meal containing 20 Gm. of fat there
is a marked increase in the lipomicrons, which
reaches a maximum at about 4 hours. Because
of the marked increase in the total number of
particles, the percentage of large particles after
a fat meal tends to decrease in both normal and
atherosclerotic patients. However, in the fasting
state a chylomicron-lipomicron ratio of 55 per
cent was found in the atherosclerotic group,
compared with 28 per cent in a non-atherosclerotic
control group (in this study the chylomicron was
defined as larger than 0.5 micron). Since the
response to a fat meal was not abnormal in
atherosclerotic cases, it was suggested that the
abnormally high percentage of large particles in
the fasting state in these patients was another
indication of an abnormality of endogenous lipid
metabolism. There is about 8 per cent cholesterol
in large lipoprotein particles. In the ultracentri-
fuge chylomicrons have an Sf of about 40,000.
Heparin in vivo but not in vitro, is a lipemia clear-
ing factor (Anfinsen et al., Science, 1952, 115,
583) which seems to aggregate these visible and
invisible lipoprotein particles, which are adsorbed
on erythrocytes and disappear from the blood
serum. In patients with atherosclerotic disease,
the most extensive studies of the chylomicron-
lipomicron ratio have been conducted by Labecki
(/. Gerontol., 1952, 7, Proc. 3) who found that
a return toward normal occurs over a period of
weeks during medication with lipotropic agents
(choline, inositol, methionine). Levy et al. (J.
Applied Physiol., 1952, 4, 848) described an
abnormal lipomicron response in older persons,
particularly those with diabetes mellitus, follow-
ing a fat meal (0.5 Gm. fat per Kg.) which they
ascribed to deficient digestive secretions in the
aged.

Distribution. — In a man weighing 65 Kg.,
there is about 210 Gm. of cholesterol, or 0.3
per cent of the wet weight (Cook Nutr. Abst.
Rev., 1942, 12, 1), distributed in part as follows:
skin 51 Gm., nervous tissue 35 Gm. The concen-
tration ranges from 0.14 per cent in muscle.
0.12 per cent in erythrocytes, 0.2 per cent in
blood plasma, to 1.9 per cent in nervous tissue
and 4.5 per cent in the adrenal gland. The con-
centration in the plasma of humans is higher

318

Cholesterol

Part I

than in any other species. In plasma, 73 per
cent is esterified with higher fatty acids, while
in erythrocytes and brain it is almost entirely
free cholesterol. In nervous tissue it exists as a
complex with phospholipid and protein which
forms a constituent of myelin (Finnean, Experi-
cntia, 1953, 9, 17). In plasma, the lipoprotein
aggregate (protein, phospholipid, cholesterol,
glyceride) is involved in the transport of fat
(glycerides) (Fieser, Science, 1954, 119, 710).
In erythrocytes the cholesterol is present on the
surface and combines to neutralize substances
which would cause hemolysis (Schulman and
Rideal, Proc. Roy. Soc, 1937, B122, 29). In
body metabolism, cholesterol is converted into
pregnanediol, progesterone, vitamin D3, etc.
Some gallstones contain 70 per cent or more
of free cholesterol and in arteriosclerosis the
aorta contains 5 to 50 times as much cholesterol
as in normal individuals. In myxedema and cer-
tain cases of familial xanthomatosus the blood
cholesterol is increased. In xanthoma tendinosum
McGinley et al. (J. Invest. Dermat., 1952, 19,
71) found extreme elevations of Sf 0 to 12 lipo-
proteins, normal values of Sf 12 to 20 lipoproteins,
and a lowered proportion of Sf 20 to 400 lipo-
proteins, while in xanthona tuberosum the Sf
12 to 400 class of lipoprotein is greatly elevated
and the 0 to 12 class is reduced.

Synthesis in Tissues. — Simply eliminating
cholesterol from the diet is perhaps a futile
gesture, since it is actively synthesized in the
tissues from such 2-carbon metabolites as acetate
resulting from the catabolism of fat, protein and
carbohydrate (Gould, Am. J. Med., 1951, 11,
209). Studies utilizing the radioisotope carbon-14
show that more cholesterol is synthesized than
is eaten in an average diet (Gould et al., Fed.
Proc, 1951, 10, 191). Biosynthesis occurs largely
in the liver but also in the adrenal cortex, skin,
intestine, kidney, brain, and even the aorta.
Tissue cholesterol is in equilibrium with circulat-
ing cholesterol. Rosenman et al. (J. Clin. Endo-
crinol., 1952, 12, 1287) found decreased synthesis
of cholesterol in hypothyroidism despite the
characteristic hypercholesterolemia; in hyperthy-
roidism the opposite was true.

Excretion. — A full understanding of the ex-
cretion of cholesterol is lacking. Much of it is
found in the feces, by way of bile, existing as
cholesterol, coprosterol, dihydrocholesterol, etc.
The turnover of cholesterol is rapid; the half-life
of isotopically labeled cholesterol in the body is
only 8 days, but the mechanism and site of deg-
radation are unknown. Studies with carbon-14-
labeled cholesterol show that the side chain is
converted in part to carbon dioxide, which is
expired, whereas carbon-14 in the ring structure
is found in the feces (Chaikoff et al., J. Biol.
Chem., 1952, 194, 413). Conversion of choles-
terol to cholate in the liver, with excretion into
the bile and and thence the feces is a mechanism
of degradation and excretion which has been
discussed by Byers et al. {Metabolism, 1952, 1,
479).

Mechanism. — The possible causes of choles-
terosis are not known with certainty; they may
include excessive biosynthesis, abnormal trans-

port (impaired stability of plasma colloids),
abnormal permeability or metabolism of the
arterial wall, excessive absorption from the gas-
trointestinal tract, and decreased excretion in the
feces. The occurrence of atherosclerotic vascular
lesions at an early age in some families with
hypercholesterolemia (Adlersberg, Am. J. Med.,
1951, 11, 600) suggests the error of metabolism
mentioned in the opening paragraph of this dis-
cussion. In such cases Jones et al. (ibid., 1951,
11, 358) found the content of lipoproteins having
an Sf in the 12 to 20 range to be increased, and
Barr et al. (ibid., 480) observed the increase of
P-lipoprotein and decrease of a-lipoprotein in
the same condition. Both the Sf 12 to 20 lipo-
proteins and P-lipoprotein are lower in premeno-
pausal females than in males, paralleling the
greater incidence of atherosclerotic vascular dis-
ease in the latter. In old age both the lipoprotein
fractions and incidence of vascular disease are
again similar in both sexes. Estrogenic therapy
decreased the content of P-lipoprotein in Barr's
patients (Trans. A. Am. Phys., 1952, 65, 102)
and the incidence of coronary atherosclerosis in
the cholesterol-fed chickens studied by Katz and
his associates (Pick et al., Circulation, 1952, 6,
858). The data on the chickens suggest that
existing coronary atheroma will regress during
estrogenic therapy; Glass et al. (Metabolism,
1953, 2, 133), however, did not find a change in
the Sf pattern of lipoproteins with estrogen
therapy. The side effects of prolonged estrogen
administration do not make this an attractive
form of therapy for most patients even if fur-
ther study showed it to be effective.

Diet. — Cholesterol-free diets obtained through
avoiding eggs, milk and other staple foods while
utilizing carbohydrates and vegetable lipids to
provide calories are possible although unpalatable ;
furthermore, such diets do not result in a de-
crease in the concentration of cholesterol in blood.
Egg yolk and brain are the only common foods
containing more than 1 per cent of cholesterol.
Some other foods containing a high proportion
of cholesterol include the following, where the
figures give the content of cholesterol in mg.
per 100 Gm. (wet weight) of the food: cod liver
oil (570), butter (244), oleomargarine (186),
cream containing 35 per cent fat (124), chicken
fat (113), lard (99).

Cholesterol is reabsorbed by the intestine from
bile as well as being absorbed from food. Fat
appears to have an important role in the intes-
tinal tract in absorption of cholesterol. A low-fat
and -cholesterol diet does cause a decrease in
the concentration of cholesterol and of Sf 10 to
20 lipoproteins in the blood (Keys, Science, 1950,
112, 79; Jones et al, Am. J. Med., 1951, 11,
358; Nelson, Northwest Med., 1952, 51, 860).
Addition of vegetable fat to such diets causes
serum cholesterol to rise again (Hildreth et al.,
Circulation, 1951, 3, 641). Subcaloric rations in
Denmark during World War II were associated
with a decreased incidence of arteriosclerosis,
which increased again when restrictions were
lifted (Dedichen et al., 5th Conf., Factors Regu-
lating Blood Pressure, J. Macy Jr. Found., New
York, 1951, p. 117). A low-calorie diet resulting

Part I

Choline Bitartrate

319

in weight loss shows a decrease of Sf 12 to 20
lipoproteins (Walker et al., Am. J. Med., 1953,
14, 654). Gofman found that administration of
thyroid extract to euthyroid persons with elevated
Sf 12 to 20 lipoproteins was followed by a
decrease in concentration of the abnormal lipo-
protein class; since these persons lost weight
during the experiment a specific effect of thyroid
feeding is not demonstrated.

Medication.- — Intravenous or intramuscular in-
jection of heparin causes a marked decrease in
the concentration of lipoproteins of the Sf 12 to 20
range in rabbits and in humans (Graham et al.,
Circulation, 1951, 4, 465). In rabbits Seifter
et al. (Proc. S. Exp. Biol. Med., 1953, 83, 468)
found that the hypercholesterolemia induced by
a diet of cholesterol and fat was inhibited by
daily injections of hyaluronidase, which presum-
ably releases surface-active depolymerized hyal-
uronic acid from tissues; both heparin and
hyaluronic acid are polysaccharides which may
be classed as lipemia-clearing factors in vivo.
Nikkila and Majanen (Scandinav. J. Clin. Lab.
Invest., 1952, 4, 204) found less heparinoid
activity, as measured by protamine-binding ca-
pacity, in the blood of atherosclerotic than in
that of normal persons, although there was a
marked increase of mucoprotein in blood at the
time of an acute myocardial infarction. The ef-
fect of thyroid and of estrogen administration
has been mentioned previously. Lipotropic agents
such as choline, inositol and methionine have
little effect on blood cholesterol (Davidson, Am.
J. Med., 1951, 11, 736) or the Sf pattern of
lipoproteins, although their effect in mobilizing
excess fat from the liver and in increasing phos-
pholipid in the blood is well known; also,
Labecki (loc. cit.) reported a favorable change
in abnormal chylomicron-lipomicron ratios. Con-
sistent blood cholesterol reduction from use of a
combination of 200 mg. of choline, 250 mg. of
inositol, and 500 mg. of polysorbate 80 (Moni-
chol, Ives-Cameron) was reported by Sherber and
Levites (J.A.M.A., 1953, 152, 682); the role of
polysorbate 80 in this otherwise ineffective lipo-
tropic medication merits further study. A similar
consistent reduction of blood cholesterol, in ani-
mals and humans, has been obtained with the
sodium salt of phenylethylacetic acid (Redel and
Cottet, Compt. rend. acad. sc, 1953, 236, 25;
J.A.M.A., 1954, 154, 935). Sitosterol, given in
a dose of 2 to 4 Gm. daily with meals, reduced
elevated blood cholesterol levels to normal in a
study by Pollak {Circulation, 1953, 7, 702).

Uses. — Cholesterol is given official recogni-
tion in the U.S. P. because it is a constituent of
Hydrophilic Petrolatum, to which it imparts
water-absorbing power, a property characteristic
of cholesterol. Wool fat contains esters of choles-
terol and other high molecular weight polycyclic
alcohols which impart to the fat its notable water-
absorbing power. The B.P. Ointment of Wool
Alcohols similarly owes its ability to absorb water
largely to the presence of cholesterol. Both choles-
terol and its esters have been variously used as
emulsifying agents in formulations of the water-
in-oil type (see /. A. Ph. A., 1940, 29, 14);
it has been incorporated in some suppositories

for this purpose. It is an ingredient of certain
enteric-coating compositions (Maney and Kuever,
/. A. Ph. A., 1941, 30, 276).

A large variety of "hair tonics" contain choles-
terol, being used as an anti-irritant, in 1 or 2
per cent concentration, in alcoholic applications
for seborrhea; it is employed similarly in hair
dyes and bleaches. Various cosmetic lotions con-
tain cholesterol or hydroxycholesterols or their
esters.

Cholesterol has been included in certain hydro-
alcoholic, repository-type preparations for intra-
muscular injection.

Some edible emulsions, including bread spreads,
utilize cholesterol as an emulsifying agent. Esters
of cholesterol are used as anti-spattering agents
in margarine. There are many industrial uses for
cholesterol and its esters; these and other uses
have been reviewed by Lower in a series of papers
in Drug Cosmet. Ind., 1953, 73, 758; 1954, 74,
200, 356.

Storage. — Preserve "in well-closed, light-
resistant containers." U.S.P.

Off. Prep.— Hydrophilic Petrolatum, U.S.P.

CHOLINE BITARTRATE. N.F.

2-Hydroxyethyl-trimethylammonium Bitartrate

[HOCH2CH2N+ (CH3)3]HC4H406-

"Choline Bitartrate, dried in a vacuum desicca-
tor over phosphorus pentoxide for 4 hours, yields
not less than 98 per cent of C9H19NO7." N.F.

The base choline was first isolated, from the
bile of pigs, in 1849. It is a structural component
of the lecithin phospholipids, which are widely dis-
tributed in animal tissues and occur also in some
plants; it is also the parent substance of acetyl-
choline, which is concerned with transmission of
nerve impulses. Choline is (2-hydroxyethyl)tri-
methylammonium hydroxide, CH2OH.CH2.N-
(CHs)30H. It is a colorless, viscid, strongly alka-
line liquid, very hygroscopic and with a tendency
to absorb carbon dioxide from the air; it is very
soluble in water and in alcohol, but is insoluble in
ether. The substances amanitine, bilineurine, bur-
sine, fagine, gossypine, luridine, sincaline, and
vidine, isolated from various sources, are all iden-
tical with choline. Choline is synthesized through
interaction of trimethylamine and ethylene oxide
or ethylene chlorohydrin.

Choline readily forms salts, several of which are
available commercially. Choline bitartrate repre-
sents 47.8 per cent of choline; it is the least
hygroscopic of the salts and so is most suitable
for tablet and capsule formulations although be-
cause of its lesser solubility in water it is not as
well suited for liquid formulations. Choline dihy-
drogen citrate, which is also official in N.F., repre-
sents 41.0 per cent of choline; it is used both in
liquid and dry formulations. Choline chloride,
official in LP., represents 86.8 per cent of choline;
it is very hygroscopic and is suited only for formu-
lation of liquid dosage forms. Choline gluconate,
recognized in N.N.R., theoretically represents 40.5
per cent of choline, but is supplied commercially
as a solution containing 59 to 64 per cent of
the salt.

320

Choline Bitartrate

Part I

Description. — "Choline Bitartrate occurs as
a white, crystalline powder. It is odorless or it
may have a faint trimethylamine-like odor. It has
an acidic taste. It is hygroscopic. Choline Bitar-
trate is freely soluble in water and slightly soluble
in alcohol. It is insoluble in ether, in chloroform,
and in benzene." NJ?.

Standards and Tests. — Identification. — (I)
On heating to boiling a solution of 500 mg. of
choline bitartrate in 2 ml. of water to which 3 ml.
of sodium hydroxide T.S. has been added the odor
of trimethylamine is detectable. (2) A reddish
brown precipitate is produced immediately when
2 ml. of iodine T.S. is added to a solution of 500
mg. of the choline salt; on adding 5 ml. of sodium
hydroxide T.S. the precipitate dissolves but on
boiling the solution a pale yellow precipitate of
iodoform, having its characteristic odor, develops.
(3) An emerald green color develops immediately
on adding to 2 ml. of cobaltous chloride T.S.
1 ml. of a 1 in 100 solution of the choline salt
and 2 ml. of a 1 in 50 solution of potassium ferro-
cyanide. (4) A solution of choline bitartrate re-
sponds to tests for tartrate. Water. — The limit is
0.5 per cent, when determined by drying in a
vacuum desiccator over phosphorus pentoxide for
4 hours or by the Karl Fischer method. Residue
on ignition. — Not over 0.1 per cent. Heavy metals.
— The limit is 20 parts per million. AT.F.

Assay. — About 100 mg. of dried choline bi-
tartrate is dissolved in water and the choline pre-
cipitated as the reineckate, which is dried at 105°
for 1 hour. The weight of choline reineckate.
multiplied by 0.5993. gives the equivalent weight
of CgHiyXO-. N.F.

Uses. — As a component of the lecithin phos-
pholipids choline is found in nearly all body tis-
sues, as well as in several secretions. It occurs in
egg yolk, liver, yeast, heart, kidney, brain, lean
meats; also in wheat and soy beans. The daily
intake of choline varies from 250 to 600 mg.
Some years ago medical interest in choline cen-
tered in its being the parent substance of the
nerve impulse mediator acetylcholine (q.v.) ;
choline has much the same action on the auto-
nomic nervous system as acetylcholine. acetyl-P-
methylcholine. and carbamylcholine. although its
effect is far less potent. Slow intravenous injection
of 100 to 200 mg. of choline chloride, in an iso-
tonic solution, caused in patients a decrease of
tone and motility of the small intestine (Sielaff,
Arch. exp. Path.'Pharm., 1951. 214, 74). Current
interest in choline concerns its lipotropic action
and its role as a donor of methyl groups in meta-
bolic processes.

Lipotropic Action. — In 1932. Best et al. (Am.
J. Physiol., Proc. 44th Annual Meeting. 1932. 101,
7) reported that deposition of fat in the livers of
normal white rats, produced by a high fat diet,
could be prevented or reduced by administration
of lecithin and that equivalent amounts of choline
which might be derived from the lecithin had a
similar inhibitory effect. A diet deficient in choline
likewise results in fatty infiltration of the liver in
experimental animals, eventually causing necrosis
and fibrosis (cirrhosis). Young animals are more
susceptible than adults; in the young hemorrhagic
lesions are produced in the kidneys, along with

hypertension (Best, Fed. Proc, 1950, 9, 506),
anemia and edema (Alexander and Engel, J. Nu-
trition, 1952, 47, 361). Arterial lesions resembling
those in human atherosclerosis were observed by
Hartroft et al. (Proc. S. Exp. Biol. Med., 1952,
81, 3S4) in choline-deficient animals. Lipocaic,
an extract of pancreas, was found to correct
the fatty liver of the pancreatectomized animal
(Dragstedt et al., Am. J. Physiol., 1936, 117, 175)
and was thought to be a hormone. Chaikoff et al.
(J. Biol. Chem., 1945. 160, 489; concluded, how-
ever, that lipocaic contained an enzyme which
released methionine bound in protein, while Abels
et al. (Proc. S. Exp. Biol. Med., 1943. 54) claimed
that the active constituent was inositol. MacLean
and Best (Brit. J. Exp. Path., 1934, 15, 193)
observed that choline prevented deposition of fat
in livers of diabetic (pancreatectomized) dogs and
rats on a high fat diet.

Interference with protein metabolism in the
absence of insulin seems to result in a lack of
methyl groups which are essential for normal
transport or deposition of fat in the liver; these
"labile" methyl groups may be supplied by inges-
tion of choline, methionine or betaine. It has been
thought that choline functions in fat mobilization
by forming phospholipid in the fiver and studies
with phosphorus radioisotope have demonstrated
an increased rate of turnover of liver phospholipid
phosphorus after administration of choline
(Chaikoff. Physiol. Rev., 1942, 22, 291). In pa-
tients with fatty liver, but not in normal indi-
viduals. Caver and Cornatzer (Gastroenterology ,
1952, 20, 385) found an increased rate of phos-
pholipid turnover after giving choline or methio-
nine. However, certain non-lipotropic compounds,
as cystine and cysteine, also increased phospho-
lipid turnover, and to further complicate the pic-
ture certain non-methylated compounds have
been found to have lipotropic action. Moreover,
synthesis of "labile" methyl groups in tissues as
well as by bacteria in the intestinal lumen has
been demonstrated by du Vigneaud et al. (Science,

1950. 112, 267). The triethyl homologue of cho-
line has one-fifth the lipotropic action of choline
(McArthur and Lucas. Biochem. J., 1950, 46,
226). In animals a low-protein diet produces a
fatty liver which is aggravated by feeding cystine,
alcohol or sucrose (Best et al., Brit. M. J., 1949,
2, 1001) but corrected by feeding protein, choline
or methionine (Jaffe et al., Am. J. Path., 1950,
26, 951). It may be noted that methionine pos-
sesses both a "labile" methyl group and also a
sulfhydryl group.

Absorption" and Excretion. — On ingestion of
2 to 8 Gm. of choline (as bicarbonate) by humans
less than 0.3 per cent of the dose was found in
the urine, while two-thirds of the ingested choline
nitrogen appeared in the urine as trimethylamine
or its oxide (Huerga and Popper, J. Clin. Inv.,

1951. 30, 463). In healthy subjects, and also in
cases of hepatobiliary disease, no choline is found
in urine following average diets. In patients with
liver disease excretion of trimethylamine in the
urine was both delayed and diminished after a
dose of choline. In vitro, feces converted from 40
to 60 per cent of added choline to trimethylamine.
Urinary excretion of trimethylamine was greatly

Part I

Choline Bitartrate

321

reduced in patients ingesting Aureomycin and
phthalylsulfathiazole, where fecal bacterial count
is greatly reduced. Following intravenous injection
of 1 or 2 Gm. of choline base in 500 or 1000 ml. of
5 per cent dextrose solution about 9 per cent
of the choline was found in the urine, with no
significant increase in urinary trimethylamine
(Huerga et al, J. Lab. Clin. Med., 1951, 38, 904).
In cases of acute hepatitis, but not in cirrhosis
of the liver, the urinary choline was approximately
doubled. After ingestion of choline the unpleasant
odor of trimethylamine appears on the breath, in
the urine, and in perspiration.

Liver Disease. — Dietary treatment of clinical
cirrhosis, in which relatively large amounts of
choline or its part-precursor methionine were ad-
ministered, has led to results in humans which
suggest that choline is effective in correcting such
disease; lack of adequate controls makes it im-
possible to be conclusive on this point. Russakoff
and Blumberg {Ann. Int. Med., 1944, 21, 848)
reported having successfully treated 7 of 9 pa-
tients suffering from cirrhosis with ascites by
administering orally 6 Gm. of choline daily for
periods up to 6 months. Broun {Bull. St. Louis M.
Soc, 1945, 39, 403) observed that a larger pro-
portion of patients, with cirrhosis, receiving a
daily supplement of 1 Gm. of choline chloride in
their diet, where improved as compared with a
similar group treated by diet alone. Similar re-
sults were reported by Beams {J.A.M.A., 1946,
130, 190), who administered a mixture of choline
and cystine, and by Morrison {Ann. Int. Med.,
1946, 24, 465). In treating infectious hepatitis
Richardson and Suffern {Brit. M. J., 1945, 2,
156) did not find a daily supplement of 1.5 Gm.
of choline chloride to have any therapeutic value.
Using a phosphorus radioisotope technic no in-
crease in phospholipid turnover was observed fol-
lowing administration of choline or methionine in
cases of acute hepatitis (Cayer and Cornatzer,
Gastroenterology, 1951, 18, 79) but a definite
increase was found in cases of cirrhosis of the
liver (Williams et al., South. M. J., 1951, 44,
369). Choline therapy caused marked improve-
ment in malnourished Chilean children afflicted
with fatty infiltration of the liver, as demon-
strated by liver aspiration biopsies (Meneghello
and Niemeyer, Am. J. Dis. Child., 1950, 80, 905).
Evaluation of the contradictory reports may be
aided by recalling the definite benefit in many
instances of the previously considered hopeless
condition of cirrhosis of the liver obtained by
Patek et al. {J.A.M.A., 1948, 138, 543) with a
high-protein and high-vitamin diet. Liver biopsy
studies of cases treated with the diet alone, com-
pared with cases receiving choline also, showed no
superiority with lipotropic therapy (Kessler et al.,
Arch. Int. Med., 1950, 86, 671 ; Post et al, Gastro-
enterology, 1952, 20, 403). No improvement in
nitrogen retention was found by Gabuzda et al.
{J. Clin. Inv., 1950, 29, 566) with choline and
methionine therapy in cases of cirrhosis whereas
positive nitrogen balance was produced by paren-
teral testosterone propionate. As an effective high-
protein diet contains 1 to 2 Gm. of choline and
4 to 5 Gm. of methionine, it seems that additional
lipotropic substances are not needed unless the

patient is not consuming the recommended diet
{J.A.M.A., 1950, 144, 1566).

Diabetes Mellitus. — Choline therapy, in ad-
dition to the indicated diet and insulin, has been
reported to be beneficial in this disease by Taub
et al. {Ann. Int. Med., 1945, 22, 852). Improve-
ment in liver function and decreased requirement
of insulin with choline therapy have been observed
(Pomeranze and Levine, Gastroenterology , 1949,
16, 771; Pelner and Waldman, J. A.M. A., 1950,
143, 1017). Gates {J. A.M. A., 1950, 142, 1136)
has emphasized that choline benefited the liver
but could not substitute for insulin. Choline ther-
apy should be considered in diabetics with
complications such as neuropathy, retinopathy,
nephropathy, etc.

Atherosclerosis. — As mentioned under Cho-
lesterol, an extensive controversy has raged re-
garding the possible therapeutic use of choline in
atherosclerotic vascular disease. Morrison and
Gonzalez {Am. Heart J., 1950, 39, 729) reported
reduced mortality during the 1 to 3 years follow-
ing an acute myocardial infarction in patients
treated with 6 to 32 Gm. of choline orally daily.
This report has been criticized bitterly; Pollak
{Delaware State M. J., 1952, 24, 157) pointed
out that choline will remove fatty deposits from
the liver but will not remove cholesterol from the
arterial wall. Herrmann {Texas State J. Med.,
1946, 42, 260) reported a decrease in hyper-
cholesterolemia in patients with atherosclerotic
vascular disease following lipotropic therapy;
Nelson {Northwest. Med., 1952, 51, 860) reported
good clinical and laboratory results in patients
who had experienced coronary occlusion following
a very rigorous low fat diet, and lipotropic and
pyridoxine therapy. In experimental studies, how-
ever, choline has failed to influence hypercholes-
terolemia or atherosclerosis (see Moses and
Longabaugh, Arch. Path., 1950, 50, 179; Stamler
et al., Circulation, 1950, 2, 714, 722; Davidson,
ibid., 1951, 3, 332). No benefit of lipotropic ther-
apy was observed in angina pectoris (Jackson and
Wilkinson, 1954 Convention Am. Col. Physicians,
Chicago), but definite improvement in cases of
cerebral atherosclerosis was obtained with a com-
bination of lipotropic, B-vitamin and thyroid ther-
apy (Bamford, N. Y. State J. Med., 1951, 51,
2913). Xanthomatous skin lesions improved on
choline therapy (Pipkin, Texas State J. Med.,
1951, 47, 267). Disappearance of vitreous opaci-
ties from the eyes has been reported to have fol-
lowed use of choline (Eggers, N. Y. State J. Med.,
1951, 51, 2255).

Cystinuria. — This rare congenital anomaly of
metabolism has been markedly improved with
choline therapy (Zinsser, /. Urol., 1950, 63, 929).
For patients with cystine stones in the urinary
tract, or other complications, this appears to be
the first effective medication.

Thyroid Disease. — Clinical improvement in
cases of hyperthyroidism in women following ad-
ministration of 1 Gm. of choline daily orally has
been reported (Esposti, Minerva Med., 1950, 41,
297). Intravenous injection of 4 Gm. of choline
chloride, in 500 ml. of an isotonic solution, caused
a decrease of 15 to 25 per cent in the metabolic
rate of euthyroid persons (Seckfort and Trojan,

322

Choline Bitartrate

Part I

Klin. Wchnschr., 1951, 29, 704). An initial de-
crease in blood sugar, followed by an increase
(except in patients with liver disease), is observed
with such intravenous dosage (Seckforth and
Weisse, ibid., 1950, 28, 693). 13

Toxicology. — The toxicity of choline varies
widely with the route of administration and with
the animal. Hodge and Goldstein (Proc. S. Exp.
Biol. Med., 1942, 51, 281) found the LD50 in
rats, following administration by stomach tube, to
be 6.7 Gm. per Kg. The lethal dose for cats, when
choline is administered intravenously, is from 35
to 65 mg. per Kg. (Arai, Arch. ges. Physiol., 1922,
193, 359; Lohmann, ibid., 1907, 118, 215). Sub-
cutaneously administered, the lethal dose has been
given as 200 mg. per Kg. for the cat and 1 Gm.
per Kg. for the rabbit. In man, choline salts seem
to be well tolerated by mouth even in doses as
large as 30 Gm. daily, except for an unpleasant
body odor or a diarrhea in some patients. Intra-
venously a dose of 1 to 2 Gm. of the base has
been given in 0.2 per cent solution without un-
toward effect; with larger doses urticaria has been
reported. Attention has been called to the need
for careful supervision of choline administration
if the drug is to be both effective and safe {Brit.
M.J., 1945, 2, 573).

Dose. — The usual dose of choline bitartrate
(which represents 47.8 per cent of choline base) is
2 Cm. (approximately 30 grains) 3 times daily, by
mouth, with a range of 1 to 3 Gm. The maximum
safe dose is 12 Gm. and 30 Gm. is not ordinarily
exceeded in 24 hours.

Storage. — Preserve "in tight containers." N.F.

CHOLINE BITARTRATE
CAPSULES. N.F.

"Choline Bitartrate Capsules contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of C9H19NO7." N.F.

Usual Size. — 500 mg. (7>2 grains).

CHOLINE BITARTRATE
TABLETS. N.F.

"Choline Bitartrate Tablets contain not less
than 95 per cent and not more than 105 per cent
of the labeled amount of C9H19NO7." N.F.

Usual Sizes.— 500 and 600 mg. {iy2 and 10
grains).

CHOLINE CHLORIDE.

Cholini Chloridum

LP.

The LP. defines Choline Chloride as the chlo-
ride of 2-hydroxyethyltrimethylammonium hy-
droxide and requires it to contain not less than
9.84 per cent of N, and not less than 24.89 per
cent of CI, both calculated with reference to the
substance dried to constant weight at 110°.

Description. — Choline chloride occurs in
white, odorless crystals, very hygroscopic. It is
very soluble in water, freely soluble in alcohol;
practically insoluble in ether, in chloroform, and
in benzene. It melts at about 240°, with decom-
position, after drying at 110°. LP.

For a discussion of the chemistry and uses of
choline chloride see under Choline Bitartrate.
Since choline chloride represents approximately

twice as much choline base as does choline bitar-
trate, the chloride should be taken in about half
the dose of the bitartrate.

Storage. — Preserve in a tightly closed con-
tainer. LP.

CHOLINE DIHYDROGEN
CITRATE. N.F.

2-Hydroxyethyl-trimethylammonium Citrate

[HOCH2CH2N+ (CH3)3]H2C6H507-

"Choline Dihydrogen Citrate, dried in a vacuum
desiccator over phosphorus pentoxide for 4 hours,
yields not less than 98 per cent of C11H21NO&."
N.F.

For a discussion of the chemistry of choline
salts see under Choline Bitartrate.

Description. — "Choline Dihydrogen Citrate
occurs as colorless, translucent crystals, or as a
white, granular to fine, crystalline powder. It is
odorless or it may have a faint trimethylamine
odor. It has an acidic taste. It is hygroscopic when
exposed to air. Choline Dihydrogen Citrate melts
between 105° and 107.5°." N.F.

Standards and Tests. — Identification. — With
the exception of the difference in the test for the
anion component, the tests for identification are
the same as for the bitartrate. pH. — The pH
of a 1 in 4 solution is not less than 3.5 and not
more than 4.5. Water. — The limit is 0.25 per cent.
Residue on ignition. — Not over 0.05 per cent.
Heavy metals. — The limit is 20 parts per mil-
lion. N.F.

Assay. — The assay is the same as for Choline
Bitartrate. The gravimetric conversion factor is
0.6989. N.F.

The uses and dose are the same as for Choline
Bitartrate (the 41.0 per cent of choline repre-
sented in the citrate salt is for therapeutic pur-
poses taken to be equivalent to the 47.8 per cent
of choline represented in the bitartrate).

Storage. — Preserve "in tight containers." N.F.

CHOLINE DIHYDROGEN CITRATE
CAPSULES. N.F.

"Choline Dihydrogen Citrate Capsules contain
not less than 93 per cent and not more than 107
per cent of the labeled amount of C11H21NO8."
N.F.

Usual Size. — 500 mg. {iy2 grains).

CHOLINE DIHYDROGEN CITRATE
TABLETS. N.F.

"Choline Dihydrogen Citrate Tablets contain
not less than 95 per cent and not more than 105
per. cent of the labeled amount of C11H21NO8."
N.F.

Usual Sizes.— 500 and 600 mg. (iy2 and 10
grains).

CHONDRUS. N.F.

Irish-moss, [Chondrus]

"Chondrus is the dried, bleached plant of
Chondrus crispus (Linne) Stackhouse, or of
Gigartina mamillosa (Goodenough et Wood-
ward) J. Agardh (Fam. Gigartinacece) ." N.F.

Carrageen; Salt Rock Moss. Fucus Crispus; Fucus

Part I

Chondrus

323

Irlandicus. Fr. Carragaheen; Mousse marine perlee. Ger.
Irlandisches Moos; Felsenmoos; Hornklee; Krausmoos;
Lebermoos; Perlmoos; Knorpeltang; Seemoos.

Chondrus crispus grows upon rocks and stones
on the coast of Europe, and is especially abun-
dant on the southern and western coasts of Ire-
land. It is also a native of the United States and
Canada, and is gathered largely along the coast
of Massachusetts, at Scituate, below Boston, and
along the coast of Maine and the Maritime
Provinces, where it is partly torn from the rocks
and partly collected from the beach, on which
it is thrown up during storms. The season for
collection at Scituate, Massachusetts, begins late
in May and continues to September, June and
July being the best months.

Chondrus is now found only on rocks that
are from 15 to 20 feet below the tide. The men
go out in sail-boats or dories on the ebbing tide
and come in at half-flood. With long rakes they
scrape the moss from the rocks, collecting thus
about 50 pounds to the boat. The moss is spread
out on the high beach for a week or so, the action
of the sun and dew bleaching it purplish color. It
is then enclosed in half-hogsheads which are
arranged around a hole which is connected with
the back water of the salt marsh by a trench.
When the tide comes in, the water flows up the
trench and fills the shallow well. The collector
dips up this water and wets down the "moss"
until it is soft. The "moss" is again spread out
and subjected to the bleaching process, this alter-
nate treatment being repeated four or five times,
until the product is of a yellowish or white color.
The final drying is done in barns, where the moss
is stored until it is packed in barrels at the end
of the season.

Tunmann (Apoth. Ztg., 1909, pp. 91 and 151)
described in detail the morphology and composi-
tion of chondrus.

Girgartina mamillosa Ag. resembles the true
Irish moss, and, growing with it upon the rocks,
may be gathered with it. It can, however, be
at once distinguished by the numerous papillae
which cover the surface and margins of the
fronds and bear the fruit (cystocarps). In chem-
ical and medicinal properties it is probably iden-
tical with C. crispus.

The commercial supplies of chondrus are
chiefly obtained from Scituate and Boston
(Massachusetts), Nimes (France) and Dublin
(Ireland).

According to LaWall and Harrisson (J. A. Ph.
A., 1932, 21, 1146) much of the chondrus col-
lected in Europe is sulfur-bleached but that
gathered in Massachusetts is free from sulfur.
They found that the sulfur-bleached chondrus
contained arsenic in excess of the tolerance of
the U. S. Department of Agriculture.

Description. — "Whole Chondrus occurs as
matted masses consisting of the broken plants;
the thalli consist of a mixture of entire thallus
from 5 to 15 cm. in length, with slender subcylin-
drical stalks from which arise a series of dichoto-
mously branching, more or less flattened segments
which vary from very narrow to 15 mm. in
breadth, emarginate, deeply cleft or irregularly
lobed; thallus frequently coated with a calcareous

deposit of a bryozoan which effervesces with a
mineral acid; sometimes with sporangia embedded
near the apex of the segments (in C. crispus) or
with sporangia borne on short tuberculated projec-
tions or stalks, more or less scattered over the
upper portion of the segments (in G. mamillosa).
The plants are somewhat cartilaginous and have
a pale yellow to yellowish brown color, a slight
seaweed-like odor, and a salty, mucilaginous
taste." N.F.

Standards and Tests. — Identification. — (1)
When chondrus is boiled with 50 parts of water
for 30 minutes (the evaporated water being re-
placed), the liquid separated by straining becomes
a thick jelly on cooling. (2) Chondrus becomes
gelatinous and translucent when softened in cold
water; the thallus remains nearly smooth and
uniform, and is not swollen except slightly at the
tips. Gelatin and starch. — On boiling 300 mg. of
chondrus with 100 ml. of water for 1 minute and
filtering the mixture, the cooled filtrate produces
no precipitate with tannic acid T.S. (gelatin),
and no blue color with iodine T.S. (starch). Sul-
fites.— No bluish purple color develops within 15
minutes in a piece of potassium iodate-starch
paper suspended in a flask above a warmed mix-
ture of 5 Gm. of chondrus, 300 ml. of water and
5 ml. of phosphoric acid. Foreign organic matter.
— Not over 2 per cent. Acid-insoluble ash. — Not
over 2 per cent. N.F.

For tests to establish the presence of Irish
moss see J.A.O.A.C, 1939, 22, 93, 726.

Constituents. — The ash of chondrus amounts
to from 8 to 15 per cent and contains traces of
iodine. On oxidation with nitric acid the dry moss
yields from 21.6 to 22.2 per cent of mucic acid.
Herberger found 79 per cent of a mucilaginous
substance resembling pectin, and 9.5 of mucus,
with fatty matter, free acids, chlorides, etc. The
pectinous substance, called carrageenin, is prob-
ably not a pure principle but a mixture of carbo-
hydrate derivatives. Percival and Buchanan
{Nature, 1940, 145, 1020) reported that ex-
traction of chondrus with hot water yielded the
calcium salt of a carbohydrate ethereal sulfate.
Dillon and O'Calla {Nature, 1940, 145, 749) had
somewhat earlier announced the isolation of two
polymeric carbohydrates, apparently galactans,
from mucilage of chondrus by acetolysis of the
latter, a reaction which appears to be accompanied
by degradation of the carbohydrate principle (see
also Haas and Wells, Biochem. J., 1929, 23, 425,
and Butler, ibid., 1934, 28, 759).

Uses. — Chondrus has found use as an emulsi-
fying agent, a demulcent, and a substitute for
gelatin in the diet. It is acceptable to the taste,
is readily digested, and has some nutritive value.
As indicated in one of its identification tests, it
forms with water a jelly when present in approxi-
mately 3 per cent concentration.

A decoction of chondrus was formerly employed
as a demulcent in chronic coughs, in diarrhea (for
which its high pectin content may be beneficial),
and in irritation of the urinary tract; it is rarely
used for these purposes today. It produces an
excellent soothing lotion for chapped hands and
for similar inflammations of the skin, and has also
been employed as the vehicle of spermicidal

324

Chondrus

Part I

jellies. Chondrus continues to find use as an
emulsifying agent. Before preparing a decoction
of it maceration in cold water, for about 10 min-
utes, generally removes any unpleasant flavor that
it may have acquired from contact with foreign
substances.

Eisner et al. (Ztschr. physiol. Chem., 1937,
246, 244) reported that chondrus contains a
nitrogenous polysaccharide sulfuric ester, chem-
ically related to heparin, which exerts an anti-
coagulant effect on blood similar to that of
heparin. In 1939 a German patent was granted
for a preparation of chondrus to be used for pre-
vention of clotting of blood. Other sulfated muco-
polysaccharides and polysaccharides, such as dex-
tran sulfate. Paritol. and Treburon, have under-
gone clinical trial as anticoagulants, but untoward
side effects have prevented their general use (see
under Heparin i .

The average dose of chondrus. as a demulcent,
is 15 Gm. (approximately 4 drachms).

CHONDRUS EXTRACT. N.F.

Irish Moss Extract

"Chondrus Extract is the dried, refined hydro-
colloidal extractive prepared from Chondrus.
either bleached or unbleached." N.F.

This extract is prepared by exhausting chondrus
with water and evaporating the liquid to dryness.

Description. — "Chondrus Extract occurs as a
coarse or fine powder, tan in color, almost odor-
less and with a mucilaginous taste. Its solutions
are alkaline to litmus. Chondrus Extract is almost
completely soluble in 100 parts of water at 85°,
forming a viscous, opalescent, colloidal solution
which flows readily. It is insoluble in alcohol
and other organic liquids. Chondrus Extract dis-
perses more readily if first moistened with alcohol,
glycerin, or simple syrup, or if first mixed with
3 or more parts of finely powdered sucrose." N.F.

The extract is used for extemporaneous prep-
aration of chondrus mucilage.

Storage. — Preserve "in tight containers." N.F.

CHONDRUS MUCILAGE. N.F.

Irish Moss Mucilage

Wash 30 Gm. of chondrus quickly with cold
water, then place it in a suitable vessel, add 1000
ml. of boiling water, and heat the mixture on a
water bath for 10 minutes, stirring frequently.
Strain through muslin, with pressure, and add
sufficient hot water through the strainer to make
1000 ml. Mix thoroughly. Alternatively mix 20
Gm. of chondrus extract with 1000 ml. of water
and heat at 85° on a water bath for 30 minutes,
with occasional stirring; after cooling add suffi-
cient water to make the product measure 1000 ml.
and mix thoroughly. X.F.

Uses. — Chondrus mucilage, usually mixed with
10 to 20 per cent of glycerin, makes a soothing
application for chapped hands. In pharmacy, it
is used as an emulsifying and suspending agent;
it has the advantage over acacia of not being
precipitated by alcohol.

Storage. — Preserve "in tight containers." N.F.

CHROMIUM TRIOXIDE. N.F.

Anhydride, "Chromic Acid," [Chromii Trioxidum]

"Chromium Trioxide contains not less than 98
per cent of CrO.s. Caution — Chromium Trioxide
should not be brought into intimate contact with
organic substances, as serious explosions are likely
to result." N.F.

Anhydridum Chromicum; Acidum Chromicum. Fr. An-
hydride chromique; Acide chromique cristallise. Ger.
Chromsaure; Chromtrioxyd; Chromsaureanhydrid. It. Acido
croraico. Sp. Anhidrido cromico; Trioxido de Cromo;
Acido cromico anhidro.

Chromium trioxide may be prepared by the
action of sulfuric acid on potassium chromate or
potassium dichromate; the crystals that form are
washed with nitric acid and the latter removed
by a current of air.

Description. — "Chromium Trioxide occurs as
dark purplish red crystals, often needle-like, or
in flakes. It is deliquescent, and is destructive
to animal and vegetable tissues. One Gm. of
Chromium Trioxide dissolves in 0.6 ml. of water."
N.F.

Standards and Tests. — Identification. — (1)
Chlorine is evolved when chromium trioxide is
warmed with hydrochloric acid. (2) Chromium
trioxide responds to tests for chromate. Alkali
salts. — Not over 2 mg. of residue is obtained
when 500 mg. of chromium trioxide which has
been ignited to the insoluble sesquioxide. is ex-
tracted with hot water, the solution filtered,
evaporated to dryness, ignited, and this residue
treated as before in order to insure having only
alkali-metal salts in the final residue. Sulfate. —
No turbidity develops within 1 minute on adding
1 ml. of barium chloride T.S. to a solution of
1 Gm. of chromium trioxide in 100 ml. of water
previouslv acidulated with 3 ml. of hvdrochloric
acid. N.F.

Chromium trioxide is a powerful oxidizing and
bleaching agent, giving up its oxygen with great
facility to organic matter. At a heat above the
melting point, it gives off half its oxygen, and is
converted into the green sesquioxide, Cr203.

Assay. — About 1.5 Gm. of chromium trioxide
is dissolved in sufficient water to make 100 ml. of
solution. An aliquot of 10 ml. of the solution is
added to a potassium iodide solution containing
hydrochloric acid. After 5 minutes the solution is
titrated with 0.1 A7 sodium thiosulfate. using
starch T.S. as indicator. A blank test is made to
determine any necessary correction. Each ml. of
0.1 N sodium thiosulfate represents 3.334 mg. of
C1O3. In this assay the valence of chromium is
reduced from six to three, with three atoms of
iodine being liberated for each molecule of chro-
mium trioxide reacting: the hydrogen equivalent
of chromium trioxide is therefore three. N.F.

Uses. — In dilute solution chromium trioxide
is a powerful coagulant of albumin and is there-
fore astringent. In more concentrated solution,
because of its oxidizing power, it destroys all
forms of tissue and is a rapid and powerful
caustic. It is also an active germicide; according
to Koch a 1 per cent solution is sufficient to de-
stroy anthrax spores after two days' exposure. By
virtue of its oxidizing effect it destroys decaying
organic matter, combining with and neutralizing

Part 1

Chrysarobin 325

the ammonia and decomposing hydrogen sulfide,
thereby acting as a deodorant. Explosions may
occur. As a caustic the liquid formed by the spon-
taneous deliquescence of the crystals may be
used; it is most frequently applied by means of
a glass rod.

In dilute solution (5 per cent) chromium tri-
oxide is used as an antiseptic and astringent wash
in leukorrhea, ozena and hyperidrosis. It has been
found useful as a foot wash for preventing sweat-
ing of the feet and to harden the skin. In 20 per
cent solution it is used as a caustic for removal of
exuberant granulation tissue, warts, syphilitic
condylomata, nasal polypi, ulcers on upper re-
spiratory tract mucosa, and other foreign growths.
It is usually used once weekly and not oftener
than 3 times weekly. For the treatment of necrotic
gingivitis (Vincent's angina or "trench mouth")
a solution containing from 6 to 15 per cent of
chromic acid has been applied to infected areas;
a mouth wash containing 0.25 to 0.5 per cent of
the acid is also used (Mil. Surg., 1945 (August),
112). It has been widely used by dentists for ther-
apy of this disease (Dental Survey, 1945, 21,
2018) but, in experiments on rats, Glickman and
Johannessen (/. A. Dent. A., 1950, 41, 674)
demonstrated that 6 per cent chromic acid solu-
tion produces degeneration and necrosis of gingiva
within 2 hours but that gingival repair, even after
a single application, results in incomplete restora-
tion to the pre-existing gingival level; they be-
lieve that use of the 6 per cent acid in gingival
disease should be discouraged.

Toxicology. — Caution should be exercised in
the use of this agent as it is a powerful poison due
to both its local irritant effect and its systemic
action. A single drop of the saturated solution
taken internally has caused violent symptoms of
gastroenteritis and fatal results have followed the
too free external use of the drug.

Since chromium was first used, but particu-
larly in the present century, industrial poisoning
has occurred (Walsh, J.A.M.A., 1953, 153, 1305).
Common uses of chromium include electroplating,
anodizing, as an anti-corrosion agent in recircu-
lating water systems in diesel motors and air con-
ditioning systems, in zinc chromate priming paint,
leather tanning, wood preservation, photoengrav-
ing, blueprinting, lithography, wool and fur dye-
ing, dry-cell batteries, matches, explosives, in
bleaching of oils and in chemical industry gen-
erally. Ingestion of chromates results in yellow
discoloration of the mouth, abdominal pain, vomit-
ing, diarrhea, albuminuria and stranguria. Re-
covery is usual. The stomach should be emptied
and adequate parenteral fluids employed. De-
mulcent drinks are indicated.

Inhalation of concentrated mists from electro-
plating baths causes pulmonary congestion, fever
and productive cough. Acute hepatitis with jaun-
dice was observed in a person employed in the
chromium electroplating industry; absorption of
chromium by inhalation of the fine spray of
chromic acid arising from the baths is sufficient
to produce significant concentrations of chromium
in the urine (Pascale et al., J.A.M.A., 1952, 149,
1385). Bronchogenic carcinoma is reported more
frequently in workers exposed to chromium dust

(Machle and Gregarius, Pub. Health Rep., 1948,
63, 1114). Lesser concentrations result in a pain-
less ulcer on the lower cartilaginous nasal septum.
Progressively the mucosa appears pale, atrophic,
grey and sloughing. After one or two months, the
area perforates. Edmundson (/. Invest. Dermat.,
1951, 17, 17) found 61 per cent of 285 workers
in a chemical plant with perforated nasal septums.
When chromic acid enters a break in the skin, a
relatively painless punched-out ulcer with a raised
collar-like indurated border and minimal inflam-
mation appears. It heals slowly as an atrophic
scar. Dust or mist causes conjunctivitis, lachrima-
tion and coryza. A dark red turbidity of the
cornea may develop.

Dermatitis, which seems to depend on hyper-
sensitivity, appears in 1 to 10 of 1000 exposed
employees per year. The dermatitis varies from
an acute, vesicular, weeping eruption to dry,
erythematous, slightly elevated squamous plaques,
frequently on the dorsum of the hands, wrists and
forearms and often on the neck and eyelids. The
moist lesions heal in 2 to 3 weeks but the dry ones
persist several months. Although three-fourths of
all shoe leathers are tanned with chromate, the
incidence of sensitivity here is extremely low, at
least to the 3 to 6 per cent trivalent chromium
in combination with the leather. Most cases of
chromium dermatitis develop within the first nine
months of exposure to the substance. In testing
for hypersensitivity, a 0.5 per cent aqueous di-
chromate solution is used as a patch test; a 0.25
per cent solution might be safer in highly sensi-
tized persons, such as patients with dermatitis.
Pre-employment patch testing is recommended
to exclude hypersensitive applicants before their
employment.

The best treatment of dermatitis is prevention.
Plant cleanliness and protective measures are
worth while. Early recognition of the symptoms,
removal from exposure, application of wet dress-
ings, if infected lesions are present, and bland
topical preparations are used. Roentgen therapy
is used by some dermatologists. A 3 per cent
dimercaprol ointment has been recommended
(Cole, Arch. Derm. Syph., 1953, 67, 20), but
injections showed little benefit (Winston and
Walsh, J.A.M.A., 1951, 147, 1133).

For concentrations of chromium trixode used
externally see above. It is rarely if ever used in-
ternally and if it is the dose should not exceed
15 mg. (approximately % grain), well diluted
with water.

Storage. — Preserve "in tight containers." N.F.

CHRYSAROBIN. U.S.P.

Chrysarobinum

"Chrysarobin is a mixture of neutral principles
obtained from Goa powder, a substance deposited
in the wood of Andira Araroba Aguiar (Fam.
Leguminosce)." U.S.P.

Acidum Chrysophanicum Crudum. Fr. Araroba purine.
Ger. Chrysarobin. It. Crisarobina. Sp. Crisarobina.

Andira Araroba (Vouacapoua Araroba (Aguiar)
Druce) is a large leguminous tree, attaining a
height of 100 feet, with a smooth trunk, common

326 Chrysarobin

Part I

in the province of Bahia, Brazil. The wood is
yellowish, with numerous vessels, besides abun-
dant irregular interspaces of lacunae, in which
there is deposited a brownish powder known as
Goa powder {crude chrysarobin). This substance
was formerly official in the B.P. 1914 under the
name of Araroba. It is generally recognized to be
the result of the breaking down of the walls of the
wood elements but the exact nature of the change
or the cause of it remain unknown. It is collected
by felling the trees, sawing the trunks into seg-
ments and splitting them lengthwise; the yellowish
araroba powder is scraped out, along with splinter
and other foreign matter. In this crude condition
it is exported, and later it is freed of wood, etc.,
by sifting, drying and powdering it. The oldest
trees yield the largest amount of the powder. The
workmen who procure it often suffer severely
from irritation of the eyes and face. As first ob-
tained, chrysarobin is stated to be of a pale prim-
rose yellow, but it rapidly darkens with age, so
that in commerce it varies from a dull ocher to
a dark chocolate or maroon-brown.

"The powder varies in color from brownish-
yellow to umber-brown. Yields to hot benzene
not less than 50 per cent of a substance which,
on evaporating the filtrate, drying and powder-
ing the residue, has the character described under
'Chrysarobinum.' " B.P. 1914.

Goa powder has a bitter taste. It is insoluble
in water and most menstrua, but yields as much
as 80 per cent of its weight to solutions of caustic
alkalies and to benzene. The substance known as
chrysarobin is obtained by extracting goa powder
with benzene, filtering the mixture, evaporating
the filtrate, and powdering the residue.

Description. — "Chrysarobin occurs as a
brown to orange yellow, microcrystalline powder.
It is odorless or has a slight odor and is tasteless.
It is irritating to mucous membranes. Chrysa-
robin is very slightly soluble in water. One Gm.
of it dissolves in 400 ml. of alcohol and in about
160 ml. of ether. One Gm. dissolves in about 15
ml. of chloroform usually leaving a small amount
of residue. It is soluble in solutions of the fixed
alkali hydroxides." U.S.P.

Standards and Tests. — Identification. — (1)
Chrysarobin is soluble in alkali hydroxide solu-
tions with formation of a deep red color. (2)
Chrysarobin dissolves in sulfuric acid, producing
a deep red color ; when the solution is poured into
water the chrysarobin separates. (3) A red brown
color develops on mixing 2 mg. of chrysarobin
with 2 drops of fuming nitric acid; on adding a
few drops of ammonia T.S. the color changes to
violet red (chrysophanic acid produces a yellow
color). Residue on ignition. — Not over 0.3 per
cent. Acidity. — On boiling 100 mg. of chrysarobin
with 20 ml. of water and filtering the mixture, the
filtrate is neutral to litmus paper. U.S.P.

Constituents. — Notwithstanding considerable
research on the isolation and identification of the
constituents of chrysarobin, its exact composition
is unknown. It is certain that chrysarobin is
largely a complex mixture of reduction products
of chrysophanol (l,8-dihydroxy-3-methylanthra-
quinone, also called chrysophanic acid), emodin
( 1 ,6,8 - trihydroxy - 3 - methylanthraquinone) , and

emodin monomethyl ether; relatively small
amounts of the parent substances have also been
reported to be present. The reduction products are
called anthrones, dianthrones, and anthranols. Un-
fortunately there is some confusion in the naming,
and uncertainty in the identification, of certain of
these derivatives, particularly in the work of
earlier investigators who gave characteristic names
to different fractions of chrysarobin, some of
which may not have been chemical individuals.
For a discussion of this earlier work see U.S.D.,
22nd edition, page 330. Details of more recent
experiments mav be found in papers by Naylor
and Gardner (J.A.C.S., 1931, 53, 4114), and
Gardner (/. A. Ph. A., 1934, 23, 1178; ibid., 1939,
28, 143).

Uses. — Chrysarobin has long been used in
South America and India as a remedy in skin
diseases, but the attention of the medical profes-
sion was first called to it in 1874 by Sir Joseph
Fayrer. It is a remedy of great value in the treat-
ment of psoriasis and trychophytosis. Schamberg.
Kolmer and Raiziss (/. Cutan. Dis., 1915, 33)
reached the conclusion that chrysarobin was with-
out germicidal properties and that its beneficent
effects were probably due to its chemical affinity
for the keratin elements of the skin, the drug
abstracting the oxygen for its oxidation, which
takes place simultaneously with this union, from
the epithelium. Strakosch {Arch. Dermat. Syph.,
1944, 49, 1) studied the action of several types
of ointment on the skin. He reported that chryso-
phanic acid was present in the ointments in about
2 per cent concentration and that it caused irrita-
tion and had no therapeutic value. Chrysarobin
was rapidly oxidized by the linoleic acid of the
skin to oxychrysarobin. It caused burning, swell-
ing, redness, vesicles and exfoliation; microscopic
examination showed hyalin and necrotic changes
in the stratum granulosum and spinosum, in-
creased formation of pigment, exfoliation of
scales, edema and inflammation. There was no real
difference in the effect of 1, 3 or 5 per cent oint-
ments with hydrous wool fat or zinc oxide paste
as the base. Both the irritant and therapeutic
effects were greater in petrolatum.

In the treatment of chronic psoriasis, chrysa-
robin may be used in 1 to 10 per cent strength
in petrolatum with good effect; as little as 0.1 per
cent has been employed effectively. Chrysarobin
must be limited to relatively small areas of the
body, as application to extensive areas may pro-
duce systemic toxicity. It is used to the point of
slight irritation, then stopped, and resumed after
signs of irritation have disappeared. It must not
be used for treatment of the scalp, or near the
eyes, as it produces a conjunctivitis. Ointment
application has the objection of staining the skin
and clothing a brownish-violet color, and its in-
corporation in other vehicles may be desirable.
Of value may be a solution in collodion, which
may be prepared by dissolving 4 Gm. of chrysa-
robin in 30 ml. of the official flexible collodion.
This is painted over the lesions with a camel's
hair brush and after it is thoroughly dried the
film may be coated with plain collodion as a
further protection against staining the clothing.
Another method of applying the drug is in 1 to

Part I

Cinchophen 327

10 per cent solution in chloroform; this is painted
on the skin, the chloroform evaporating and leav-
ing a thin film of chrysarobin. Goodman (Arch.
Dermat. Syph., 1944, 49, 16) employed a 5 per
cent solution of chrysarobin in chloroform for
hyperkeratotic lesions of ringworm of the toes
and interdigital webs. For treating hemorrhoids
Kossobudskji highly recommended an ointment
containing 25 grains of chrysarobin, 9 grains of
iodoform, and 18 grains of belladonna extract per
ounce of petrolatum. Benzin is sometimes useful
to remove the stains caused by chrysarobin.

Orally, chrysarobin causes severe gastrointesti-
nal irritation with vomiting and diarrhea, as well
as renal irritation due to excretion of the small
amount of drug absorbed, the latter evidenced
by albumin, casts and red cells in the urine. Suf-
ficient percutaneous absorption may result from
its external application to affect the kidneys; an
alkaline urine is colored red. B

Storage. — Preserve in "well-closed contain-
ers." U.S.P.

CHRYSAROBIN OINTMENT. U.S.P.

[Unguentum Chrysarobini]
Sp. Ungiiento de Crisarobina.

Triturate 60 Gm. of chrysarobin with 70 Gm.
of chloroform, and gradually incorporate 870 Gm.
of yellow ointment, previously melted; stir until
the mixture congeals. Avoid loss of chloroform
by evaporation. U.S.P.

The purpose of the chloroform in the U.S.P.
process is to facilitate dispersion of the chrysa-
robin; in this respect, at least, a better product
than one made by trituration of chrysarobin with
the base is obtained.

Uses. — Chrysarobin ointment is a valuable ap-
plication for psoriasis, ringworm, and other dis-
eases of the skin; it has the disadvantage of
leaving a permanent stain on linen.

CINCHOPHEN. N.F., B.P.

Phenylcinchoninic Acid, 2-Phenylquinoline-4-carboxylic
Acid, [Cinchophenum]

C00H

"Cinchophen, dried at 105° for 1 hour, con-
tains not less than 99.5 per cent of C16H11NO2."
N.F. The B.P. requires a purity of 99.0 per cent
calculated on the basis of the substance dried to
constant weight at 105°.

Atophan (Schering and Glatz); Atocin; Quinophan;
Chinophen. Acidum Phenylcinchonicum; Acidum Phenyl-
chinolincarbonicum. Fr. Acide a-phenylcinchonique. Ger.
Phenylchinolinkarbonsaure; Phenylcinchoninsaure. It.
Acido fenilchinolincarbonico. Sp. Acido fenilquinoleino-
carbonico.

Cinchophen may be prepared by heating to-
gether aniline and benzaldehyde to form benzyli-
deneaniline and then condensing this substance
with pyruvic acid (CH3.CO.COOH). Another
method of preparing it is to condense isatin with
acetophenone in alkaline solution.

Description. — "Cinchophen occurs as small,

white or almost white, needle-like crystals, or as
a fine powder, and is stable in the air. It is nearly
odorless, has a slightly bitter taste, and is affected
by light. One Gm. of Cinchophen dissolves in
about 400 ml. of chloroform, in about 100 ml. of
ether, and in about 120 ml. of alcohol. It is prac-
tically insoluble in water. Cinchophen melts be-
tween 213° and 216°." N.F.

Standards and Tests. — Identification. — (1)
A saturated solution of cinchophen in hot diluted
hydrochloric acid yields a yellowish brown crys-
talline precipitate with platinic chloride T.S. (2)
A white crystalline precipitate forms on adding
3 ml. of ammonium chloride T.S. to a solution
of 500 mg. of cinchophen in 3 ml. of 1 N sodium
hydroxide. (3) A clear yellow liquid results on
heating 500 mg. of cinchophen in a test tube; on
continued heating carbon dioxide is evolved and
a light yellow distillate of phenylquinoline, crys-
tallizing as it cools, is obtained. If the phenyl-
quinoline is removed and dissolved in 3 ml. of
warm alcohol a yellow, crystalline precipitate of
phenylquinoline picrate may be obtained on add-
ing 3 ml. of a saturated solution of trinitrophenol
in alcohol. Loss on drying. — Not over 2 per cent,
when dried at 105° for 1 hour. Residue on igni-
tion.— Not over 0.25 per cent. Readily carboniz-
able substances. — A solution of 100 mg. of cin-
chophen in 5 ml. of sulfuric acid has no more
color than matching fluid O and no reddish or
brown color is obtained on adding 3 drops of
nitric acid. Aniline derivatives. — A clear, almost
colorless solution is obtained on warming 1 Gm.
of cinchophen with 5 ml. of 1 N sodium hydrox-
ide; addition of 10 ml. of sodium hypochlorite
T.S. to this solution does not produce a brown
color or render it not clear. N.F.

Assay. — About 500 mg. of cinchophen, dried
at 105° for 1 hour, is dissolved in neutralized
alcohol and titrated with 0.1 A7 sodium hydroxide,
using phenolphthalein T.S. as indicator. Each ml.
of 0.1 A7 sodium hydroxide represents 24.93 mg.
of C16H11NO2. N.F.

The B.P. includes the following test of iden-
tity: A 5 per cent solution prepared with the aid
of ammonia water yields a white flocculent pre-
cipitate with silver nitrate, a yellow one with
solution of lead acetate, and a green one with
solution of copper sulfate.

When cinchophen is to be prepared in a form
suitable for intravenous injection it is dissolved
in water with sufficient sodium hydroxide to form
the soluble sodium salt; the amount of alkali
added should produce a pH of about 7.5 in the
solution.

Uses. — Despite the definite therapeutic efficacy
of cincophen as an analgesic and antipyretic and
as an uricosuric agent (see under Nephrotropic
Agents, in Part II) in gout, it is not recommended
by many physicians because of the danger of
severe toxic reactions (hepatitis) and the availa-
bility of other effective and less toxic drugs. In
reviewing the literature, Hueper (Medicine, 1948,
27, 43) concluded that it was a valuable drug
which could be employed safely if the patient
was watched carefully. Because of reports of
acute yellow atrophy of the liver, the Federal
Food and Drug Administration in 1938 declared

328 Cinchophen

Part I

it a dangerous drug, not to be sold except on the
prescription of a physician. The survey of clini-
cians and pathologists by Klumpp (J. A.M. A.,
1941, 117, 1182) indicated that it was not an
essential drug, that it could not be administered
with complete safety and that recovery from poi-
soning with cinchophen was infrequent. More re-
cently a derivative, 3-hydroxy-2-phenylcinchoninic
acid, received a great deal of study because of its
"pituitary-stimulating" action, but again untoward
side effects, notably photosensitization, prevented
its general use.

Gout. — Cinchophen usually causes a marked
increase in the quantity of uric acid eliminated
through the kidneys. This effect may be manifest
either on a purine-rich diet or during starvation.
As one of the outstanding symptoms of the
metabolic disturbance commonly known as gout
is an increase of the uric acid in the blood, the
effects of cinchophen on purine excretion natu-
rally suggested its use in the treatment of these
and allied disorders. In the management of 31
patients with gout, Bartels {Am. Int. Med., 1943,
18. 21) reported excellent results with a regimen
consisting of a low-fat. low-purine. high-carbohy-
drate diet with added vitamin supplements and
abstinence from alcoholic beverages and adminis-
tration of cinchophen in doses of 500 mg. three
times daily for three days of each week. When
the blood uric acid level, which was determined
at intervals of 1 to 3 months, decreased, the fre-
quency of administration of cinchophen was de-
creased to twice and then once daily and finally
omitted entirely when the level was near normal.
Probenecid (see in Part II) is being evaluated
currently as a means of increasing uric acid
excretion.

Rheumatic Fever. — Mendel {Deutsche tned.
Wchnsckr., 1922, 48, 829) considered cinchophen
to have an antiphlogistic action and to be of value
in all sorts of inflammatory' conditions. Hanzlik
and Scott {J. A.M. A., 1921, 76, 1728) showed that
large doses of cinchophen produced the same type
of relief in rheumatic fever as obtained with
salicylates; these quantities of cinchophen caused
the characteristic ringing in the ears, nausea, etc.,
observed after full doses of the salicylates, and
also albuminuria and other evidences of renal
irritation. The derivative 3-hydroxy-2-phenyl-
cinchoninic acid was found to be most effective
in rheumatic fever (Blanchard et al, Bull. Johns
Hopkins Hosp., 1950. 87, 50) and useful in gout
and the so-called collagen diseases.

Toxicology.— Barron {J.A.M.A., 1924, 82,
2010) reported severe circulatory collapse from
a single dose of 1 Gm. of cinchophen. Worster-
Drought {Brit. M. J., Jan. 27, 1923) reported a
case of acute hepatitis following its use. Palmer
and Woodall {J.A.M.A., 1936, 107, 760) col-
lected the records of 191 cases of jaundice re-
sulting from use of cinchophen. the mortality
being 46 per cent. The smallest fatal dose was
300 mg.. given 3 times a day for 6 days. In sev-
eral cases the symptoms (fever, jaundice, pruritus,
tender liver, stupor) did not appear for a week
or two after the drug had been stopped. Spurling
and Hartman (/. Pharmacol, 1926. 30, 185),
showed that the drug very greatly increased the

output of bile by the liver. In view, however, of
the wide use of this drug — both by the profession
and by the laity — for years before its toxic effects
were discovered, it is obvious that there must be
some factor of personal idiosyncrasy involved
(Snyder et al, J. Lab. Clin. Med., 1936, 21, 545).
Among the precautions which should be observed
are: to avoid its use in anyone who has had
symptoms of liver disorder; not to give it in ex-
cessive doses or over long periods of time; and
to immediately withdraw the drug on the slightest
malaise or anorexia or other evidence of hepatic
disturbances. Neocinchophen is generally con-
sidered a less dangerous remedy.

Therapeutic employment of cinchophen is prob-
ably to be condemned. Since its toxicity is un-
related to dosage or to previous use, there is no
way of anticipating untoward reactions. Toxic
reactions vary from mild hepatitis to fulminating
yellow atrophy of the liver. Once symptoms ap-
pear, they proceed despite cessation of medication
{J. A.M. A., 1945, 127, 190). Treatment is sympto-
matic and supportive, including a high carbo-
hydrate intake, either orally or parenterally.
Methionine may be useful but large parenteral
doses must be used with caution in acute and
severe cases.

The usual dose of cinchophen is 500 mg. (ap-
proximately lYz grains) three times daily.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

CINCHOPHEN TABLETS. N.F.

[Tabellae Cinchopheni]

"Cinchophen Tablets contain not less than 92.5
per cent and not more than 107.5 per cent of the
labeled amount of CeHiiN02." N.F.

Usual Sizes. — 5 and 7J^ grains (approxi-
mately 300 and 500 mg.).

CINNAMON. N.F.

Saigon Cinnamon, [Cinnamomum]

"Cinnamon is the dried bark of Cinnamomum
Loureirii Nees (Fam. Lauracece). Cinnamon
yields, from each 100 Gm., not less than 2.5 ml.
of volatile oil." N.F. The B.P. recognizes under
this name the inner bark of coppiced plants of the
Cinnamomum zeylanicum Nees (described under
Ceylon Cinnamon).

Saigon Cassia. Cinnamomum Saigonicum. Fr. Cannelle
de Saigon. Sp. Canela.

Both cinnamomum and cassia were terms em-
ployed by the ancients, but whether exactly as
now understood it is impossible to determine.

From what source the ancients derived their
cinnamon and cassia is not certainly known.
Neither the plants nor their localities, as de-
scribed by Dioscorides. Pliny, and Theophrastus.
correspond precisely with our present knowledge;
but in this respect much allowance must be made
for the inaccurate geography of the ancients. It
is probable that the Arabian navigators at a very
early period conveyed this spice within the limits
of the Phoenician and Grecian, and subsequently
of the Roman, commerce.

The three principal varieties of cinnamon are

Part I

Cinnamon

329

known as Saigon Cinnamon, Ceylon Cinnamon
and Cassia Cinnamon. Of these the U.S. P. has
favored various ones in its previous editions. At
present the N.F. recognizes both the Saigon and
the Ceylon varieties and the B.P. only the Ceylon
(see Ceylon Cinnamon).

The genus Cinnamomum is a group of ever-
green trees with mostly three-nerved leaves. The
flowers which are either perfect or polygamous
are of a pale yellow color and borne in panicles.
Herail regards both C. Loureirii Nees and C. Cassia
Blume as varieties of Cinnamomum obtusifolium
Nees, Saigon cinnamon, accordingly, being de-
rived from C. obtusifolium var. Loureirii Perrot
and Eberhardt, and cassia cinnamon, or Chinese
cassia, from C. obtusifolium var. Cassia Perrot
and Eberhardt.

Cinnamomum Loureirii Nees, Saigon Cinna-
mon tree, is of medium height, native to China
and Japan. Its branches are glabrous and bear
opposite and alternate, rigid, entire, elliptic to
oblong, attenuate-acuminate leaves having a cori-
aceous texture. The petioles of these are l/i inch
or less in length, the blades 3 to 5 inches long.
The flowers are very small; they are, in the dried
state, an article of commerce under the name of
Flores Cassice or Cassia buds. The fruit is a berry
which adheres to the receptacle.

Saigon cinnamon is collected chiefly from wild
but also from cultivated trees, especially in the
mountainous districts of Annam, in French Indo-
China. The greater portion of it is from branches
and small stems, and is of good quality, although
sometimes chips of the thick trunk bark are mixed
with the quills. This variety is called Saigon be-
cause it is exported from the city of that name
in the southern part of Cochin China. Consider-
able of this bark is transhipped to Europe and
America via Hongkong.

Cinnamomum Cassia (Nees) Blume is culti-
vated for the bark, buds and oil of cassia in the
provinces of Kwangsi and Kwantung, southeast-
ern China. The bark after collection is scraped
and dried. It is then made into bundles weighing
from Yz to 1 kilo, which are tied with split bam-
boo, packed into bamboo cases which are then
covered with bamboo mats. Very frequently these
bundles contain chips and dirt in the center which
are obscured from view by long quills on the out-
side. The commercial supplies of cassia cinnamon
bark come from Canton and Hongkong. The
poorer grades are known as "cassia lignea." From
this tree is derived the spice known as cassia buds.
This consists of the calyx surrounding the young
ovary. Cassia buds have some resemblance to
cloves, and are compared to small nails with
round heads. The enclosed ovary is sometimes
removed, and they are then cup-shaped at top.
They have a brown color, and the flavor of cinna-
mon. Under the name of cassia vera there is sold,
in London, a bark which is probably derived from
C. Burmanni DC.

During 1952 this country imported 4,907,269
pounds of unground cassia and cassia vera from
French Indochina, Indonesia, Netherlands, Ni-
geria and Hong Kong, and 268,267 pounds of
cassia buds from Indonesia, Indochina, China
and Madagascar.

Allied Species. — C. iners Reinw. is distin-
guished from C. zeylanicum by the nervation of
its leaves, which are also paler and thinner. It is
probably only a variety, not a distinct species.
It yields the so-called wild cinnamon of Japan.
C. obtusifolium Nees, growing in Ceylon, Java,
and on the mainland of India, is said to have
been the chief source of the drug known formerly
by the name of Folia Malabathri and consisting
of the leaves of different species of Cinnamomum
mixed together. C. Culilawan Blume of the Moluc-
cas yields the aromatic bark culilawan; similar
barks are obtained from C. Sintoc of Java. Massoy
bark, from which an aromatic volatile oil is ob-
tained called oil of massoy, is the product of
Massoia aromatica Becc. In the mountains of
eastern Bengal, at a height of 1000 to 4000 feet,
flourish C. obtusifolium Nees, C. pauciflorum
Nees, and C. Tamala Nees et Ebern., and these,
with other unknown species, afford quantities of
bark which are shipped from Calcutta, Java,
Timor, etc., to Europe under the name of wild
cassia. The bark of the C. pedatinervium Meissn.,
a tree indigenous to Fiji, yields nearly one per
cent of a white aromatic volatile oil, with a
pungent spicy taste. These barks are mostly highly
aromatic, resembling cinnamon more or less
closely in flavor, and are distinguished by yielding
to cold water an abundant mucilage. Holmes de-
scribed the bark of C. pedativum Meis., and con-
cluded that it might be of value as a source of
safrol and linalool (Pharm. J., 1904, p. 892).

Description. — "Unground Cinnamon occurs
in quills up to 30 cm. long and 4 cm. in diameter,
the bark from 0.5 to 7.0 mm. in thickness, or in
broken irregular pieces or in flattened slabs up to
10 mm. in thickness. The outer surface of the
bark is light brown to dark purplish brown, often
with grayish patches of crustose lichens and
numerous bud-scars, finely longitudinally wrinkled
when from young twigs, otherwise, more or less
rough from corky patches surrounding the lenti-
cels, the inner surface is reddish brown to dark
brown, granular and slightly striate. The fracture
is short, the odor is characteristically aromatic.
The taste is sweetish, aromatic and pungent."
N.F. For histology see N.F. X.

"Powdered Cinnamon is yellowish brown or
reddish brown. It contains numerous single and
2- to 4-compound starch grains, the single grains
from 5 to 25 n in diameter; stone cells irregular
in shape, occasionally with one wall much thinner
than the other walls, sometimes containing starch;
fibers from 300 to 1500 |x in length, with very
thick, more or less wavy and slightly lignified
walls; parenchyma cells with reddish brown walls;
elongated secretion cells containing volatile oil or
mucilage; phloem ray cells with minute needles
of calcium oxalate; and fragments of somewhat
lignified cork." N.F.

Chinese cinnamon, or Cassia {Cinnamomum
Cassia, U.S. P., 1890), the source of Cinnamon
Oil, U.S. P., occurs in quills, usually single, some-
times double, very rarely more than double, from
30 to 60 cm. long, 2 to 5 cm. wide, and
0.2 to 3 mm. thick. In some instances the bark is
rolled very much upon itself, in others is not even
completely quilled, forming segments more or less

330

Cinnamon

Part I

extensive of a hollow cylinder. It is of a redder
or darker color than the finest Ceylon cinnamon,
thicker, rougher, denser, and breaks with a shorter
fracture. It has a stronger, more pungent and
astringent, but less sweet and grateful taste, and
though of a similar odor, is less agreeably fra-
grant. It is the kind almost universally kept in our
shops. Under the name of cassia have also been
brought to us very inferior kinds of cinnamon,
collected from the trunks or large branches of the
trees, or injured by want of care in keeping, or
perhaps derived from inferior species. Chinese
cinnamon is "in quills of varying length and about
1 mm. or more in thickness; nearly deprived of
the corky layer, yellowish-brown; outer surface
somewhat rough; fracture nearly smooth; odor
fragrant; taste sweet, and warmly aromatic."
U.S.P. 1890.

Standards. — Cinnamon contains not more
than 2 per cent of foreign organic matter. N.F.

Assay. — This is performed as directed for the
official Volatile Oil Determination. N.F.

Dodge (Am. Perfumer, 1939, 38, 30) described
a method for the determination of aldehyde in
cinnamon which permits the detection of syn-
thetic cinnamic aldehyde.

Constituents. — Cinnamon bark contains from
0.5 to 6.0 per cent of an essential oil (see Cinna-
mon Oil), some gum. coloring matter and a tan-
nin of the variety which gives a blue-black pre-
cipitate with ferric salts. Bucholz found in cassia
lignea 0.8 per cent of volatile oil. 4.0 per cent of
resin, 14.6 per cent of gummy extractive (prob-
ably including tannin), 64.3 per cent of lignin and
bassorin, and 16.3 per cent of water.

Adulterants. — Powdered cinnamon has been
grossly adulterated with sugar, ground hazelnut,
almond and walnut shells, galanga rhizome and
various other substances. Powdered cassia buds
are frequently added to the inferior cinnamon
powders. They contain a larger proportion of
volatile oil than the lower grades of cinnamon.

The cheap kinds of cassia, known as cassia
vera, may be distinguished from the more valu-
able Chinese cassia as well as from cinnamon by
their richness in mucilage; this can be extracted
by cold water; it is a thick glairy liquid, giving
dense ropy precipitates with corrosive sublimate
or neutral lead acetate, but not with alcohol.

The coarser cassia bark, or cassia lignea,
usually has some of the external or corky layer
adherent to it, and always the parenchymatous
mesophlceum or middle bark, but the inner bark
constitutes the chief mass. Isolated bast fibers
and thick-walled stone cells are scattered even
through the outer layers of a transverse section.
In the middle zone they are numerous, but do
not form a coherent sclerenchymatous ring as in
Ceylon cinnamon.

For a detailed description of the microscopical
structure of the commercial cinnamon, see Winton
and Moeller, The Microscopy of Vegetable Foods.
Spaeth described the microscopical characteristics
of the several kinds of cinnamon, and also the
adulterants of powdered cinnamon and the means
of detecting them (Pharm. Zentr., 1908, pp. 724,
729).

The chief substitute and adulterant for both

Saigon and cassia barks within recent years has
been the Fagot or Batavia cassia. This bark is
obtained from Cinnamomum Bunnanni Blume, a
tree native to Java and probably other East India
islands. It occurs in single or double quills that
are scraped, up to 3 mm. thick, light-brown to
reddish externally, extremely mucilaginous and
less aromatic than the other 3 main varieties.
The powdered bark, unlike the other cinnamon
barks described, forms a shiny mass in water and
may also be distinguished from these by the pres-
ence therein of tabular and prismatic crystals of
calcium oxalate.

Windisch reported (Ztschr. Untersuch. Nahr.
Genusm., 1921, 41, 78) ferric oxide to be a fre-
quent sophisticant of cinnamon.

Uses. — Cinnamon has a warming, cordial effect
on the stomach, is carminative, distinctly astrin-
gent, and, like most other substances of this class,
more powerful as a local than as a general stimu-
lant. It is seldom prescribed alone, though, when
given in powder or infusion, it will sometimes
allay nausea, and relieve flatulence. It is chiefly
used as an adjuvant, and is an ingredient of sev-
eral official preparations. It is often employed in
diarrhea, in connection with chalk and other
astringents.

Dose, of powder, 0.6 to 1.2 Gm. (approxi-
mately 10 to 20 grains).

Off. Prep. — Cinnamon Oil, U.S.P. Compound
Cardamon Tincture; Compound Lavender Tinc-
ture; Aromatic Rhubarb Tincture, N.F.

CEYLON CINNAMON. N.F. (B.P.)

Cinnamomum Zeylanicum

"Ceylon Cinnamon is the dried inner bark of
the shoots of coppiced trees of Cinnamomum
zeylanicum Nees (Fam. Lauracece). Ceylon Cin-
namon yields, from each 100 Gm., not less than
0.5 ml. of volatile oil." N.F. The B.P. recognize;
the same drug under the name Cinnamon.

B.P. Cinnamon; Cinnamomum. Cinnamomum zeylani-
cum (Fr.); Cortex Cinnamomi (Ger); Cinnamomi Cortex
(It.); Cinnamomum (Sp.). Fr. Cannelle de Ceylon. Ger.
Ceylonzimt; Javazimt; Malabarzimt; Echter Kanel; Echter
Zimt. It. Cannella; Cannella di Ceylan; Cannella regina.
Sp. Canela; Canela de Ceylan; Canela de Holanda; Corteza
de Canela.

Cinnamomum zeylanicum Nees is a native of
Ceylon and the neighboring Malabar coast. In
the wild state it is a bushy evergreen tree about
20 to 50 feet high, covered' with a thick, scabrous
bark. The branches are numerous, strong, hori-
zontal, and declining, and the young shoots are
beautifully speckled with dark green and fight
orange colors. The leaves are 4 to 7 inches long,
petiolate, opposite for the most part, coriaceous,
entire, ovate or ovate-oblong, obtusely pointed,
and three-nerved, with the lateral nerves vanish-
ing as they approach the point. There are also
two less obvious nerves, one on each side arising
from the base, proceeding toward the border of
the leaf, and then quickly vanishing. In one variety
the leaves are very broad and somewhat cordate.
When mature, they are of a shining green upon
their upper surface, and lighter-colored beneath.
The tree emits no odor perceptible at any dis-
tance. The bark of the root has the odor of cin-

Part I

Cinnamon, Ceylon

331

namon with the pungency of camphor, and yields
this principle upon distillation. The leaves have
a spicy odor when rubbed, and a hot taste. A
volatile oil has been distilled from them. The
petiole has the flavor of cinnamon. The flowers
have a disagreeable, fetid odor. The fruit has a
terebinthinate odor when opened, and a taste in
some degree like that of juniper berries. A fatty
substance, called cinnamon-suet, is obtained from
it when ripe, by bruising it and then boiling it in
water, and removing the oleaginous matter which
rises to the surface and concretes upon cooling.

The Ceylon cinnamon is produced chiefly from
cultivated plants growing in Ceylon, the principal
gardens being in the vicinity of Colombo. In 1938,
there were approximately 26,000 acres of this
cinnamon under cultivation in Ceylon. Here the
plant is never allowed to become a tree but by
vigorous cutting back is forced to produce a bushy
growth of slender stems. The seeds are planted
in seed beds or in holes of the plantation and the
young plants set out 6 to 10 feet apart. During
the second or third year the stems are cut down
to within several inches from the ground and, by
coppicing, produce a new crop of shoots. Only 5 or
6 of these shoots are allowed to grow from each
stump and these are kept straight by pruning.
The shoots are 6 to 8 feet high when they are
ready for cutting. Most of the harvesting occurs
during the rainy season, but continues throughout
the rest of the year on a limited scale.

Before decortication the shoots are trimmed
up, and the small pieces, when dried, constitute
cinnamon chips. The bark is divided by longi-
tudinal incisions, of which two are made in the
smaller shoots, several in the larger, and is then
removed in strips by means of a suitable instru-
ment. The pieces are next collected in bundles,
and allowed to remain in this state for a short
time, so as to undergo a degree of fermentation,
which facilitates the separation of the epidermis.
This, with the green matter beneath it, is removed
by placing the strip of bark upon a convex piece
of wood and scraping its external surface with a
curved knife. The bark now dries and contracts,
assuming the appearance of a quill. The peeler
introduces the smaller tubes into the larger, and
connects them also endwise, thus forming a con-
geries of quills which is about 36 inches long.
These are rolled by hand, when fresh and soft,
and slightly pressed, subsequently laid on mats
and dried for 3 days in the sun and 3 days in the
shade. During the drying process the quills are
rolled by hand every day and slightly pressed to
prevent swelling and splitting. During drying the
original white color of the quills turns to a yel-
lowish-brown hue. When sufficiently dry, these
cylinders are collected into bundles and bound
together by pieces of split bamboo. These are
transported from the plantations to buying cen-
ters (Colombo, Ambalangoda or Matara) where
dealers collect the bundles and bleach the quills
with sulfur, assort them into different grades and
make them up into bales of approximately 100
pounds each for the exporters.

The C. zeylanicum is also cultivated to a lim-
ited extent in some of the West India islands —
especially Jamaica, Martinique and Cayenne — and

in Brazil. The bark from this source is generally
regarded as inferior to that from Ceylon; it is
known commercially as Cayenne cinnamon. The
commercial supplies are imported from Colombo
(Ceylon) and Calcutta (India).

Description. — "Unground Ceylon Cinnamon
occurs in closely rolled congeries of quills, com-
posed of from 7 to 12 thin layers of separate
pieces of bark, up to about 1 meter in length and
from 8 to 13 mm. in diameter; the individual
pieces of bark attain a thickness of 1 mm. The
outer surface of the bark is light yellowish brown
to weak orange, smooth, longitudinally striate
with narrow yellowish groups of bast fibers, and
shows circular or irregular brownish patches and
occasional perforations marking the nodes. The
inner surface is light yellowish brown to weak
orange and shows faint longitudinal striations.
The fracture is short, with projecting bast fibers.
Ceylon Cinnamon has a delicately aromatic odor
and a sweetish and warmly aromatic taste." N.F.
For histology see N.F. X.

"Powdered Ceylon Cinnamon is light yellow-
ish brown to light brown. It contains spheroidal,
plano-convex or polygonal starch grains mostly
less than 10 \i- in diameter and occasionally up to
4-compound; numerous colorless stone cells up
to 150 n in diameter, occasionally with 1 wall
much thinner than the others and sometimes con-
taining starch grains; almost colorless pericyclic
fibers and slightly lignified bast fibers from 300
to 800 \i in diameter, spindle shaped and having
thick, more or less wavy, porous walls; elongated
secretion cells containing volatile oil or mucilage,
fragments of parenchyma tissue with reddish
brown walls, and raphides of calcium oxalate from
5 to 8 m. in length. The parenchyma cells, stone
cells and fibers frequently contain an amorphous
reddish brown substance, which is for the most
part insoluble in ordinary reagents." N.F.

According to Siebold, the bark of the large
branches is of inferior quality and is rejected;
that from the smallest branches resembles Ceylon
cinnamon in thickness, but has a very pungent
taste and odor, and is little esteemed, while the
intermediate branches yield an excellent bark,
about 2 mm. in thickness, which is even more
highly valued than the cinnamon of Ceylon, and
yields a sweeter and less pungent oil.

Standards and Tests. — Other cinnamons. —
Powdered Ceylon cinnamon contains not more
than a trace of lignified cork cells, few starch
grains exceeding 10 n in diameter, and no fibers
over 30 h- in breadth. Meals. — No aleurone grains
nor seed-coat tissues characteristic of linseed,
cottonseed or other oil-seeds may be present.
Foreign organic matter. — Not over 2 per cent.
Acid-insoluble ash. — Not over 2 per cent. N.F.
The B.P. limits total ash at 7 per cent and acid-
insoluble ash at 2 per cent.

Assay. — The volatile oil in 100 Gm. of Ceylon
cinnamon is determined by the official Volatile
Oil Determination, using the separator for oils
heavier than water. N.F.

Uses. — Ceylon cinnamon may be used for the
same purposes as Saigon cinnamon. To the extent
that the effect desired is dependent on concentra-
tion of oil in the drug it should be kept in mind

332 Cinnamon, Ceylon

Part I

that Saigon cinnamon yields, on the average, five
times as much oil as the Ceylon variety; on the
other hand the quality of the oil from the latter
is more highly esteemed.

Storage. — Preserve "in well-closed contain-
ers." N.F.

Off. Prep. — Compound Tincture of Carda-
mom; Aromatic Powder of Chalk, B.P.

CINNAMON OIL. U.S.P. (B.P.)

Cassia Oil, [Oleum Cinnamomi]

"Cinnamon Oil is the volatile oil distilled with
steam from the leaves and twigs of Cinnamomum
Cassia (Nees) Nees ex Blume (Fam. Lanracece),
rectified by distillation. It contains not less than
80 per cent, bv volume, of the total aldehydes of
Cinnamon Oil." U.S.P.

The B.P. recognizes only oil from the bark of
Cinnamomum zeylanicum Nees containing not
less than 55.0 per cent and not more than 68.0
per cent, by weight, of cinnamic aldehyde, C9H8O
(for description, see Oil of Ceylon Cinnamon in
this article).

B.P. Oil of Cinnamon. Oleum Cassis; Oleum Cinnamomi
-flithereum; Essentia Cinnamomi. Fr. Essence de cannelle
de Ceylan. Ger. Zimtbl ; Cassiaol. It. Essenza di can-
nella. Sp. Esencia de canela.

There are two cinnamon oils in commerce, one
obtained from Ceylon cinnamon, the other from
Chinese cinnamon (Cinnamormim Cassia) and
often distinguished by the name of cassia oil. For
many purposes the two oils are equivalent; that
of the Chinese cinnamon, which is much the
cheaper and more abundant of the two, will prob-
ably continue to be generally employed, notwith-
standing that the Ceylon product has the finer
flavor.

Description. — "Cinnamon Oil is a yellowish
or brownish liquid, becoming darker and thicker
by age or by exposure to air, and having the
characteristic odor and taste of cassia cinnamon.
One volume of Cinnamon Oil dissolves in 1 vol-
ume of glacial acetic acid and in 1 volume of
alcohol. One volume of Cinnamon Oil dissolves in
2 volumes of 70 per cent alcohol." U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 1.045 and not more than 1.063.
Optical rotation. — Between —1° and +1°, in a
100-mm. tube. Refractive index. — Not less than
1.6020 and not more than 1.6135, at 20°. Heavy
metals. — The oil meets the requirements of the
test for Heavy metals in volatile oils. Halogens. —
Under an inverted beaker, the interior surface of
which has been moistened with distilled water, is
ignited 3 or 4 drops of oil; the products of com-
bustion washed from the interior of the beaker
show no turbidity on addition of silver nitrate
T.S. and nitric acid. Rosin or rosin oils. — On
shaking 2 ml. of oil with 5 to 10 ml. of petroleum
benzin, the latter is but slightly colored and when
it is shaken with an equal volume of 1 in 1000
cupric acetate solution the mixture does not ac-
quire a green color. U.S.P.

Assay. — For total aldehydes. — A 5-ml. portion
of the oil is reacted with saturated solution of
sodium sulfite which has been neutralized to
phenolphthalein T.S. with sodium bisulfite solu-

tion. As the aldehyde constituents of the oil react
to form sodium bisulfite addition compounds,
sodium hydroxide is liberated and must be pro-
gressively neutralized in order that the reaction
may go to completion, as evidenced by cessation
of development of a pink color. The non-aldehyde
constituents, which remain insoluble in the aque-
ous mixture, are estimated by reading the volume
of the oily layer formed in the mixture. A cassia
flask, having a graduated neck, permits of the
measurement of the volume. U.S.P.

Constituents. — Cinnamon oil of the U.S.P.
contains up to 90 per cent of cinnamaldehyde,
CeHs.CEFCH.CHO; small amounts of methoxy-
cinnamaldehyde, cinnamic acid, cinnamyl acetate,
and eugenol are also present. Upon exposure to
air, the oil darkens and thickens, taking up oxygen
to form cinnamic acid and resinous products.

Oil of Ceylon Cinnamon. — This oil, recog-
nized by the B.P., is commonly distilled from in-
ferior grades of bark which are not suitable for
export. The oil is yellow when freshly distilled
but gradually changes to a reddish-brown with
age.

The B.P. states that the oil is soluble in 3
volumes of 70 per cent alcohol with not more
than a slight opalescence. The weight per ml.,
at 20°, is between 0.994 and 1.034 Gm.; the re-
fractive index is between 1.565 and 1.582 at 20°.
The B.P. assay is carried out with a weighed
amount of oil dissolved in benzene, treated with
alcoholic hydroxylamine hydrochloride solution,
and titrated with 0.5 N alcoholic potassium hy-
droxide, using methyl orange as indicator. Each
ml. of 0.5 N potassium hydroxide is equivalent to
66.61 mg. of cinnamic aldehyde. The B.P. pro-
vides a test for absence of cinnamon leaf oil in
which it is specified that a slight green, but not
a blue or deep brown color may be produced on
adding 0.1 ml. of 5 per cent w/v ferric chloride
solution to 0.1 ml. of oil dissolved in 10 ml. of
alcohol.

Cinnamic aldehyde is the chief constituent, but
about 10 per cent of eugenol is also present, along
with phellandrene and other terpenes.

The cinnamon leaf oil contains much eugenol
and very little cinnamic aldehyde; safrol and
benzaldehyde are present as minor constituents.
It has a brownish color, a penetrating fragrant
odor, and a very pungent taste, resembling in
these respects clove oil. Schimmel & Co. found it
to have a sp. gr. 1.056 to 1.060, and to contain
87 per cent of eugenol, and about 0.1 per cent of
cinnamic aldehyde.

Uses. — Although a very powerful germicide,
cinnamon oil. because of its irritant properties,
is rarely used in medicine as an antibacterial.
The oil is an active fungicide and Kingery recom-
mended a mixture containing 1 per cent of it and
0.5 per cent of thymol as an application for tinea
capitis (Arch. Dermat. Syph., 1929, 20, 797).
The oil has the cordial and carminative properties
of cinnamon, without its astringency, and was
formerly much employed as an adjuvant to stom-
achic or carminative medicines. As a powerful
local stimulant, it has been sometimes prescribed
in gastrodynia. flatulent colic, and gastric debility.

Cinnamaldehyde, the predominant constituent

Part I

Citric Acid

333

of cinnamon oil, was found to be an effective anti-
mold agent for syrups in a concentration of 1 in
10,000 (Lord and Husa, /. A. Ph. A., 1954, 43,
438).

Mitscherlich found six drachms to kill a mod-
erate-sized dog in five hours, while two drachms
killed another in forty hours. Inflammation and
corrosion of the gastrointestinal mucous mem-
brane were observed after death.

Dose, 0.06 to 0.2 ml. (approximately 1 to 3
minims).

Storage. — Preserve "in well-filled, tight con-
tainers and avoid exposure to excessive heat."
U.S.P.

Off. Prep. — Cinnamon Water; U.S.P.; Com-
pound Cardamom Spirit; Aromatic Castor Oil;
N.F. Dentifrice; Compound Vanillin Spirit, N.F.;
Concentrated Cinnamon Water, B.P.

CINNAMON WATER. U.S.P.

Aqua Cinnamomi

"Cinnamon Water is a clear, saturated solu-
tion of cinnamon oil in purified water, prepared
by one of the processes described under Waters."
U.S.P.

Hydrolatum Cinnamomi. Fr. Eau distillee de cannelle.
Ger. Zimtwasser. It. Acqua di cannella. Sp. Agua de
Cancla.

Cinnamon water is much used as a vehicle for
disagreeable medicines, but it should not be used
indiscriminately in inflammatory affections. Ordi-
narily it is diluted with an equal volume of water.

Off. Prep.— Chalk Mixture, N.F.

CONCENTRATED CINNAMON
WATER. B.P.

Aqua Cinnamomi Concentrata

Concentrated cinnamon water is prepared from
20 ml. of cinnamon oil, 600 ml. of alcohol and
sufficient distilled water to make 1000 ml.; the
mixture is shaken with 50 Gm. of talc, set aside
for a few hours, with occasional agitation, and
filtered. It contains approximately 54 per cent
v/v of alcohol. The B.P. gives the dose as from
0.3 to 1 ml. (approximately 5 to 15 minims).

Concentrated cinnamon water may be diluted
with 39 volumes of distilled water to provide
essentially the equivalent of cinnamon water pre-
pared by saturating distilled water with oil;
such a diluted water contains about 1.3 per cent
of alcohol.

CITRIC ACID. U.S.P., B.P.

[Acidum Citricum]

CH2— COOH
I
HO— C— COOH
I
CH2— COOH

"Citric Acid is anhydrous or contains one
molecule of water of hydration. It contains not
less than 99.5 per cent of CgHsOt, calculated on
the anhydrous basis." U.S.P. The B.P. requires
not less than 99.5 per cent and not more than
the equivalent of 101.0 per cent of C0H8O7.H2O.

Fr. Acide citrique. Ger. Zitronensaure; Citronensaure.
It. Acido citrico. Sp. Acido citrico.

Citric acid, chemically 2-hydroxy-l,2,3-pro-
panetricarboxylic or beta-hydroxytricarballylic
acid, is the acid to which lemons and other citrus
fruits owe their sourness but which occurs also
in other natural sources, such as tobacco. It is a
normal constituent of whole cow's milk, occurring
to the extent of 0.19 Gm. per 100 ml. Citric acid
may play an important role in carbohydrate
metabolism.

Prior to the development of the microbiological
process for manufacturing citric acid Italy pro-
duced about 90 per cent of the world supply of
citric acid from citrus fruits. Extraction of citric
acid from this source usually involves precipita-
tion of calcium citrate by addition of a calcium
salt, followed by liberation of citric acid with sul-
furic acid, and crystallization of the former from
the acid liquor.

In 1893 it was discovered that citric acid is a
product of mold metabolism in media containing
sugars; many species of Penicillium and Asper-
gillus are capable of synthesizing the acid. The
control of the pH of the nutrient medium is
highly important; at a pH of 6 to 7 oxalic acid is
the principal product while in the range of pH 1
to 2, citric acid is formed to the exclusion of oxalic
acid. In 1923 commercial production of citric
acid by microbiological synthesis from molasses
was started in the United States and development
was so rapid that in a few years this country pro-
duced sufficient, and sometimes more than enough,
citric acid for its own requirements. Various the-
ories to explain the mechanism of citric acid
formation have been offered; a plausible one
assumes degradation of the sugar to pyruvic
acid, CH3.CO.COOH, which adds carbon dioxide
to form oxaloacetic acid, COOH. CH2. CO. COOH,
and then, by condensation with acetic acid, is
converted to citric acid. The acetic acid for
this reaction may be produced by decarboxyla-
tion of another molecule of pyruvic acid to form
acetaldehyde, which is then oxidized to acetic acid.

Citric acid may be synthesized by the action
of hydrocyanic acid upon acetonedicarboxylic
acid and subsequent hydrolysis of the product,
but the process is not economical. Citric acid
has also been synthesized from glycerin, and
from acetoacetic ester. These syntheses served
to establish the chemical formula of citric acid.

When crystallized from its solution by cooling,
it contains one molecule of water. Crystals con-
taining half a molecule of water have also been
prepared. Witter (Pharm. Zentr., 1892, 1003)
obtained anhydrous citric acid, in crystals melt-
ing at 153°, by heating aqueous solutions of
the hydrated acid to 130°. On the other hand
Berlingozzi (Ann. chim. app., 1934, 217) deter-
mined that the temperature for transformation
of dry citric acid monohydrate to the anhydrous
acid to be 56° to 58°. If citric acid is further
heated after all its water of crystallization has
been driven off, there is produced aconitic
acid, COOH.CH:C(COOH)CH2.COOH, which is
found naturally in aconite, larkspur, black helle-
bore, equisetum, yarrow, and other plants.

Description. — "Citric Acid occurs as color-

334

Citric Acid

Part I

less, translucent crystals, or as a white, granular
to fine, crystalline powder. It is odorless, has
a strongly acid taste, and the hydrous form is
efflorescent in dry air. One Gm. of Citric Acid
dissolves in 0.5 ml. of water, in 2 ml. of alcohol,
and in about 30 ml. of ether." U.S.P.

Standards and Tests. — Identification. — Cit-
ric acid responds to tests for citrate. Water. —
Anhydrous citric acid contains not more than
0.5 per cent, and hydrous citric acid contains not
more than 8.8 per cent, of water, when deter-
mined by the Karl Fischer method. Residue on
ignition. — Not over 0.05 per cent. Oxalate. — No
turbidity is produced on adding calcium chloride
T.S. to a solution of citric acid, previously neu-
tralized with ammonia, then acidified with diluted
hydrochloric acid. Sulfate. — No turbidity is pro-
duced on adding barium chloride T.S. to a solu-
tion of citric acid. Heavy metals. — The limit is
10 parts per million. Readily carbonizable sub-
stances.— A solution of 500 mg. of citric acid in
5 ml. of sulfuric' acid maintained at 90° for 1
hour has no more color than matching fluid K.
U.S.P.

The B.P. includes a test for limit of copper
and iron. The arsenic limit is 1 part per million
and the lead limit is 20 parts per million.

Assay. — About 3 Gm. of citric acid is dis-
solved in water and titrated, as a tribasic acid,
with 1 N sodium hydroxide, using phenolphtha-
lein T.S. as indicator. Each ml. of 1 N sodium
hydroxide represents 64.04 mg. of CeHsOi. U.S.P.
The British assay is essentially the same except
that thymol blue is used as the indicator.

Incompatibilities. — Citric acid is incompati-
ble with alkali hydroxides and carbonates, con-
verting them into citrates, in the latter case
with effervescence; with calcium and strontium
salts citric acid and its compounds produce white
precipitates of the insoluble citrates of these re-
spective elements.

Aqueous solutions of citric acid generally show,
on standing, fungoid growth.

Uses. — Action and Metabolism. — In human
biochemistry citric acid appears to be established
as an important intermediate in a metabolic
cycle, commonly called Krebs citric acid cycle,
which represents the pathway of aerobic oxida-
tion of pyruvic acid in the body. Not only does
this cycle explain many aspects of carbohydrate
metabolism but it also integrates fat and protein
metabolism in a final pathway common to all
three classes of substances. It is worthy of note
that in this cycle the conversion of pyruvic acid
to citric acid may take place in essentially the
same manner as citric acid is produced microbio-
logically from sugars by way of pyruvic acid (see
preceding discussion). For further information
concerning the citric acid cycle, also known as
the tricarboxylic acid cycle, reference should be
made to a textbook of biochemistry.

Except for its local irritant action citric acid
is almost without effect upon the system. In any
ordinary quantity it is entirely oxidized in the
body and eliminated through the lungs as car-
bonic acid. For this reason the citrates of sodium
and potassium, although neutral salts in them-

selves, tend to alkalize the system, appearing in
the urine as carbonates. This change probably
occurs in nearly all the tissues of the body. Ad-
ministered in toxic quantities, citric acid and
citrates produce in animals a sequence of symp-
toms identical with that following calcium ion
deficiency and is probably the result of precipi-
tation of calcium (Gruber and Helbeisen, /.
Pharmacol., 1948, 94, 65). According to Woods
(J.A.M.A., 1927, 88, 168) only after enormous
doses does some of the citric acid appear in the
urine unchanged. So efficient is the oxidation of
citric acid that it can replace glucose in relieving
insulin hypoglycemia (Mackay et al., J. Biol.
Chem., 1940, 133, 59). Hagelstam (Acta Cliir.
Scandinav., 1944, 90, 37) found the blood citric
acid concentration elevated in hepatitis but not
in obstructive jaundice. A report (Ztschr. phyisol.
Chem., 1940, 265, 244) that blood pyruvate de-
creases to 22 per cent of the initial level following
oral administration of sodium citrate was not con-
firmed (Proc. Soc. Exp. Biol. Med., 1944, 57,
314).

Urolithiasis. — Citric acid is important in the
formation and treatment of urinary calculi
(Shore, J. Urol, 1945, 53, 507). In the human
the 24-hour urine contains from 0.4 to 1.5 Gm.
of citric acid. In women it is near the lower
amount at the time of menstrual flow, increasing
to the higher level at the time of ovulation and
remaining elevated until a few days before the
onset of the next period. In both sexes adminis-
tration of estrogenic substances increases urinary
critic acid excretion; androgenic material de-
creases the excretion; progesterone has no effect
by itself but it enhances the action of estrogens.
The amount of citric acid is greater in alkaline
urine or in urine containing an increased amount
of calcium. A soluble, but weakly ionized, com-
plex salt — Ca[CaCitrate]2 — increases the solu-
bility of calcium, particularly in alkaline urine,
and decreases the tendency of calcium and phos-
phate ions to reach sufficient concentration to
precipitate in the urinary tract. Patients troubled
with recurrent stone formation show a subnormal
concentration of citrate in the urine (/. Urol.,

1943, 50, 202) and almost no increase of urinary
citric acid following the oral or parenteral ad-
ministration of citric acid or the citrates. Many
of the bacteria found in urinary tract infections
associated with stone formation, such as B. Pro-
teus, consume the citric acid in the urine in their
metabolism and produce a highly alkaline urine
by splitting urea to ammonia. The hard substance
of bone contains up to 1.5 per cent of citric acid
— about 70 per cent of the total body content of
citric acid (Biochem. J., 1941, 35, 1011)— but
this store is not mobilized by the administration
of either alkalinizing or acidifying salts (/. Biol.
Chem., 1944, 155, 503). Since the administration
of citric acid causes no real increase in urinary
citrate and sodium citrate increases the alkalinity
and calcium content (Proc. Soc. Exp. Biol. Med.,

1944, 56, 226) of urine, Shore suggested the
administration of natural estrogens in the treat-
ment of patients who are recurrent formers of
calcium phosphate or carbonate or magnesium

Part I

Clove

335

ammonium phosphate urinary calculi in either
sterile or infected urine. Acidification of the urine
is usually impossible in the presence of infection
with urea-splitting bacteria and acidification de-
creases the concentration of citric acid in the
urine. Shore also advised a low phosphorus diet
and aluminum hydroxide orally; this decreases
excretion of phosphate in the urine to as little
as 10 per cent of its previous level but does
not disturb the metabolic balance of calcium,
phosphorus or nitrogen in these patients.

Some success (see Hamer and Mertz, /. Urol.,
1944, 52, 475) has been obtained in dissolving
stones already formed in the bladder or even the
renal pelvis by continuous irrigation with solu-
tion "G", which consists of citric acid monohy-
drate 32.25 Gm., magnesium oxide (anhydrous)
3.84 Gm., sodium carbonate 4.37 Gm. and sterile
distilled water to make 1000 ml. Continuous irri-
gation, or repeated instillation, with 1.5 to 3 liters
of this solution daily is required for 10 days
or much longer to dissolve large stones. Solution
"M" differs from "G" in using sodium carbonate
8.84 Gm. ; it is less irritating but likewise less acid
and less solvent. Citric acid will not dissolve
calcium oxalate, uric acid or cystine stones.

Rickets. — The daily addition to the feeding
formula of the infant of 30 ml. of molar sodium
citrate (294 Gm. of Na3C6H507.2H20 per liter)
and 20 ml. of molar citric acid (210 Gm. of
H3C6H5O7.H2O per liter) cures rickets in the
infant at about the same rate as with large doses
of vitamin D (Hamilton and Dewar, Am. J. Dis.
Child., 1937, 54, 548; Shohl, /. Nutrition, 1937,
14, 69). In active rickets, the blood citrate con-
centration is low and is elevated rapidly when
vitamin D is administered. Citrate therapy, how-
ever, will not prevent rickets; an adequate diet
including vitamin D is essential.

Miscellaneous Uses. — Citric acid is mildly
astringent and is sometimes used in inflamed con-
ditions of the skin, such as sunburn. A concen-
tration of about 1.6 per cent has been used in
collyria, and up to 20 per cent has been employed
in mouth washes.

Citric acid, in the form of citric acid syrup, is
used as a vehicle for salty drugs. The acid is
sometimes employed in formulations containing
iron salts and tannin to retard development of
color. The acid is also an important ingredient
of effervescent salts, the water of hydration
present in it serving to provide sufficient water
to produce the pasty mass essential for the forma-
tion of a granular salt. Citric acid is included in
several U.S. P. and N.F. preparations.

Dose. — The usual dose of the acid is 0.3 to 2
Gm. (approximately 5 to 30 grains).

Storage. — Preserve "in tight containers."
U.S.P.

Labeling. — "Label Citric Acid to indicate
whether it is anhydrous or hydrous. Where the
quantity of Citric Acid is indicated in the labeling
of any preparation containing Citric Acid, such
indication is in terms of anhydrous Citric Acid,
unless otherwise specified in the monograph."
U.S.P.

CITRIC ACID SYRUP. U.S.P. (B.P.)

[Syrupus Acidi Citrici]

B.P. Syrup of Lemon; Syrupus Limonis. Sirupus Citri.
Fr. Sirop d'acide citrique ; Sirop de lemon. Ger. Kiinstlicher
Citronensirup. It. Sciroppo di limone. Sp. Jarabe de
limon; Jarabe de Acido Citrico.

Dissolve 10 Gm. of citric acid in 10 ml. of
purified water, add 950 ml. of syrup and mix well.
Add 10 ml. of lemon tincture, and enough syrup
to make 1000 ml. Mix thoroughly. This prepara-
tion must not be dispensed if it has a terbinthinate
odor or taste or shows other indications of de-
terioration. U.S.P.

The B.P. calls this preparation Syrup of Lemon,
and makes it by macerating fresh lemon peel in
a small quantity of alcohol to which is added,
after filtering, citric acid and syrup. The propor-
tion of citric acid in the finished product is 2.4
per cent w/v. The B.P. directs that it should be
stored in a container which has previously been
washed with boiling water and kept in a cool
place. The acidity of the B.P. product is more
than twice that of the U.S.P. preparation.

Alcohol Content. — Less than 1 per cent, by
volume, of C2H5OH. U.S.P.

Use. — Because of its acidity, as well as sweet-
ness, this syrup has utility as a vehicle for bitter
or salty drugs; it has no remedial value. Its acid
reaction may give rise to incompatibilities with
alkaline ingredients, such as phenobarbital sodium,
from which it precipitates phenobarbital.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 25°." U.S.P.

CLOVE. N.F., B.P.

Caryophyllus, Cloves

"Clove is the dried flower-bud of Eugenia
caryophyllata Thunberg (Fam. Myrtacece) . Clove
yields, from each 100 Gm., not less than 16 ml.
of clove oil." N.F. The B.P. recognizes Eugenia
caryophyllus (Spreng.) Sprague as the botanical
origin of Clove. This is merely a botanical syno-
nym for Eugenia caryophyllata Thunb.

Caryophyllum; Caryophylli Aromatici; Flores Caryophylli;
Clavi Aromatici. Fr. Girofle ; Clou de girofle. Ger. Gewiirz-
nelken; Kneidenelken ; Nagelein. It. Chiodi di garofano.
Sp. Clavo de especia; Clavo. Portug. Clavo da India.
Dutch. Kruidnagel.

The clove-tree is a small tree inhabiting the
Molucca Islands and southern Philippines. It has
a pyramidal form, is evergreen, and is adorned
throughout the year with a succession of beautiful
rosy flowers. The stem is of hard wood, and
covered with a smooth, grayish bark. The leaves
are opposite, petiolate, about four inches in
length by two in breadth, obovate-oblong, acumi-
nate at both ends, entire, sinuate, with many
parallel veins on each side of the midrib. They
have a firm consistence and a shining green color,
and when bruised are highly fragrant. The flowers
are disposed in terminal corymbose panicles, and
exhale a strong, penetrating, and grateful odor.

The natural geographical range of the clove is
extremely limited, being confined to the Molucca
or, as they were one time called, Clove Islands.
According to Fliickiger, cloves were known in
western Europe as early as the sixth century, long

336

Clove

Part I

before the discovery of the Moluccas by the
Portuguese. After the conquest of the Molucca
Islands by the Dutch, the monopolizing policy of
that commercial people led them to extirpate
the trees in nearly all the islands except Amboyna
and Ternate, which were under their immediate
inspection. Notwithstanding their vigilance, a
French governor of the Islands of France and
Bourbon, named Poivre, succeeded, in 1770, in
obtaining plants from the Moluccas and introduc-
ing them into the colonies under his control.
Five years afterward the clove-tree was intro-
duced into Cayenne and the West Indies, in
1803 into Sumatra, and in 1818 into Zanzibar.
At present the spice is cultivated both in the
West and East Indies, in tropical Africa, and in
Brazil. Approximately three-fourths of the
world's clove supply is grown in Zanzibar and
the neighboring island of Pemba.

The unexpanded flower buds are the part of
the plant employed under the ordinary name of
cloves. They are, first gathered when the tree
is about six years old. The fruit has similar
aromatic properties, but much weaker. The buds
are at first white, then become green, and then
bright red. They are gathered when their lower
part turns from green to red. This is done by
hand picking from movable platforms or by beat-
ing the trees with bamboos and catching the fall-
ing buds. In the Moluccas they are said to be
sometimes immersed in boiling water and after-
ward exposed to smoke and artificial heat before
being spread out in the sun. In Zanzibar, Pemba,
Cayenne, and the West Indies they are dried
simply by solar heat, often on mats, and separated
from their pedicels and peduncles ("clove
stems"). The "stems" of the flowers also enter
commerce. They possess the odor and taste of
the cloves, but they are worth only about one-fifth
the price of the cloves, as they deficient in vola-
tile oil. They are largely used as an adulterant
in ground cloves, and are used in the manufacture
of oil of cloves. In France they are generally
known by the name of griffes de girofle.

In commerce the varieties of cloves are known
by the names of the localities of their growth, and
so closely resemble one another as to be distin-
guished only by experts. The Penang and Am-
boyna cloves are the largest and thickest and
have been especially prized; the Bencoolen cloves
from Sumatra are also valuable. During 1952, a
total of 1,867,560 pounds of unground cloves was
imported into the U. S. A. from British East
Africa, Ceylon and Madagascar. In the same year,
456,816 pounds of clove oil entered this country
from Madagascar, British East Africa, France
and Netherlands.

Description. — "Unground Clove is a flower bud
from 10 to 17.5 mm. in length, of a dark brown
or dusky red color, consisting of a sub-cylindrical,
slightly flattened, four-sided hypanthium which
contains in its upper portions a 2-celled, inferior
ovary with numerous ovules attached to a central
placenta, the hypanthium terminated by 4 thick,
divergent sepals and surmounted by a dome-
shaped corolla, consisting of 4 membranous, im-
bricated petals, which enclose numerous curved
stamens having introrse anthers, and 1 style, at

the base of which is a nectar disc. Its odor is
strongly aromatic and its taste pungent and aro-
matic, followed by a slight numbness of the
tongue. Clove stems are sub-cylindrical or
4-angled, attaining a length of 25 mm. and a
diameter of 4 mm., either simple, branching, or
distinctly jointed, and less aromatic than the
flower buds.

"Powdered Clove is dark brown. It consists of
parenchyma fragments showing the large oval
schizolysigenous oil reservoirs, spiral vessels, and
a few rather thick-walled, spindle-shaped fibers.
Calcium oxalate occurs in rosette aggregates,
from 10 to 15 ix in diameter. Fragments of the
walls of anthers with characteristic reticulated
cells and numerous tetrahedral pollen grains
from 15 to 20 n in diameter are also present. A
50 per cent solution of potassium hydroxide added
to a microscope mount of powdered cloves re-
acts with the volatile oil of the oil reservoirs to
form acicular crystals of potassium eugenate."
N.F.

Standards and Tests. — Other foreign mat-
ter.— Not over 1 per cent of foreign matter
other than stems. Crude fiber. — Not over 10
per cent. Acid-insoluble ash. — Not over 0.75
per cent. Clove stems. — Stone cells, irregular or
polygonal, up to about 70 n in diameter, with
thick, porous walls and large lumina, sometimes
filled with an orange or yellow amorphous sub-
stance, are few or absent. Clove contains not
more than 5 per cent of clove stems. Clove fruit
or cereals. — Starch grains are absent. — N.F.

Assay. — This is performed as directed for
the official Volatile Oil Determination. N.F.

The best cloves exude a small quantity of oil
on being pressed or scraped with the nail. When
light, soft, wrinkled, pale, and of feeble taste
and odor, they are inferior. Those from which
the essential oil has been distilled are sometimes
fraudulently mixed with the genuine. For mono-
graph on the microscopical structure of cloves,
clove stems and clove fruit see Winton, The
Structure and Composition of Foods, Vol. 3.
Powdered cloves sometimes contain an excess of
clove stems, and may be adulterated with all-
spice, wheat middlings and powdered peas or
beans. Occasionally clove stems alone are ground
and sold as cloves. It is claimed that an enormous
quantity of exhausted cloves are dishonestly
marketed. The amount of volatile ether extract
is the best criterion of the value of cloves.

Constituents. — The most important constitu-
ent is a volatile oil (see Clove Oil). Tromms-
dorff found in cloves 18 per cent of volatile oil,
17 per cent of tannin, 13 per cent of gum, 6
per cent of resin, 28 per cent of vegetable fiber,
and 18 per cent of water. Peabody (1895) found
the percentage of tannin in cloves to range from
10 to 13 per cent, also that it has the same com-
position as gallotannic acid. Lodibert afterward
discovered a green fixed oil, and a tasteless, white,
resinous substance which crystallized in silky
needles, soluble in ether and boiling alcohol. This
substance was called by Bonastre (1827) caryo-
phyllin. It is a methylated phenanthrene deriva-
tive containing a hydroxyl and a carboxyl group,
of the formula CsoEUsCte, and identical with

Part I

Cobalamin Concentrate

337

oleanolic acid isolated from a number of plants.

Uses. — Clove is among the most stimulant of
the aromatics, but, like others of this class, acts
less upon the system at large than on the part
to which it is immediately applied. Clove has
been administered in the form of powder or
as an infusion to relieve nausea and vomiting,
correct flatulence, and excite languid digestion.

Dose, 120 to 600 mg. (approximately 2 to 10
grains).

Storage. — Preserve "in well-closed containers
and avoid exposure to excessive heat." N.F.

Off. Prep. — Compound Lavender Tincture;
Aromatic Rhubarb Tincture, N.F.

CLOVE OIL. U.S.P., B.P.

Oleum Caryophylli

"Clove Oil is the volatile oil distilled with
steam from the dried flower buds of Eugenia
caryophyllata Thunberg (Fam. Myrtacece). It
contains not less than 85 per cent by volume of
total phenolic substances, chiefly eugenol
(C10H12O2)." U.S.P.

The B.P. recognizes the oil distilled from clove,
containing not less than 85.0 and not more than
90.0 per cent of eugenol, C10H12O2.

Oleum Caryophylli vEthereum; Oleum Caryophyllorum;
Essentia Caryophilli. Fr. Essence de girofle. Ger. Nelkenbl.
It. Essenza di garofani. Sp. Esencia de clavo.

For a description of the plant from which
this oil is derived see under Clove. The oil is
obtained by distilling clove with steam, the aque-
ous phase of the distillate being returned to the
still to avoid loss of oil which dissolves in the
water. A good quality of clove yields up to about
20 per cent by weight of oil. Most of the oil was
formerly brought from Holland or the East
Indies, but since the introduction of the cayenne
cloves into our markets the reduced price and
superior freshness of the drug have rendered the
distillation of oil of clove profitable in this coun-
try, and the best now sold is of domestic
extraction.

Description. — "Clove Oil is a colorless or
pale yellow liquid, becoming darker and thicker
by aging or exposure to air, and having the char-
acteristic odor and taste of clove. One volume of
Clove Oil dissolves in 2 volumes of 70 per cent
alcohol." U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 1.038 and not more than 1.060.
Optical rotation. — Not more than — 1° 30' in a
100-mm. tube. Refractive index. — Not less than
1.5270 and not more than 1.5350, at 20°. Heavy
metals. — The oil meets the requirements of the
test for Heavy metals in volatile oils. Phenol. —
Shake 1 ml. of oil with 20 ml. of hot water: the
water is not more than slightly acid toward blue
litmus paper. On cooling the aqueous liquid, fil-
tering it through a wetted paper, and treating the
filtrate with 1 drop of ferric chloride T.S. only a
transient, grayish-green color, but not a blue or
violet color, is produced. U.S.P.

Assay. — A 5-ml. portion of oil is heated, in a
cassia flask, with a potassium hydroxide solution
which converts eugenol, as well as any aceteugenol
that may be present, to potassium eugenolate,

which is soluble in the aqueous liquid. The por-
tion of the oil which is not eugenol remains
insoluble and its volume is determined by bringing
it into the graduated neck of the flask. The vol-
ume of the oily layer should not exceed 0.75 ml.,
indicating the presence of not less than 85 per
cent by volume of total phenolic substances in
the oil. U.S.P.

Constituents. — Clove oil contains small
amounts of vanillin, methyl alcohol and furfurol,
but is mainly composed of the unsaturated phenol
eugenol (see Eugenol), its acetyl derivative, and
a sesquiterpene caryophyllene. Eugenol acetyl-
salicylate has also been reported. The eugenol
content is the most important criterion of the
quality of clove oil.

The characteristic aromatic odor of clove oil,
as distinguished from that of eugenol, is due to
methylamylketone , CH3.CO.C5H11, which is pres-
ent only in minute quantity.

Uses. — By virtue of its local irritant effect
clove oil stimulates peristalsis and has frequently
been employed in the treatment of flatulent colic.
It also possesses some local anesthetic action,
being a favorite remedy for toothache; for this
purpose a small pledget of cotton is saturated
with oil and inserted into the carious cavity. It
is a powerful germicide, about eight times as
strong as phenol, but is not frequently used,
except by dentists, because of its irritant prop-
erties. Eugenol, the principal constituent of clove
oil, has been used internally in daily doses of
3 ml. (approximately 45 minims) as an antiseptic
antipyretic; it has also been used in treating
patients with gastric or duodenal ulcers by instil-
lation into the stomach (see under Eugenol for
detailed information). Little, however, is known
of its physiological action. According to Leu-
buscher (Wien. med. Bl., 1889), it is a feeble
local anesthetic. Landis (Therap. Gaz., 1909, 33,
386) used clove oil as a stimulant expectorant
in tuberculosis and bronchiectasis with good
results.

Dose, from 0.12 to 0.4 ml. (approximately 2
to 6 minims).

Storage. — Preserve "in well-filled, tight con-
tainers and avoid exposure to excessive heat."
U.S.P.

Off. Prep. — Diphenhydramine Hydrochloride
Elixir, U.S. P.; Compound Cardamom Spirit; Aro-
matic Castor Oil; Aromatic Eriodictyon Syrup;
N.F. Toothache Drops, N.F.

COBALAMIN CONCENTRATE. N.F.

Vitamin B12 Activity Concentrate

"Cobalamin Concentrate consists of the dried,
partially purified product resulting from the
growth of selected Streptomyes cultures or other
cobalamin-producing microorganisms. It may con-
tain harmless diluents and stabilizing agents.
Cobalamin Concentrate contains in each Gm. not
less than 500 meg. of Cobalamin activity." N.F.

Cobalamin concentrate contains cyanocobalamin
(vitamin B12) and/or closely related cobalamins
and represents a less purified form of the vitamin
suitable for many oral formulations; since it is
not carried through the purification procedures

338

Cobalamin Concentrate

Part I

required of cyanocobalamin it is less costly than
the pure vitamin. For information concerning the
cobalamins, their occurrence, composition, etc.,
see under Cyanocobalamin.

Description. — "Cobalamin Concentrate occurs
as pink to brown granules or as a fine powder. It
may be hygroscopic and its solutions may be
affected by light." N.F.

Standards and Tests. — Identification. — After
igniting cobalamin concentrate the residue is
tested for the presence of cobalt through forma-
tion of bluish green cobaltous thiocyanate. Loss
on drying. — Not over 5 per cent, when determined
in a suitable vacuum drying apparatus at 60°.
pH. — The pH of a 1 in 200 solution is between
4.0 and 8.0. Microbiological assay. — Not less than
85 per cent of the potency stated on the label is
found. N.F.

This preparation, as indicated above, may be
used in certain formulations where vitamin B12
activity is desired. For uses of the vitamin see
under Cyanocobalamin.

Storage. — Preserve "in tight containers, pro-
tected from light." N.F.

COCAINE. N.F., B.P., LP.

[Cocaina]

"Cocaine is an alkaloid obtained from the
leaves of Erythroxylon Coca Lamarck and other
species of Erythroxylon (Fam. Erythroxylacea) ,
or by synthesis from ecgonine or its derivatives."
N.F. The B.P. definition, in which cocaine is
identified as methyl benzoylecgonine, is similar.
The LP. defines it as 3-tropanylbenzoate-2-
carboxylic acid methyl ester.

I.P. Cocanium. Cocain; Methylbenzoylecognine. Co-
cainura. Fr. Cocaine ; Cocaine gauche. Ger. Kokain. Cocain.
Sp. Cocaina.

Coca leaves (for description see under Coca,
Part II) contain a number of alkaloids of which
the majority belong to the group having tropane
as the parent substance; they are therefore re-
lated to such alkaloids as atropine, hyoscyamine
and hyoscine. The tropane-derived alkaloids found
in coca are cocaine (methylbenzoylecgonine),
cinnamylcocaine (methylcinnamoylecgonine) ,
alpha-truxilline (methyl-alpha-truxilloylecgonine,
known also as cocamine or gamma-iso-atropylco-
caine), beta-truxilline (methyl-beta-truxilloylec-
gonine, known also as isococamine or delta-iso-
atropylcocaine) , tropacocaine (benzoylpseudo-
tr opine), benzoyltr opine, benzoylecgonine, and
dihydroxy 'tropane. Other alkaloids occurring in
coca in small amounts, and probably belonging
to the pyrrolidine group of alkaloids (see under
Alkaloids, Part I), are alpha- and beta-hygrine,
and cuscohygrine.

The more important of these alkaloids are esters
of ecgonine, a nitrogen base containing both a
carboxyl and an alcoholic hydroxyl group, as
shown in the following formula:

CH2-

■CH-

•CH.C00H

N-CH3 CH.0H

CH2 CH-

The relationship of ecgonine to tropane and to
tr opine (see atropine) may be seen by compari-
son with the formulas of the two latter:

H2C CH

-CH,

H2C

-CH-

-CH,

N-CH, CH,

H„C CH CH„

N.CH,

J/H

-OH

H2C CH-

CH,

Tropane

Tropine

CH2

Both the carboxyl and alcoholic hydroxyl
groups of ecgonine are capable of esterification.
In cocaine, the carboxyl is methylated and the
hydroxyl benzoylated; cinnamylcocaine differs
from cocaine in having a cinnamoyl group in
place of the benzoyl; in the truxillines a truxilloyl
group is found in the place of the benzoyl in
cocaine.

Since it is an ester, cocaine may be hydrolyzed;
by prolonged boiling with water it is at least in
part converted to benzoylecgonine and methanol,
while in the presence of acids or alkalis it is
hydrolyzed to ecgonine, benzoic acid and metha-
nol. Inasmuch as the removal of either the
methyl or the benzoyl group destroys the anes-
thetic property of cocaine it is apparent that any
hydrolysis which may occur in solutions of
cocaine or its salts will be accompanied by a
reduction in activity.

The total alkaloidal content of coca is between
0.5 and 1.5 per cent, occasionally being as high
as 2.5 per cent. Bolivian coca does not contain
as much of the alkaloids as either Java or
Truxillo coca leaves, but the content of cocaine
in the former is considerably greater than in
either of the latter. On the other hand, there
is evidence that the specific alkaloids found in
a particular plant depends on the age of the
leaves, the youngest containing the largest
amounts of cinnamylcocaine while in the older
this is replaced by cocaine or truxilline.

All of the ecgonine-derived alkaloids may be
economically converted into cocaine by hydrolyz-
ing the former to ecgonine and then methylating
and benzoylating the latter to form methylbenz-
oylecgonine, which is cocaine; the process is de-
scribed in the following.

For the extraction of the alkaloids from coca
leaves benzene is a satisfactory solvent, although
almost any organic solvent can be used. The
powdered leaves are thoroughly moistened with
solution of sodium carbonate and extracted with
cold benzene. From the benzene the alkaloids
are extracted with small quantities of dilute sul-
furic acid and this solution is alkalinized with
sodium carbonate. The resulting precipitate of
alkaloids is dissolved in ether, the ether solution
separated from water, dried with sodium carbon-
ate, filtered and carefully evaporated to dryness.
The residue is dissolved in methyl alcohol and
the solution heated with sulfuric acid or with alco-
holic hydrogen chloride. This treatment splits
off any acids from the ecgonine and esterifies the
carboxyl group. Dilution with water and ex-
traction with chloroform removes the organic
acids. The aqueous layer, carefully concentrated
and neutralized, deposits methyl ecgonine sulfate

Part I

Cocaine Hydrochloride 339

upon cooling. This is benzoylated by heating with
benzoyl chloride or benzoic anhydride at about
150°. The mixture, to which water is added, is
treated with a slight excess of sodium hydroxide
in the presence of ether. The ether solution is
then concentrated to the point of crystallization
of cocaine, which is purified by recrystallization.

The alkaloids of coca leaves may also be ex-
tracted by means of dilute sulfuric acid. The
salts thus formed are converted to the corre-
sponding bases with sodium carbonate, the alka-
loids being subsequently extracted with petro-
leum ether and treated in a manner similar to
that described above. However, this method has
been largely replaced by methods involving direct
extraction with an immiscible solvent.

Cocaine was first isolated, from Brazilian coca,
by Gaedicke in 1855, and five years later Nie-
mann, a pupil of Wohler, purified it. Roller
and Freud were the first to note the anesthetic
properties of cocaine and in 1880 they applied
it in surgical practice; its introduction in America
is generally credited to Hall (1884) and to Hal-
stead (1885) who employed it for infiltration
anesthesia. Willstatter et al. (Ann. Chem., 1923,
434, 119) succeeded in synthesizing cocaine
from tropinone, the ketone of tropine.

Description. — "Cocaine occurs as colorless
to white crystals, or as a white, crystalline pow-
der. A solution of Cocaine in diluted hydro-
chloric acid is levorotatory. Its saturated solu-
tion is alkaline to litmus paper. One Gm. of
Cocaine dissolves in about 600 ml. of water, in
7 ml. of alcohol, in 1 ml. of chloroform, in 3.5 ml.
of ether, in about 12 ml. of olive oil, and in
from 80 to 100 ml. of liquid petrolatum. It is
very soluble in warm alcohol. Cocaine melts
between 96° and 98°." N.F.

Standards and Tests. — Identification. — (1)
The odor of methyl benzoate is apparent on heat-
ing 100 mg. of cocaine with 1 ml. of sulfuric acid
for 5 minutes at 100° after which 2 ml. of water
is cautiously added; on cooling, crystals of benzoic
acid separate. (2) A yellow precipitate, which
redissolves on shaking the mixture, is produced
when 5 drops of a 1 in 20 chromium trioxide solu-
tion is added to 100 mg. of cocaine dissolved in
0.4 ml. of 1 N hydrochloric acid and enough water
to make 5 ml.; on adding 1 ml. of hydrochloric
acid a permanent, orange-colored precipitate is
formed. (3) A violet, crystalline precipitate is
produced on evaporating just to dryness a solu-
tion of 10 mg. of cocaine in 1 ml. of 0.02 N
hydrochloric acid, dissolving the residue in 2 drops
of water and adding 1 ml. of 0.1 N potassium
permanganate; the precipitate appears brownish
violet when collected on a filter, and shows char-
acteristic violet red crystalline aggregates under
the low power of a microscope. Loss on drying. —
Not over 1 per cent when dried over sulfuric acid
for 3 hours. Residue on ignition. — The residue
from 500 mg. of cocaine is negligible. Readily
carbonizable substances. — A solution of 500 mg.
of cocaine in 5 ml. of sulfuric acid has no more
color than matching fluid A. Cinnamyl-cocaine
and other reducing substances. — A solution of
300 mg. of cocaine in 1 ml. of 1 N hydrochloric
acid is diluted to 15 ml.; a 5-ml. portion of this

solution treated with 0.3 ml. of 1 N sulfuric acid
and 0.1 ml. of 0.1 N potassium permanganate
does not lose its violet color entirely within 30
minutes. Isoatropyl-cocaine. — Another 5-ml. por-
tion of the solution of cocaine prepared in the
preceding test is diluted with 80 ml. of water,
0.2 ml. of ammonia T.S. is added, and the solu-
tion stirred vigorously during 5 minutes, occasion-
ally rubbing the inner wall of the container with
a stirring rod: the solution precipitates crystalline
cocaine but the supernatant liquid remains clear.
It is said that the presence of as little as 0.5 per
cent of isoatropyl-cocaine prevents crystallization
of most of the cocaine and causes the supernatant
liquid to be milky. N.F.

Uses. — For most purposes cocaine hydrochlo-
ride is preferred to the base, but the latter is
better for ointments and oily solution because of
its greater solubility in fatty substances. A 4 per
cent ointment has been used on the skin and for
hemorrhoids. A 2 per cent solution in castor oil
has been prescribed for the eye and a 5 to 10 per
cent spray has been used for the larynx. Cocaine
in the basic form acts more powerfully on the
sensory nerves than when combined in a salt
(Regnier and David, Bull. sc. Pharmacol., 1925,
32, 513).

Difficulty is sometimes experienced in obtain-
ing a clear solution in liquid petrolatum due to
traces of moisture in the cocaine. The alkaloid
can be dried over sulfuric acid in a suitable desic-
cator or it can be carefully heated on a water bath.

For medicinal uses, see Cocaine Hydrochloride.

Storage. — Preserve "in well-closed, light-re-
sistant containers." N.F.

COCAINE HYDROCHLORIDE.
U.S.P., B.P., LP.

Cocainium Chloride, [Cocainae Hydrochloridum]

H2C

R,C-

•CH— COOCH

HN+CH,

CH— 0-
I
■CH,

co!0

The B.P. defines Cocaine Hydrochloride as the
hydrochloride of the alkaloid cocaine, but neither
the U.S. P. nor LP. have an official definition.

LP. Cocaini Hydrochloridum. Cocaine Chloride; Hydro-
chlorate of Cocaine; Neurocaine Hydrochloride. Cocainae
Hydrochloras; Cocainae Chlorhydricum; Cocainum Hydro-
chloricum; Cocainae Chlorhydras; Cocainum Muriaticum;
Chloretum Cocainicum. Fr. Chlorhydrate de cocaine ;
Chlorhydrate de cocaine gauche. Ger. Kokainhydrochlorid;
Salzsaures Cocain. It. Cloridrato di cocaina. Sp. Clor-
hidrato de cocaina.

For information concerning the sources and
chemical structure of cocaine hydrochloride see
under Cocaine.

Description. — "Cocaine Hydrochloride occurs
as colorless crystals, or as a white, crystalline
powder. One Gm. of Cocaine Hydrochloride dis-
solves in 0.5 ml. of water, in 3.5 ml. of alcohol,
and in 15 ml. of chloroform. It is soluble in
glycerin and insoluble in ether." U.S.P. The B.P.
and LP. give the melting point as not below 197°,
the tube being placed in the heating bath at 193°.

340 Cocaine Hydrochloride

Part I

Standards and Tests. — Identification. — The
identity tests for cocaine hydrochloride are sub-
stantially the same as those described under
cocaine; the salt also responds to tests for chlo-
ride. Specific rotation. — Not less than —71° and
not more than —73°, when determined in a solu-
tion containing 200 mg. of dried cocaine hydro-
chloride in each 10 ml. Acidity. — A solution of
500 mg. of cocaine hydrochloride in 10 ml. of
water requires not more than 0.5 ml. of 0.02 N
sodium hydroxide for neutralization, using methyl
red T.S. as indicator. Loss on drying. — Not over
1 per cent, when dried over sulfuric acid for 3
hours. Residue on igyiition. — The residue from
500 mg. of cocaine hydrochloride is negligible.
Carbonizable substances. — A solution of 500 mg.
of cocaine hydrochloride in 5 ml. of sulfuric acid
has no more color than matching fluid F. Cinnamyl-
cocaine and other reducing substances. — The violet
color of a mixture of 5 ml. of 1 in 50 solution of
cocaine hydrochloride. 0.3 ml. of 1 AT sulfuric acid,
and 0.1 ml. of 0T1 A" potassium permanganate does
not disappear entirely within 30 minutes. Iso-
atropylcocaine. — A 1 in 50 solution of cocaine
hydrochloride meets the requirements for this test
under Cocaine. U.S. P.

Incompatibilities. — Cocaine is precipitated
by the usual alkaloidal reagents. With strong acids
or with concentrated solutions of alkali hydrox-
ides it is hydrolyzed with the formation of methyl
alcohol, benzoic acid and ecgonine. With borax,
cocaine hydrochloride is precipitated from solu-
tion as the base; it is reported that the use of
equal parts of boric acid and borax will prevent
this precipitation. In the presence of moisture
cocaine simultaneously reduces and oxidizes calo-
mel, forming metallic mercury and mercuric chlo-
ride respectively, the latter then combining with
the cocaine to form an insoluble derivative.

Sterilization. — There is a widespread belief
among both pharmacists and physicians that solu-
tions of cocaine cannot be sterilized by heat
without danger of decomposition, but several
chemists have shown that if the solution is not
allowed to become alkaline the degree of hydroly-
sis is insignificant. Salis (Chem. Abs., 1940, 34,
168) found that cocaine solutions were more
stable at a low pH, but less active than those less
acid; the solutions tend to become more acid on
sterilization (see also Compt. rend. soc. biol.,
1937, 125, 1012).

Uses. — Any consideration of pharmacological
actions of cocaine must clearly distinguish be-
tween the local and systemic effects of the drug.

Local Action. — When locally applied cocaine
is a paralyzant to the peripheral ends of the
sensory nerves, and to a lesser degree to the motor
nerves, and stimulating to the muscular coats of
the blood vessels. As a result of these actions,
when painted over mucous membranes it causes
a blanching of the part and diminished sensation.
It produces not only lessened sensibility to pain
and touch but also of the acuity of the special
senses; thus it diminishes in the mouth the power
of taste and in the nose that of smell. For an
account of the discovery of the local anesthetic
action of cocaine see Roller (J.A.M.A., 1928, 90,
1742; 1941, 117, 1284). It was the first useful

topical and infiltration anesthetic although its
toxicity stimulated the search for better agents.

A theory of anesthetic action of cocaine was
offered by Schueler (/. Chetn. Educ, 1945, 22,
585); he interpreted the freedom of dogs receiv-
ing both acetylcholine and cocaine from symp-
toms of either drug as suggesting that the action
mechanism of cocaine, Stovaine (1-diethylamino-
2-methyl-2-butanol benzoate), butacaine sulfate
and other local anesthetics is due to competition
of the anesthetic with acetylcholine, which is
structurally similar. The anesthetics are open
chain or cyclized alkylamino-alkyl esters of ben-
zoic acid and differ from acetylcholine principally
by having an a-phenyl instead of an u-methy]
group. Since cocaine potentiates the action of
epinephrine Torda (/. Pharmacol., 1943, 77, 123)
suggested that it inhibits esterincation of phenolic
compounds such as epinephrine.

Central Nervous System Action. — System-
ically cocaine is a stimulant to all parts of the
central nervous system, including the brain, spinal
cord, and medulla. Its effects upon the brain are
shown by an exaltation of the intellectual faculties
similar to that which is produced by caffeine. In
overdose it produces a delirium somewhat re-
sembling that of atropine, to which it is chemi-
cally related. Cocaine has a stimulating action on
the spinal cord, first increasing reflexes, then pro-
ducing clonic and tonic convulsions. The effects
on the medullary centers are shown by an increase
of the rapidity of respiration and sometimes also
of its depth. After toxic doses the primary stimu-
lation is followed by a depression of the respira-
tory center.

Circulatory Effects. — Blood pressure is ele-
vated by cocaine, chiefly through constriction of
arteries by action directly upon arterial walls. In
addition, after absorption there is a central vaso-
motor stimulation as well as an effect in increasing
blood pressure by increase of the cardiac rate.
In large doses cocaine decreases blood pressure.
There is difference of opinion as to effects on the
heart. Prus (Ztschr. exp. Path. Ther., 1913, 14,
161) and Kcchman (Arch. ges. Physiol., 1921,
190, 158) found that small doses stimulated re-
spectively the isolated mammalian heart and the
isolated frog heart but Kuroda (/. Pharmacol.,
1915, 7, 423) could not find any evidence of
cardiac stimulation. According to Reichert (Penn.
M. J., 1902), small doses slow the pulse rate by
stimulating the cardio-inhibitory center, moder-
ate quantities increase the rate by depressing the
inhibitory mechanism, while after large toxic
doses there may be a second slowing of the heart
through depression of its motor ganglia.

General Effects. — Although cocaine does not
appear to increase the contractile power of volun-
tary muscles, it is well known to augment muscu-
lar performance in the intact animal. This is due
to the masking of a sense of fatigue by the central
stimulation. It appears also to have some effect
upon the nutritive processes since it causes a
marked rise in the bodily temperature. This is
caused by increased muscular activity, stimula-
tion of the heat regulating center, and diminution
in heat loss by virtue of the vasoconstriction.
Action on the Eye. — When instilled into the

Part I

Cocaine Hydrochloride 341

eye cocaine causes dilatation of the pupil, usually
without paralysis of accommodation. It has been
used to facilitate ophthalmoscopic examination.
The widening of the pupil seems to be the result
of an action upon the peripheral ends of the
sympathetic nerve and can be further increased
by instillation of atropine (Gold, /. Pharmacol.,
1924, 23, 365). The duration of its local anes-
thetic effect in the eye is sufficiently less than that
of more recently introduced compounds (see
monograph on Local Anesthetic Agents, in Part
II) as to make it unattractive for such use.

Therapeutic Uses. — The most important use
of cocaine is as a local application to mucous
membranes, either for the purpose of contracting
blood vessels or lessening sensation. It has, how-
ever, been demonstrated to be inferior to ephed-
rine as a vasoconstrictor (Sternstein, Arch. Oto-
laryng., 1942, 36, 713). Its vasoconstrictive effect
has been utilized in relieving congestions such
as hay fever, coryza, or laryngitis, and to control
or prevent hemorrhage from the nose or throat.
There are three important drawbacks to such use
of cocaine : the primary contraction of blood ves-
sels is likely to be followed by a reactive relaxa-
tion; there is the danger of habituation; finally,
such use is accompanied by the possibility of
acute poisoning because cocaine is absorbed more
rapidly than it is detoxified by the liver. There is
little to justify use of cocaine as a nasal decon-
gestant when there are so many more satisfactory
agents available (see the monograph on Sympa-
thomimetic Amines, in Part II).

As a local anesthetic cocaine has been used in
operations on the eye, nose, and throat, also in
treating painful hemorrhoids, fissure in ano,
vomiting, gastralgia, and other painful diseases
of the mucous membranes. While cocaine passes
through all mucous membranes more or less
readily, the unbroken skin offers a practically im-
passable barrier to aqueous solutions. It is neces-
sary, therefore, when the drug is to be used to
produce local anesthesia for operative purposes to
inject it beneath the skin, but here again it has
been largely replaced by less toxic compounds
(see Procaine Hydrochloride, also Local Anes-
thetic Agents, in Part II).

Cocaine finds little use internally in modern
therapy because of its toxicity and its tendency
to produce addiction. In discussing problems re-
lating to drug addiction Isbell and Fraser pointed
out that in some respects intoxication with cocaine
may be more harmful than is addiction to mor-
phine, in spite of the lack of physiological de-
pendence (withdrawal symptoms) developed to-
ward cocaine (/. Pharmacol., 1950, 99, 355).
Perhaps the chief use of cocaine is in inoperable
gastric carcinoma, where it may alleviate nausea
and vomiting.

For local application to mucous membranes an
aqueous solution of a salt of cocaine, commonly
the hydrochloride, is generally preferred; Gross
{Arch. exp. Path. Pharm., 1910, 63, 80), how-
ever, presented evidence that cocaine base is a
much more powerful anesthetic than when it is
in salt form, and some clinicians prefer to use oil
solutions of cocaine alkaloid. E3

Toxicology. — There are two distinct types of

cocaine poisoning, the one characterized by circu-
latory failure and the other by neurotoxic symp-
toms. The first type is usually seen after rela-
tively small doses of the drug in persons who
possess an idiosyncrasy toward it. The prominent
symptoms are pallor of the face, vertigo, nausea,
failure of the pulse, and usually more or less com-
plete loss of consciousness. The treatment of this
type of poisoning is to place the patient in a
horizontal position and to give rapidly acting
stimulants, such as hypodermic injections of am-
monia or camphor. Kamenzove {Arch, internat.
pharmacodyn. therap., 1911, 21, 5) attributed
these symptoms to arterial spasm, causing anemia
of the brain.

The more common type of cocaine poisoning is
characterized by delirium, increased reflexes, more
or less violent convulsions, the pulse usually being
rapid and fairly strong but later may become
weak; syncope and cyanosis may intervene and
there may by Cheyne-Stokes respirations. The
delirium is frequently associated with hallucina-
tions and at times the patient may develop a
violent mania of even homicidal character. In
fatal cases death is usually due to respiratory fail-
ure although the circulation is also depressed.

Knoefel and Loevenhart (/. Pharmacol., 1930,
39, 397) produced two types of poisoning in
lower animals; one by subcutaneous injection,
which is characterized by convulsions and death
from respiratory failure, and the other following
intravenous injection in which there is sudden
arrest of the heart. They believe these two types
correspond to the clinical ones described above.

In 1925 Tatum showed that intravenous injec-
tion of barbital sodium would save the life of ani-
mals following hypodermic injection of more than
twice the usually fatal dose of cocaine. The value
of barbiturates in the prophylaxis or in the treat-
ment of cocaine poisoning seems, in the convul-
sive type of cocaine poisoning, to be well estab-
lished. Maloney (/. Pharmacol, 1934, 51, 127)
found that of all of the barbituric acid derivatives
pentobarbital gave the best results, although
other rapidly acting ones were also of service.
Draystedt and Lang (/. Pharmacol., 1928, 32,
215) found that conjoint use of atropine with
barbital greatly enhanced antidotal efficiency. It
is now a routine procedure in many hospitals to
administer barbital or phenobarbital an hour
before an operation in which cocaine is to be em-
ployed; such prophylactic use of barbiturates has
greatly reduced cocaine accidents. In the collapse
type of poisoning it is a priori improbable that
barbiturates would be beneficial, and Knoefel and
Loevenhart found them of no benefit in the
cardiac type of experimental poisoning. They also
tried ephedrine, ouabain, and other stimulating
drugs, but without avail. Eggleston and Hatcher
(/. Pharmacol., 1919, 13, 433), from observa-
tions in an experimental study highly recom-
mended, in the treatment of cocaine poisoning,
intravenous injection of epinephrine combined
with artificial respiration. Nielsen and Higgins
(/. Lab. Clin. Med., 1923, 8, 440) found a pitui-
tary solution to exercise both a preventive and
curative effect. A tourniquet may be applied to
delay absorption from some locations.

342 Cocaine Hydrochloride

Part I

Addiction. — The habitual use of cocaine as a
narcotic stimulant is a problem of sociological
importance. In the United States the conditions
under which it may be prescribed or dispensed
are strictly limited both by federal and, in most
states, by state laws. The cocaine habit is not only
one of the most seductive but also one of the
most rapidly injurious and difficult of eradication
of all drug habits. The characteristic symptoms
are changes in mental and moral qualities, espe-
cially characterized by alternate periods of exalta-
tion and depression, hallucinations and paranoid
delusions, loss of appetite and of weight, peculiar
pallor of the skin, insomnia, and general failure
of health. There is psychic rather than physio-
logical dependence on the drug. A symptom which
is seen in many cases, and is said to be charac-
teristic of chronic cocaine poisoning, is a sensory
hallucination, as of some foreign body under the
skin or of insects crawling over the person. Since
there are now available superior products for
practically every use of cocaine it would appear
that employment of the drug can justifiably be
discouraged, thereby reducing the potential of the
social problems its use may create.

Cocaine hydrochloride is employed topically on
mucous membranes in 2 to 5 per cent aqueous
solution. For nasal anesthesia, 10 to 20 per cent
solutions, with epinephrine to delay absorption,
have been used. By mouth, from 15 to 30 mg.
(approximately J4 to Vz grain) is given; the
maximum safe dose is about 100 mg. (approxi-
mately V/2 grains).

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S.P.

LAMELLiE OF COCAINE. B.P.

Lamellae Cocainae

Discs of Cocaine. Lamellae Ophthalmicse cum Cocaina.
Sp. Discos oftalmicos con cocaina.

Lamellae of cocaine are discs of gelatin with
glycerin, each weighing about 3.5 milligrams (%o
grain) and containing 1.3 milligrams (%o grain)
of cocaine hydrochloride.

COCAINE HYDROCHLORIDE
TABLETS. N.F.

[Tabellae Cocainae Hydrochloridi]

"Cocaine Hydrochloride Tablets contain not
less than 91 per cent and not more than 109 per
cent of the labeled amount of C17H21XO4.HCI."
X.F.

Assay. — A representative portion of powdered
tablets, equivalent to about 60 mg. of cocaine
hydrochloride, is dissolved in distilled water, the
solution alkalinized with ammonia T.S. and the
cocaine extracted with ether. The combined ether
extracts are concentrated to one-half their volume,
shaken with several portions of distilled water to
remove any ammonia which may be present, then
with 10 ml. of 0.05 N sulfuric acid to extract the
cocaine. The acid layer is separated, the ether
layer washed with distilled water, and the acid
in the combined aqueous portions titrated with
0.02 AT sodium hydroxide, using methyl red T.S.

as indicator. Each ml. of 0.05 N sulfuric acid
represents 16.99 mg. of C1-H21NO4.HCI. N.F.

Usual Sizes. — 1 grain (approximately 60 mg.)
dispensing tablets; %, 34 and Yz grain (approxi-
mately 8, 15 and 30 mg.) hypodermic tablets;
1.14 and 2.28 grain tablets for the preparation
of solutions.

COCAINE NITRATE. LP.

Cocaini Nitras
Cl-H1.lXO4.HNO3

The LP. recognizes the anhydrous form of
cocaine nitrate; the salt occurs also as a dihydrate.

Description. — Cocaine nitrate occurs as color-
less crystals or as a white, crystalline powder; it
is odorless, and has a bitter taste which is fol-
lowed by a sensation of tingling and numbness.
It is freely soluble in water and in alcohol. LP.

The tests specified by the LP. are essentially
the same as those for cocaine hydrochloride; loss
on drying to constant weight at 100° is limited
to 1.0 per cent.

The utility of this salt, as compared with
cocaine hydrochloride, is that of compatibility
with silver nitrate, when both drugs are desired
to be used simultaneously.

Storage. — Preserve in a well-closed container,
protected from light. LP.

COCHINEAL. N.F, B.P.

Coccus

"Cochineal consists of the dried female insects,
Coccus cacti Linne (Fam. Coccidce), enclosing
the young larvae." U.S.P. The B.P. definition
differs in giving the name of this insect as Dacty-
lopius coccus Costa and specifying that it contain
eggs as well as larvae.

Cochineal Insect; Red Scale Insect. Fr. Cochenille.
Ger. Coccionella; Alkermeskorner; Kaktusschildlaus. Sp.
Cochinilla.

The cochineal insect is indigenous to Mexico,
Peru and Central America and in general appear-
ance resembles a wood louse. The red dye found
in the remains of the female insect has been long
esteemed by the old races in these subtropical
countries. Indeed, not only did they appreciate its
value, but in order to increase the supplies, the
cacti with the insects were successfully cultivated
many years before even Cortez landed in Mexico
in the early part of the sixteenth century.

The family CoccidcB includes the scale-like in-
sects which are characterized by the fact that the
wingless female dies shortly after producing her
eggs, the latter being covered up by her dead
scale-like body. In the case of the cochineal insect
the larvae are found within her inflated body.

The cochineal insect was first described by
Hernandez in 1651. It is ordinarily in scientific
works referred to as Coccus cacti Linne. In the
eighth edition of the U.S.P. the name was changed
to Pseudococcus cacti (Linne) Burmeister. In
a Catalogue of the Coccida. of the World, Maria
E. Fernaldo gave preference to the name Dae-
tylopius coccus Costa.

The insect feeds upon various species of the

Part I

Cochineal

343

Cactacece, more especially the Nopalea (Opuntia)
coccinellifera (Mill.) S. Dyck, a native of Mexico
and Peru. It has spread into other parts of South
and Central America and has been introduced into
the West Indies, East Indies, Canary Islands,
Southern Spain, Algeria, and is said to be found
in Florida and California.

The cultivation of cochineal is rather simple
in a tropical climate; all that is necessary is to
have the cochineal insects and the proper cacti.
During the rainy season the insects are protected
by spreading shelters over the plants on which
they are propagated. When the weather condi-
tions have become favorable the insects are
"sown" on the cacti in the open fields, where
fecundation takes place. After this the females
attach themselves to the plant and when their
bodies have become swollen from the develop-
ment of the enormous number of eggs, they are
scraped off and killed either by boiling water or
by the fumes of burning sulfur. Some of the
insects are left behind and deposit their eggs, the
female dying after the eggs are laid; these furnish
seed for a new crop.

Kraemer prepared an extensive monograph on
the nature and structure of cochineal {Am. J.
Pharm., 1913, p. 444), and presented in detail the
life history of the insect. A summary appears in
U.S.D., 24th ed., p. 306.

Description. — "Unground Cochineal occurs
as plano-convex, entire insects somewhat ovate
in outline, from 3.5 to 6 mm. in length and from
2.5 to 4.5 mm. in width. Each insect exhibits a
convex dorsal surface, showing from 9 to 12 seg-
ments, and a concave ventral surface. Externally
the insect is grayish to grayish purple or purplish
black to very dusky red purple. The ventral sur-
face shows two straight, 7-jointed antennae located
in the anterior end, three pairs of short legs each
terminating in a single claw and a highly modified
mouth showing externally a long filiform proboscis
composed of four very fine chitinous styles, in
two pairs, the anterior pair representing the
mandibles and the posterior pair representing the
first maxillae. The antennae, legs, and mouth parts
are more or less broken. Four spiracles are visible,
an anterior pair occurring between the middle
and hind legs. The entire surface is more or less
chitinous and shows numerous solitary or clus-
tered, tubular or spinneret wax glands. The insect,
after decolorization, exhibits numerous larvae
characterized by their proboscides appearing as
two circular coils, rows of tubular wax glands,
and in the more developed stages, three pairs of
legs, antennae, and other features of the mature
insect. It is easily pulverizable. The odor is char-
acteristic ; the taste slightly bitter.

"Powdered Cochineal is very dusky to very
dark red. It contains fragments of muscle fibers;
portions of the chitinous epidermis with wax
glands; fragments of larvae with coiled probos-
cides; occasional claws and segments of the legs;
and fragments of antennae and other parts de-
scribed under the unground drug." N.F.

As found in commerce, the finer cochineal,
grana fina of Spanish commerce, or "Madres
cochineal," is in irregularly circular or oval, some-

what angular grains, about one-eighth of an inch
in diameter, convex on one side, concave or flat
on the other, and marked with several transverse
wrinkles. Two varieties of this kind of cochineal
are available, these being distinguished by their
external appearance. One is of a reddish-gray
color, formed by an intermixture of the dark
color of the insect with the whiteness of a powder
by which it is almost covered, and with patches
of a rosy tinge irregularly interspersed. From its
diversified appearance, it is called by the Span-
iards cochinilla jaspeada. It is the variety com-
monly found in commerce. The other, cochinilla
renegrida, or grana nigra, is dark-colored, almost
black, with only a minute quantity of the whitish
powder between the wrinkles. The two are dis-
tinguished in our markets by the names of silver
grain and black grain cochineal. If the insects are
dried on trays for several hours in the hot sun
or in an oven at about 65°, the silver grain
cochineal is produced. The color of this variety
results from the wax covering not being melted;
if, however, the insects are dried at a temperature
higher than the melting point of their wax cover-
ing, i.e., at more than 106°, the variety known as
black grain cochineal results.

Small, immature, cochineal insects and larvae,
which are separated from the larger by sifting,
are sometimes sold under the name of granilla.

Cake cochineal and grana sylvestra are forms
which have entirely disappeared from commerce;
see U.S.D., 20th ed., p. 365.

During 1952 a total of 83,713 pounds of cochi-
neal was imported into this country from Canary
Islands, Peru and Chile.

Standards and Tests. — Identification. — The
red color of cochineal solutions is changed to red-
dish purple by alkalies and to weak orange by
acids. Weighting materials. — No insoluble powder
separates on macerating whole cochineal with
water. N.F. The B.P. requires not less than 35.0
per cent of cochineal to be soluble in 45 per cent
alcohol; the limit of ash is 7.0 per cent, and that
of foreign organic matter is 2.0 per cent.

Constituents. — Cochineal contains, besides
animal matter constituting the skeleton of the
insect, a coloring principle, stearin, olein, an
odorous fatty acid, and various salts. The coloring
principle is known as carminic acid, C22H20O13,
a complex, glycosidal substance. It occurs as a
dark, reddish-brown or bright red powder, which
decomposes at 13 5C. It is freely soluble in water
and alcohol, in alkalies and in concentrated sul-
furic acid; slightly soluble in ether, insoluble in
chloroform. It has indicator properties, showing
a yellow color at a pH of 4.8, violet at a pH of 6.2
and bright red when alkaline. It may be obtained
by macerating cochineal in ether to remove fatty
matter, then treating the residue with successive
portions of boiling alcohol, which dissolves the
carminic acid.

Salts of zinc, bismuth, and nickel produce with
carminic acid a lilac-colored precipitate, and those
of iron a dark purple approaching to black. Salts
of tin, especially the nitrate and the chloride,
form with it a brilliant scarlet precipitate, which
is the basis of scarlet and crimson dyes used in

344

Cochineal

Part I

the arts. The aluminum lake of carminic acid is
known as carmine.

Liebermann found that the coating of silver
cochineal consisted of a wax, which he named
coccerin, C3oH6o(C3iH6i0.s)2; this is soluble in
benzene, but nearly insoluble in ether (Pharm. J.,
1885, 186).

Carmine, which was official in N.F. IX, is the
aluminum lake of the coloring principle of cochi-
neal. It "occurs as irregular, angular, vivid red
fragments or as a powder, without odor or taste.
When burned, it emits an odor resembling that
of burned feathers. Carmine is slightly soluble in
water, to which it imparts a red color; it is freely
soluble in diluted ammonia solution or alkaline
liquids, forming a strong to deep red solution."
N.F. IX. Carmine Solution, also official in N.F.
IX, was prepared by triturating 65 Gm. of
carmine to a fine powder, gradually adding 365
ml. of diluted ammonia solution and then 365 ml.
of glycerin, while triturating constantly. The mix-
ture was transferred to a porcelain dish and heated
on a water bath until it was free from ammoniacal
odor, after which it was cooled and diluted with
distilled water to make 1000 ml.

Adulterants. — Cochineal has been adulterated
by causing certain heavy substances, such as pow-
dered talc, lead carbonate, and barium sulfate, by
shaking in a bag or otherwise, to adhere, by means
of some glutinous material, to the surface of the
insects, and thus increase their weight. This fraud
is detectable either by a high percentage of ash or
by microscopic examination which shows the ab-
sence of a woolly appearance which characterizes
the white powder upon the surface of the un-
adulterated insect. For other adulterants formerly
encountered, see U.S.D., 20th ed., p. 366.

Uses. — Cochineal was at one time supposed
by some to possess anodyne properties, and used
in whooping-cough and neuralgia. At present it
is employed only as a coloring agent. For this
purpose Cochineal Solution, also known as Cochi-
neal Color, was the preparation commonly used.
The formula for this solution, as provided in
N.F. IX, is as follows: Intimately triturate 65
Gm. of cochineal, in fine powder, with 32 Gm. of
potassium carbonate; then add, successively, 500
ml. of distilled water, 32 Gm. of alum, and 65
Gm. of potassium bitartrate. Heat the mixture
slowly to boiling, in a capacious vessel, and set
it aside to cool; then add 450 ml. of glycerin,
filter the mixture and add enough distilled water
through the filter to make 1000 ml. of solution.
N.F.

The function of the alum in this solution is to
prepare an aluminum lake of the coloring prin-
ciples of cochineal, thus producing a solution
similar to carmine solution, carmine being the
aluminum lake of the coloring principle obtained
from cochineal.

Off. Prep. — Compound Cardamom Tincture,
N.F.,B.P.

COD LIVER OIL. U.S.P. (B.P., LP.)

Oleum Morrhuae

"Cod Liver Oil is the partially destearinated
fixed oil obtained from fresh fivers of Gadus

morrhua Linne and other species of tne Family
Gadida. Cod Liver Oil contains in each Gm. not
less than 255 micrograms (850 U.S.P. Units) of
Vitamin A and not less than 2.125 micrograms
(85 U.S.P. Units) of Vitamin D.

"Cod Liver Oil may be flavored by the addition
of not more than 1 per cent of a suitable flavoring
substance or a mixture of such substances." U.S.P.

The B.P. defines cod liver oil as the oil obtained
from the fresh liver of Gadus callarias L. and
other species of Gadus, clarified by filtration at
about 0 . It is required to contain in each Gm.
not less than 600 Units of vitamin A activity, and
not less than 85 Units of antirachitic activity
(vitamin D). The LP. definition recognizes Gadus
morrhua L. and other species of the family
Gadidae as the source of the oil; the rubric is
identical with that of the B.P.

B.P. Cod-liver Oil. LP. Oleum Jecoris Aselli. Oleum
Tecoris Aselli; Oleum Gadi. Fr. Huile de foie de morue.
Ger. Lebertran; Dorschlebertran. It. Olio di fegato di
merluzzo. Sp. Aceite de higado de bacalao.

Gadus morrhua Linne {Morrhua vulgaris
Storer), the common cod, is between two and
three feet long, with brown or yellowish spots
on the back. The body is moderately elongated
and somewhat compressed, and covered with soft,
rather small scales, being quite conspicuous also
on the head. Of the fins, which are soft, there
are three on the back (dorsal), two anal, and a
distinct caudal, and the fin (ventral) under the
throat is narrow and pointed. The jaws are fur-
nished with pointed irregular teeth, in several
ranks. The gills are large, with seven rays. This
species of cod inhabits the cold waters of the
northern Atlantic.

Besides the common cod, several other species
of Gadus, frequenting the seas of northern Europe
and America, contribute to furnish the cod liver
oil of commerce. Among these De Jongh men-
tions Gadus Callarias L. or dorsch {Morrhua
americana of Storer), G. molva L. or ling, G.
carbonarius L. or coal fish, and G. pollachius L.
or pollack, as affording the oil on the coast of
Norway, where from 17,000.000 to 35,000,000 of
codfish have been annually taken.

On the American coast, in addition to the
species above mentioned, it is obtained also from
the hake {G. merluccius L.) and the haddock
{G. ceglefinus L.).

The habits of the codfish are not definitely
known. It would seem that most of their life is
spent in the deep waters of the ocean and that
in the late fall they migrate to the coastal regions
probably for the purpose of spawning. The time
of year at which they appear is quite different
in various fishing grounds. Along the American
coast, although they are caught in small quanti-
ties throughout the summer, they are most abun-
dant usually in November and December. At
Lofoten Islands, the cod season begins in Febru-
ary and lasts about two months. At Finmarken
the best fishing is in June. In the Western
Hemisphere they are taken with hand lines, set
lines or nets, usually on "banks" at a depth of
from 200 to 400 feet. The average codfish weighs
about 20 pounds but occasionally they grow to
a size of more than 100 pounds.

Part I

Cod Liver Oil

345

Cod liver oil is produced along our New Eng-
land coast. The oil is also largely produced in
Newfoundland, Canada, Great Britain, Norway,
and Iceland.

Preparation. — In the early days of the in-
dustry, the livers were allowed to accumulate in
tanks or barrels and underwent a process of spon-
taneous decomposition in which the cells were
ruptured and the oil exuded. The oil thus obtained
was contaminated with decomposition products
and possessed a disagreeable odor and a nause-
ating taste. Later the oil was obtained by steam-
ing or by pressure and as sanitary conditions
improved and scientific knowledge advanced the
effort has been made to extract the oil from the
livers while they are in as fresh a condition as
possible. For this reason some of the former
grades of cod liver oil such as the "raw" oil and
"brown" oil are no longer seen or heard of.

The first high quality medicinal oil was ob-
tained by treating the livers with steam to rup-
ture the cell membranes, much in the same manner
in which lard is "rendered." In the best equipped
establishments the livers are "extracted" immedi-
ately after being taken from the fish, it having
been found that exposure even if only for a few
hours is generally detrimental to the quality of
the oil that is obtained. In the United States and
Canada the oil is frequently separated on the
fishing vessel, which may remain at sea for some
time. But in Norway, where the fishing is done
relatively close to the shore, the separation of the
oil is done in special factories. The livers are
carefully sorted, all stained or abnormal livers
being rejected. They are then placed in tin-lined
tanks provided with open steam coils and low
pressure steam is blown through the mass which
causes an immediate separation of oil. Application
of vacuum extraction methods and extraction in
an atmosphere of carbon dioxide have been pro-
posed but the steam extraction method just de-
scribed appears to be used in the majority of
establishments.

The oil separated as described is filtered to
separate cellular tissue fragments and is then
bleached by treatment with fuller's earth or by
exposure to sunlight. The oil thus prepared will
congeal at low temperatures because of the pres-
ence of stearin (see Non-destearinated Cod Liver
Oil). In some establishments this is removed by
chilling to —10°, followed by expression, the
separated stearin being sold for soap making, and
the oil being called "non-congealing oil."

Other processes of extracting cod and other
liver oils consist in subjecting comminuted livers
to high pressures which result in mechanically
forcing out the oil, and in solvent extraction of
the oil followed by removal of the solvent by
distillation. The former of these processes results
in uneconomical recovery of the oil and the latter
in an oil which is likely to be more or less con-
taminated with traces of solvent and generally
adversely affected in therapeutic virtue.

Description. — "Cod Liver Oil is a thin, oily
liquid, having a characteristic, slightly fishy, but
not a rancid, odor, and a fishy taste. Cod Liver
Oil is slightly soluble in alcohol. It is freely solu-

ble in ether, in chloroform, in carbon disulfide,
and in ethyl acetate." U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 0.918 and not more than 0.927.
Identification for vitamin A. — Antimony trichlo-
ride T.S. added to a chloroform solution of the
oil produces a blue color immediately. Color. —
Viewed transversely in a tall, cylindrical, stand-
ard oil-sample bottle of about 120-ml. capac-
ity, the color of cod liver oil shall not be more in-
tense than that of a mixture of 11 ml. of cobaltous
chloride C.S., 76 ml. of ferric chloride C.S. and
33 ml. of water, in a similar bottle of the same
internal diameter. N on-destearinated cod liver oil.
— The oil remains clear and does not deposit
stearin when cooled in a mixture of ice and water
for 3 hours. Unsaponifiable matter. — Not more
than 1.3 per cent. Acid value. — Not more than
1 ml. of 0.1 N sodium hydroxide is required to
neutralize a solution of 2 Gm. of cod liver oil dis-
solved in 30 ml. of a neutralized mixture of alco-
hol and ether, the solution being boiled gently
under a reflux condenser for 10 minutes, then
cooled; phenolphthalein T.S. is the indicator.
Iodine value. — Not less than 145 and not more
than 180. Saponification value. — Not less than
180 and not more than 192. Carbon dioxide, if it
has been used as a preservative, must be dissipated
by exposing the oil in a vacuum desiccator for 24
hours before weighing. U.S.P.

The B.P. gives the refractive index, at 40°, as
from 1.4705 to 1.4745; the acid value as not
greater than 1.2. The LP. specifies the refractive
index, at 20°, as from 1.4770 to 1.4835; the acid
value as not greater than 2.

Cod liver oil readily becomes rancid, contain-
ing varying amounts of free fatty acids, even
when freshly rendered. The amount of acid that
may be present is, of course, limited by official
specifications.

Assay. — For vitamin A. — The spectrophoto-
metric assay explained under Oleovitamin A is
employed. For vitamin D. — The biological assay
discussed under Synthetic Oleovitamin D is used.
U.S.P. The B.P. and LP. assays are similar in
principle to those of the U.S.P.

Vitamin A is easily oxidized, and improperly
stored cod liver oil may lose much of its thera-
peutic value without very obvious alteration.
Evers (Quart. J. P., 1929, 2, 556) found that
under proper conditions of storage (in a dark,
cool place) there was no perceptible loss of vita-
min for several years, but that the vitamin dis-
appeared rapidly if the oil were exposed to
sunlight. Gisvold et al. (J. A. Ph. A., 1948, 37,
232) found that addition of 0.05 per cent of
nordihydroguaiaretic acid and 0.01 per cent of
ascorbyl palmitate to cod liver oil afforded more
protection against peroxide accumulation and de-
struction of vitamin A than did nordihydro-
guaiaretic acid alone or lower concentrations of
the combination of stabilizers.

Composition. — The composition of cod liver
oil is very complex. Heyerdahl, in 1895, found
that it contained from 10 to 18 per cent of the
glycerides of saturated fatty acids — principally
palmitic and myristic — but consisted chiefly of
glycerides of a number of unsaturated fatty acids,

346

Cod Liver Oil

Part I

the most abundant of which were jecoleic and
thcrapic acids. Subsequent studies by Andre
{Bull. sc. Pharmacol., 1928, 35) indicated that
jecoleic acid is not a chemical individual but a
mixture of isomeric compounds, and also showed
the presence of numerous other unsaturated fatty
acids of which clupanodonic is the most abundant
and the most unsaturated of the group. In addi-
tion asellic, gadinic, jecoric and zoomaric acids
were described and traces of such well-known
fatty acids as linoleic and linolenic were found.
The mixture of the unsaturated fatty acids is
sometimes known as morrhuic acid (see also
Sodium Morrhuatc Injection). Halden and Griin
{Anal, der Fette und Wachse, 1929) stated that
mixed glycerides of the following acids have been
found in cod liver oil: arachidonic, clupanodic,
linolenic, linoleic. zoomaric, and clupanodonic.
Other acids which have been reported as present
include oleic, stearidonic, selacholeic. and gadoleic.
It is claimed by Farmer (/. Soc. Chem. Ind.,
1938, 57, 24) that the principal acid of cod liver
oil is not clupanodonic but an acid containing 22
carbon atoms and six double bonds.

The glycerides of the lower fatty acids, such
as acetic, butyric, valeric, and capric acids, stated
by various authors to occur in cod liver oil, are,
according to Salkowski and Steenbuch. secondary
products due to the putrefaction of the livers.

A characteristic constituent of cod liver oil is
cholesterol, which can be isolated by saponifying
the oil and exhausting the soap with ether. The
quantity of cholesterol, according to Allen and
Thomson, is from 0.46 to 1.32 per cent. A higher
proportion than 1.5 per cent would indicate shark
liver, dogfish, sunfish, mineral, or rosin oil. The
presence of phytosterol would indicate the pres-
ence of vegetable oil. Of historical interest is the
content of organic bases (0.035 to 0.05 per cent)
and of iodine, bromine, and phosphorus, to each
of which, in the past, has been attributed the char-
acteristic virtues of the oil. Many of these bases
were of putrefactive origin and none is of thera-
peutic significance. The best known of these bases
were called morrhuine and gaduine. Holmes {Ind.
Eng. Chem., 1935, 26, 573) found the arsenic of
American cod liver oil to range from 1.4 to 5.1
parts per million; the average of twenty samples
was 2.6 parts. Today the most important con-
stituents are considered to be vitamins A and D.

Uses. — History. — Although cod liver oil had
been used as a folk remedy by Dutch peasants
for a long time, its introduction into medicine is
attributable chiefly to the researches of Professor
Bennett of Edinburgh in the middle of the nine-
teenth century. During the course of the last hun-
dred years the therapeutic virtues of cod liver oil
have been attributed to a variety of constituents,
and sometimes even completely denied.

Fat-soluble Vitamins. — The value of cod
liver oil is usually attributed to its content of
vitamins A and D (see under Oleovitamin A and
Synthetic Oleovitamin D I . Much of the vitamin D
activity of cod fiver oil is derived from activated
7-dehydrocholesterol (vitamin D3) which is the
chief form of vitamin D found in the animal king-
dom, whereas activated ergosterol (calciferol or
vitamin D2) is the predominant form in plant

sources (Bills, J. A.M. A., 1938, 110, 2150). Al-
though these two forms have similar potencies
for rats, vitamin D3 is much more effective for
chickens; however, in the management of human
rickets there seems to be little difference in the
effect of the two forms. Vitamin D3 is the form
which is produced by the action of sunlight on
the skin. Kirschner {Am. Rev. Tuberc, 1922, 6,
401) believed that the value of cod fiver oil was
due in part to the fact that the unsaturated fatty
acids, in addition to being more completely ab-
sorbed by the intestine, also promote absorption
of other fats. The role of unsaturated fatty acids
in the maintenance of normal nutrition may be
significant (see Burr and Barnes, Physiol. Rev.,
1943, 23, 256). Cod fiver oil is most frequently
used for one or more of the following: in the
treatment or prevention of diseases of bone such
as rickets, infantile tetany and osteomalacia; to
promote the formation and maintenance of sound
teeth; to facilitate absorption of calcium and
phosphorus by the intestine; in various forms of
tuberculosis; and in many states of general mal-
nutrition.

Rickets. — It has been customary to commence
administration of cod fiver oil or some other
source of vitamin D early in infancy to all infants
for prophylaxis of rickets. Since most diets con-
tain inadequate amounts of vitamin D and since
sunlight seems inadequate to meet the needs,
some other source has been needed. The daily
oral prophylactic dose is 5 to 10 Gm. of the official
cod fiver oil; this should be started with a small
dose when the infant is one or two weeks old and
increased to the full dose by the age of four to
eight weeks. The curative dose for rickets is about
20 Gm. daily but much larger doses may be re-
quired, especially in premature infants. Cod fiver
oil has been largely superseded by more concen-
trated solutions of vitamin D because of the
smaller volume to be administered and because
the supply of this oil has been very limited.

Tuberculosis. — The usefulness of cod fiver
oil in phthisis and other forms of tuberculosis
seems well-established although based chiefly on
empirical evidence. Williams {Brit. M. J., 1912,
2, 1700) found that unsaturated fatty acids of
the oil had an inhibiting effect on the growth of
the tubercle bacillus but it is improbable that
these acids could ever circulate in the body in
sufficient amount to exert a therapeutic effect. It
is not unlikely that its beneficial action in these
cases is due largely to its food value although the
influence of vitamin A on the respiratory mucous
membrane may also play some part. The value
of 30 ml. of cod fiver oil, with 100 ml. of ice-cold
tomato juice, twice daily for patients with in-
testinal tuberculosis is unquestioned although un-
explained (Granet, Am. J. Digest. Dis., 1935, 2,
209).

Nutrition. — Cod fiver oil is valuable in many
conditions of undernourishment. Thus it is of
service in infantile marasmus and nearly all
wasting diseases in which it is acceptable to the
digestive tract. It is absorbed through the skin,
at least by young infants, in sufficient quantity to
have a perceptible influence on nutrition.

Topical Uses. — Cod liver oil has come into

Part I

Cod Liver Oil, Non-destearinated 347

considerable use as a local application to wounds
and burns (Daughtry, Surgery, 1945, 18, 510).
Puestow and associates {Surg. Gynec. Obst.,
1938, 66, 622) concluded that vitamin D ac-
celerated the healing of burns and that a mixture
of vitamins A and D was more efficient. Rectal
instillation of 60 to 120 ml. daily relieved tenes-
mus in ulcerative colitis (Best, Am. J. Digest.
Dis., 1938, 5, 426). Several investigators reported
that cod liver oil possesses bactericidal activity
under certain conditions; others have failed to
observe such activity. Ross and Poth (/. Lab.
Clin. Med., 1945, 30, 226) investigated the rea-
son for this lack of agreement and discovered that
fresh oils are not bactericidal, but that old or
rancid oils are active. Development of bactericidal
activity in a fresh oil may be brought about
by adsorbing the natural antioxidants in it with
activated charcoal so that oxidation may be ac-
celerated. Addition of the antioxidant hydro-
quinone to an oil retarded oxidation and de-
velopment of bactericidal action. Ross and Poth
further observed that vapors from an active oil
were likewise bactericidal and since the former
were found to contain aldehydes it is possible
that the active component is acrolein. Lichtenstein
(Lancet, 1939, 2, 1023) suggested that peroxides
were the effective components.

Cod liver oil has been employed in ointment
and lotion form as beneficial topical therapy in a
variety of dermatoses. The role of vitamins A
and D in local skin metabolism is not clear, but
their nonsensitizing and nonirritating properties
are recognized. Behrman et al. (Ind. Med. Surg.,
1949, 18, 512) used cod liver oil in a formula-
tion containing also zinc oxide, talc, petrolatum
and lanolin for local treatment of eczematoid
and contact dermatitis, atopic eczema, diaper
rash, stasis dermatitis and traumatic ulcers, and
in pyoderma, with benefit. In denuded, ulcerated
surfaces the effects were to diminish pain, inhibit
infection, stimulate granulation and accelerate
epithelization. Heimer et al. (Arch. Pediat., 1951,
68, 382) treated 654 newborn infants routinely
with the cod liver ointment, comparing its effects
with sterile mineral oil in a comparable number
of cases, and noted lessened incidence of sympto-
matic, erythematous dermatoses in the diaper and
thigh areas, and decreased pustulation. Grayzel
et al. (N. Y. State J. Med., 1953, 53, 233) and
Holland (/. M. Soc. New Jersey, 1952, 49, 469)
evaluated the effect of cod liver oil in a lotion
containing also zinc oxide, magnesium carbonate,
rose and lime water, used in the treatment of in-
flammatory dermatoses, and emphasized its sooth-
ing and nonirritating qualities. Turrell (N. Y.
State J. Med., 1950, 50, 2282) used the ointment
as a postoperative anorectal lubricant and in acute
fissures and perineal dermatitis, and observed
good healing and universal tolerance. |v]

Dose. — The usual dose of cod liver oil is 4 ml.
(1 fluidrachm) one or more times daily by mouth,
with a range of 4 to 16 ml. The usual maximum
single dose is 32 ml. Each 4 ml. contains 900
micrograms (3000 U.S. P. units) of vitamin A and
7.5 micrograms (300 U.S. P. units) of vitamin D.
Topically it is used undiluted or as an ointment
containing 10 per cent or more of the oil.

Of the various measures which have been sug-
gested to overcome the fishy taste of cod liver
oil, none is entirely satisfactory. To some persons
it is more palatable in the form of an emulsion
which may be flavored with one of the volatile
oils or with malt extract.

Storage. — "Preserve Cod Liver Oil in tight
containers. It may be bottled or packaged in con-
tainers from which air has been expelled by the
production of a vacuum or by an inert gas." U.S. P.

Off. Prep.— Cod Liver Oil Emulsion, N.F.,
B.P.; Cod Liver Oil Emulsion with Malt, N.F.;
Extract of Malt with Cod-Liver Oil, B.P.

NON-DESTEARINATED COD LIVER
OIL. U.S.P.

[Oleum Morrhuae Non-destearinatum]

"Non-destearinated Cod Liver Oil is the entire
fixed oil obtained from fresh liver of Gadus
morrhua Linne and other species of the Family
Gadidce, containing not more than 0.5 per cent by
volume of water and liver tissue. Non-destearin-
ated Cod Liver Oil contains in each Gm. not less
than 255 micrograms (850 U.S.P. Units) of Vita-
min A and not less than 2.125 micrograms (85
U.S.P. Units) of Vitamin D." U.S.P.

Sp. Aceite de Higado de Bacalao no Desestearinizado.

In the modern process of separating cod liver
oil, using steam, the oil contains considerable
stearin which on chilling precipitates and gives
the oil a cloudy appearance. While this does not
in any way affect the therapeutic virtues of the
oil it does affect its salability and, therefore, both
the U.S.P. and B.P. recognize an oil from which
the stearin has been separated by chilling and
filtration. This clarification requires for an official
oil rather extensive equipment and much of the
Norweign cod liver oil which is sold in this coun-
try is imported undestearinated. So that this
product may be utilized as a medicinal, the U.S.P.
has established standards for it.

Description. — "Non-destearinated Cod Liver
Oil is a thin, oily liquid at room temperature, and
has a characteristic, slightly fishy, but not a rancid
odor, and a fishy taste. Non-destearinated Cod
Liver Oil congeals or deposits stearin upon chill-
ing. Non-destearinated Cod Liver Oil is slightly
soluble in alcohol, and is freely soluble in ether
and in chloroform." U.S.P.

Standards and Tests. — Water and sediment.
— The oil contains not over 0.5 per cent. Iodine
value. — Not less than 128 and not more than 180.
Other requirements. — Non-destearinated oil satis-
fies the requirements of the tests for identification
of vitamin A, color, unsaponifiable matter, sapon-
ification value, and acid value under Cod Liver
Oil. U.S.P.

Assay. — The assays are the same as required
of Cod Liver Oil. U.S.P.

The non-destearinated cod liver oil, while it
possesses all the therapeutic properties charac-
teristic of this oil, is practically never employed
in human medicine. It is, however, used as a
vitamin-supplying food for chickens and other
animals.

Labeling. — "The Vitamin A potency and Vita-

348

Cod Liver Oil, Non-destearinated

Part I

min D potency of Non-destearinated Cod Liver
Oil, when designated on the label, are expressed
in United States Pharmacopeia Units per Gm. of
oil. These units may be referred to as U.S. P.
Units." U.S.P.

Storage. — "Preserve Non-destearinated Cod
Liver Oil in tight containers. It may be stored
in containers from which the air has been ex-
pelled by the production of a vacuum or by an
inert gas." U.S.P.

COD LIVER OIL EMULSION.

N.F. (B.P.)

Emulsum Olei Morrhuae

B.P. Emulsion of Cod-liver Oil. Emulsio Olei Mor-
rhuae. Emulsio Olei Jecoris Aselli. Fr. Emulsion de huile de
foie de morue. Ger. Lebertranemulsion. It. Emulsione di
olio di fegato di merluzzo. Sp. Emulsion de aceite de
higado de bacalao.

Mix thoroughly and quickly 125 Gm. of finely
powdered acacia with 500 ml. of cod liver oil in
a dry mortar or other suitable vessel, then add
at once 250 ml/ of purified water, and emulsify
by trituration or with the aid of a suitable me-
chanical device. When a thick, white, homogeneous
emulsion is formed add 4 ml. of methyl salicylate
and 100 ml. of syrup, in small divided portions,
triturating thoroughly after each addition, and
then add, in the same manner, sufficient purified
water to make the product measure 1000 ml.
Mix thoroughly. N.F.

The methyl salicylate in this emulsion may be
replaced by not more than 1 per cent of any other
flavoring substance or any mixture of flavoring
substances recognized officially. If a preserva-
tive is needed, 60 ml. of alcohol may be used, re-
placing a like quantity of purified water, or,
instead of the alcohol, 60 ml. of sweet orange peel
tincture or 2 Gm. of benzoic acid may be used.
For permissible variations see under Emulsions.
N.F.

The British emulsion differs from that of the
N.F. in the following respects: (1) It contains
a small amount of tragacanth in addition to the
acacia; (2) it is flavored with volatile oil of bitter
almond instead of methyl salicylate; (3) it is
sweetened with saccharin sodium instead of with
syrup; (4) it contains a small amount of chloro-
form, presumably as a preservative.

This emulsion was introduced for the purpose
of providing a reasonably palatable and perma-
nent preparation of cod liver oil. A palatable
preparation has been prepared in which the flavor-
ing agents used were Worcestershire sauce and
mustard. Beringer (Proc. N. J. Ph. A., 1914,
p. 81) claimed that the best disguishing flavors
for this emulsion are those of coriander and
geranium; less effective are anise and cardamom,
then bitter almond, clove, pimenta and vanilla.
Of inferior value are peppermint, spearmint,
lemon, orange and cinnamon and least valuable
of all are caraway, sassafras, wintergreen and
nutmeg. An excellent emulsion may be made with
malt extract as the emulsifying agent (see Cod
Liver Oil Emulsion with Malt).

Because of the oxidase in acacia it has been
claimed that this emulsion will decrease in vita-
min A content on standing. Griffiths, Hilditch and

Rae (Analyst, 1933, 58, 65), however, found that
cod liver oil emulsions can be kept for at least
four months without serious loss of vitamin A,
if stored in well-filled amber glass bottles and kept
in the dark.

Under the name of Black Bottle, there has
long been used in New England an emulsion of
cod liver oil flavored with licorice and aromatic
oils, the following formula for which was con-
tributed to the Apothecary, 1913, p. 24, by
Newton: Powdered acacia, 13 drachms; cod liver
oil, 6^2 fluidounces; flavoring oil, 15 minims;
pure extract of licorice, 5 drachms; glycerin, 2^
fluidounces; water, to make 1 pint. Prepare an
emulsion. The flavoring oil mixture is made as
follows: Oil of cassia, 1 fluidounce; oil of laven-
der, l/2 fluidounce; oil of clove, 1 fluidrachm; oil
of peppermint, ^ fluidrachm; mix.

Dose, 8 to 15 ml. (approximately 2 to 4 flui-
drachms).

COD LIVER EMULSION WITH
MALT. N.F. (B.P.)

Malt and Cod Liver Oil, Emulsum Olei Morrhuae
cum Malto

Mix 300 ml. of cod liver oil with 3 Gm. of
tragacanth, in fine powder, add 150 ml. of purified
water, and agitate the mixture until a homoge-
neous emulsion is formed. Finally add sufficient
malt extract, in divided portions and shaking the
mixture thoroughly after each addition, until the
product measures 1000 ml. N.F.

The B.P. recognizes, under the title Extract of
Malt with Cod-Liver Oil, a preparation contain-
ing 900 Gm. of extract of malt and 100 Gm. of
cod liver oil, mixed thoroughly with the aid of
gentle heat.

Malt has the property of masking the fishy
taste of cod liver oil and to many persons this
is one of the least disagreeable forms for admin-
istering the oil.

The dose of the N.F. and B.P. preparations
ranges from 4 to 30 ml. (approximately 1 to 8
fluidrachms).

Storage. — Preserve "in tight containers."
N.F.

CODEINE. N.F., LP.

[Codeina]
C18H21NO3.H2O

"Codeine is an alkaloid obtained from opium
or prepared from morphine by methylation."
N.F. The LP. defines codeine as morphine methyl
ether, and requires it to contain not less than 99.0
per cent and not more than the equivalent of
100.3 per cent of C18H21O3N.H2O.

I. P. Codeinum. Methylmorphine. Codeinum. Fr. Codeine.
Ger. Codein. It. Codeina. Sp. Codeina.

Codeine was discovered in opium by Robiquet
in 1832, and recognized as the methyl ether of
morphine in 1881 by Grimaux. The codeine
content of opium varies according to the kind
of opium; on the average it is about 1 per cent.
It exists in opium combined, like morphine, with
meconic acid, and is extracted along with that
alkaloid as a hydrochloride (see Morphine).

Part I

Codeine

349

When the solution of the mixed morphine and
codeine hydrochlorides is treated with ammonia,
the former alkaloid is precipitated, and the
codeine, remaining in solution, may be obtained
by concentration and crystallization. It may be
purified by dissolving the crystals with hot ether,
and recrystallizing the codeine.

Much codeine is prepared synthetically by the
methylation of morphine. Among the methylat-
ing agents which have been employed are methyl
iodide, various salts of methylsulfuric acid, nitro-
somethylurethane, diazomethane, dimethyl sul-
fate, methyl benzenesulfonate, and trimethyl-
phenylammonium chloride or sulfate.

Description. — "Codeine occurs as colorless
or white crystals, or as a white, crystalline pow-
der. It effloresces slowly in dry air and is af-
fected by light. In acid or alcohol solutions
it is levorotatory. A saturated aqueous solution
of Codeine is alkaline to litmus paper. One Gm.
of Codeine dissolves in 120 ml. of water, in 2 ml.
of alcohol, in about 0.5 ml. of chloroform, and in
50 ml. of ether. When heated in an amount of
water insufficient for complete solution, Codeine
melts to oily drops which crystallize on cooling.
Codeine, rendered anhydrous by drying at 80°
for 4 hours, melts between 154° and 156°." N.F.

Standards and Tests. — Identification. — (1)
A green color, changing rapidly to blue, then
slowly back to green, is produced when a 1 in
200 solution of selenious acid in sulfuric acid is
added to codeine. (2) A blue color, changing to
red on addition of 1 drop of nitric acid, is pro-
duced on adding a drop of ferric chloride T.S. to a
solution of 10 mg. of codeine in 5 ml. of sulfuric
acid, the mixture being warmed. (3) An in-
tensely purple color results when sulfuric acid,
containing a drop of formaldehyde T.S. in each
ml., is added to codeine. (4) A light orange
color, fading to greenish yellow within a minute,
results when 2 drops of nitric acid is added to
2 mg. of codeine (difference from morphine).
(5) A light greenish yellow color is produced on
adding several drops of potassium ferricyanide
T.S. containing 1 drop of ferric chloride T.S. in
each ml. to a solution of 5 mg. of codeine in
5 ml. of diluted sulfuric acid (difference from
morphine). Loss on drying. — Not over 6 per cent,
when dried at 80° for 4 hours. Residue on ignition.
— The residue from 500 mg. is negligible. Readily
carbonizable substances. — A solution of 10 mg.
of codeine in 5 ml. of sulfuric acid has no more
color than matching fluid S. Morphine. — No blue
color is produced immediately on adding to a
solution of 50 mg. of potassium ferricyanide in
10 ml. of distilled water 1 drop of ferric chloride
T.S. and 1 ml. of a neutral or slightly acid aque-
ous solution of codeine (1 in 100) prepared with
the aid of sulfuric acid. N.F.

Assay. — The I.P. directs that about 150 mg.
of codeine be dissolved in 5 ml. of reagent etha-
nol, the solution mixed with 20 ml. of water, and
titrated with 0.1 iV hydrochloric acid in the
presence of methyl red indicator. Each ml. of
0.1 N hydrochloric acid represents 31.74 mg. of
C18H21O3N.H2O.

Sterilization. — Dietzel and Sollner (Apoth-
Ztg., 1930, 45, 1030) found that solutions of

codeine may be sterilized at temperatures up to
100° without alteration; heating under pressure
does cause decomposition. Aqueous solutions of
codeine and its salts become discolored as a
result of oxidative changes which are hastened
by ultraviolet light and by elevated temperature
(Arch. Phar., 1938, 276, 621).

Incompatibilities. — Codeine in aqueous solu-
tion is precipitated by most alkaloidal reagents,
but not by alkaline carbonates, bicarbonates, or
ammonium carbonate. Due probably to its mark-
edly alkaline properties, aqueous solutions of
codeine yield precipitates with solutions of many
metallic and alkaloidal salts. Codeine liberates
ammonia from some ammonium salts.

Uses. — Codeine resembles morphine in its
general physiological action although much
weaker (see under Morphine). Adler and Shaw
(/. Pharmacol., 1952, 104, 1) found that under
aerobic conditions, incubation of rat liver slices
with Krebs-Ringer-bicarbonate solution to which
codeine was added resulted in the disappearance
of codeine and the formation of morphine. The
total amount of morphine formed represented
less than one-half the metabolized codeine. Co-
deine is less narcotic, less constipating and almost
without euphoric effect. The pain threshold was
found to be elevated 50 per cent, 90 minutes
after the injection of 60 mg., for a period of
about 3 hours (Wolff et al., J. Clin. Inv., 1940,
19, 659); 8 mg. of morphine had a similar effect
and acetylsalicylic acid had about half the effect.
Von Schroeder (Arch. exp. Path. Pharm., 1883,
17) demonstrated that codeine heightens the
reflex activity of the spinal cord. It exerts a
depressant effect on the higher cerebral centers
(Macht, /. Pharmacol., 1916, 8, 1); the effective
dose was 3 or 4 times as large as that of mor-
phine. Its sedative action upon the respiratory
center is similar in type to that of morphine,
although it requires (Macht, /. Pharmacol., 1915,
7, 339) almost 10 times as much codeine as it
does morphine to produce a corresponding effect.
Like morphine it tends to increase the tone of
unstriped muscle tissue (Macht, /. Pharmacol.,
1918, 11, 389) and has been shown to increase
the pressure within the gall bladder. Grass and
co-workers (Proc. Mayo, 1951, 26, 81) found
abnormally high serum amylase and serum lipase
values following administration of codeine, and
warn of possible false positive tests where co-
deine has been administered.

Codeine is used for the relief of pain and as
a respiratory sedative. As an analgesic it is in-
ferior in power to morphine and scarcely strong
enough for acute suffering. It is commonly pre-
scribed in combination with the so-called coal
tar analgesics for such pains as those of neu-
ralgia, although Wolff et al. (loc. cit.) ques-
tioned the virtue of this practice. As a cough
sedative, taking all factors into consideration,
it is probably the most frequently useful drug
of its class. Diehl (J.A.M.A., 1933, 101, 2042)
found a combination of 16 mg. each of codeine
sulfate and papaverine hydrochloride (Copavin,
Lilly) of value in acute coryza not merely to
relieve symptoms but also to lessen duration of
the disease. Gurdjian and Webster (Am. J. Surg.,

350

Codeine

Part I

1944, 63, 236) recommended its use to alleviate
pain in head trauma, and it is efficacious in com-
bination with sodium pentobarbital to produce
sleep in such cases, without any increase in
cerebrospinal fluid pressure.

The great advantage over morphine, which
makes codeine the most frequently prescribed
opiate in the United States, is the comparatively
small danger of giving rise to a drug habit (see
Wolff, Bull. Health Organ., League of Nations,
1938, 546). While codeine addiction is compara-
tively rare, it is habit-forming. Schwarz (Deutsche
med. Wchnschr., 1930, p. 8) reported three cases
of codeine addiction; and Himmelsbach (J. A.M. A.,
1934, 103, 1420) found that codeine is capable
of alleviating the abstinence symptoms in the
morphine addict but that when the codeine is
stopped there is the same type of withdrawal
symptoms as seen in morphine addiction. |v]

Toxicology. — The symptoms of codeine poi-
soning in man differ considerably from those of
morphine. There is usually narcosis, sometimes
preceded by a , feeling of exhilaration and fol-
lowed by convulsions. In most of the reported
cases nausea and vomiting have been prominent
symptoms and there has also been evidence of
circulatory depression. The pupils are contracted,
the pulse rate is usually increased. Only two
fatalities have been reported in the literature
(Cohen and Rudolph, J. A.M. A., 1932, 98, 1864;
Cornell, Ann. Int. Med., 1951, 34, 1274). In
both instances the patients were asthmatics. In
the former case the dose consumed was not
recorded but in the case reported by Cornell
the patient consumed between 875 mg. (13 gr.)
and 1750 mg. (26 gr.) of codeine sulfate as a
result of improper compounding of a prescription.
Alarming symptoms have followed the ingestion
of 250 mg. (Myrtle, Brit. M. J., 1874), and
Boissonnas (Rev. med. Suisse Rom., 1919, 39,
581) reported a case of violent poisoning in a
child of 3 years from 40 mg. Palmer (Arch.
Dermat. Syph., 1943, 47, 654) reported contact
dermatitis due to codeine and allied substances
having the phenanthrene nucleus. The treatment
of codeine poisoning should be along the same
lines as that of morphine poisoning.

Dose. — The N.F. gives the usual dose as 30
mg. (approximately }4 grain).

Storage. — Preserve "in tight, light-resistant
containers." N.F.

Off. Prep. — Terpin Hydrate and Codeine
Elixir, N.F.

CODEINE PHOSPHATE.
U.S.P., B.P., LP.

Codeinium Phosphate, [Codeinae Phosphas]

H2P04".l|H2p

CHaO

"Codeine Phosphate contains not less than 70
per cent of anhydrous codeine (C18H21NO3)."
U.S.P.

The B.P. recognizes a codeine phosphate con-
taining but one molecule of water; it is required
to contain not less than 73.3 per cent and not
more than 75.7 per cent of anhydrous codeine,
calculated with reference to the substance dried
to constant weight at 105°. The LP. recognizes
the same salt as does the U.S. P., and has the same
purity rubric.

LP. Codeini Phosphas. Codeinura Phosphoricum. Fr.
Phosphate de codeine. Ger. Kodeinphosphate ; Phos-
phorsaures Codein. It. Fosfato di codeina. Sp. Fosfato de
codeina.

Codeine phosphate may be obtained by neu-
tralizing codeine with phosphoric acid and crys-
tallizing the resulting salt from a hydroalcoholic
solution. The phosphate salt, being considerably
more soluble in water than the sulfate, is com-
monly the preferred dosage form of codeine.

Description. — "Codeine Phosphate occurs as
fine, white, needle-shaped crystals or as a white,
crystalline powder. It is odorless. It readily loses
water of hydration on exposure to air and is
affected by light. Its solution is acid to litmus
paper. One Gm. of Codeine Phosphate dissolves
in 2.5 ml. of water, and in 325 ml. of alcohol. One
Gm. dissolves in 0.5 ml. of water at 80°, and in
125 ml. of boiling alcohol." U.S. P.

Standards and Tests. — Identification. — Co-
deine phosphate responds to identity tests under
codeine; a solution of it, neutralized with
ammonia T.S. and treated with silver nitrate T.S.,
produces a yellow precipitate which is soluble in
diluted nitric acid and in ammonia T.S. Chloride.
— A 10-ml. portion of a 1 in 100 solution of co-
deine phosphate shows no opalescence on adding
a few drops of silver nitrate T.S. and 2 drops of
nitric acid. Sulfate. — A 10-ml. portion of a 1 in
100 solution of codeine phosphate yields no tur-
bidity immediately on adding a few drops of
barium chloride T.S. Morphine. — The test is iden-
tical with the corresponding test under Codeine.

The B.P. limits loss on drying, to constant
weight at 105°, to 7.0 per cent. The LP. loss on
drying to constant weight at 100° is required to
be not less than 4.0 per cent and not more than
7.0 per cent; the residue is required to be white
or not more than slightly yellow.

Assay. — A solution of about 500 mg. of co-
deine phosphate is made strongly alkaline with
ammonia T.S. and the liberated codeine is ex-
tracted with several portions of chloroform. After
washing the combined chloroform solutions with
water most of the chloroform is evaporated and
the residue is dissolved in 0.1 AT sulfuric acid.
After warming to expel the rest of the chloroform
the excess of acid is titrated with 0.1 A7 sodium
hydroxide, using methyl red T.S. as indicator.
Each ml. of 0.1 N sulfuric acid represents 29.94
mg. of C18H21NO3. U.S.P. The B.P. and LP.
assays are similar.

Uses. — The medicinal properties of codeine
phosphate are the same as those of codeine
(q.v.). Because of its ready solubility and its
high content of codeine (about 70 per cent) it is
well suited for hypodermic injections. S

Part I

Colchicine

351

The usual dose, orally or parenterally, is 30
mg. (approximately ]/2 grain), every 4 hours
if necessary, with a range of 15 to 60 mg.; the
maximum safe dose is usually 100 mg. (approxi-
mately \Yz grains) and the total dose in 24 hours
will rarely exceed 360 mg.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

Off. Prep. — Codeine Phosphate Tablets,
U.S.P., B.P., LP.; Compound White Pine Syrup
with Codeine, N.F. Compound Tablets of Co-
deine, B.P.

CODEINE PHOSPHATE TABLETS.

U.S.P. (B.P.) (LP.)

[Tabellae Codeinae Phosphatis]

"Codeine Phosphate Tablets contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of C1SH21NO3H3PO4.-
l^HoO." U.S.P. The B.P. requires each tablet
of average weight to contain not less than 90.0
per cent and not more than 110.0 per cent of
the prescribed or stated amount of codeine
phosphate. The LP. specification is identical
with that of the U.S.P.

B.P. Tablets of Codeine Phosphate. LP. Compressi
Codeini Phosphatis.

Usual Sizes. — IS, 30, and 60 mg. (approxi-
mately lA, J<2, and 1 grain).

COMPOUND TABLETS OF CODEINE.
B.P.

Tabellae Codeinae Compositae, Tablets of Aspirin,
Phenacetin and Codeine

Each Compound Tablet of Codeine is formu-
lated to contain 0.2592 Gm. (4 grains) of acetyl-
salicylic acid, 0.2592 Gm. (4 grains) of
phenacetin, and 8.1 mg. (J/i grain) of codeine
phosphate. They must contain not less than
94.5 per cent and not more than 105.0 per cent
of the amount of acetylsalicylic acid (as C9H8O4)
required by the formula, not less than 95.0 per
cent and not more than 105.0 per cent of the
amount of phenacetin (as C10H13O2N) required
by the formula, and not less than 92.5 per cent
and not more than 107.5 per cent of the amount
of codeine phosphate (as C18H21O3N.H3PO4)
required by the formula. B.P.

The tablets are used where combined anal-
gesic and antipyretic action is desired, in doses
of 1 or 2 tablets.

CODEINE SULFATE. N.F.

Codeinium Sulfate, [Codeinae Sulfas]

(Ci8H2iN03)2.H2S04.5H20

Codeinum Sulphuricum. Fr. Sulfato de codeine. Ger.
Codeinsulfat; Schwefelsaures Codein. It. Solfato di codeina.
Sp. Sulfato de codeina.

Codeine sulfate may be prepared by neutraliz-
ing an aqueous solution of codeine with sulfuric
acid, then concentrating it by evaporation until
the salt crystallizes.

Description. — "Codeine Sulfate occurs as
white crystals, usually needle-like, or as a white,
crystalline powder. It effloresces in dry air and
is affected by light. One Gm. of Codeine Sulfate

dissolves in 30 ml. of water and in 1280 ml. of
alcohol. One Gm. dissolves in 6.5 ml. of water at
80°. It is insoluble in chloroform and in ether."
N.F.

Standards and Tests. — Identification. — Co-
deine sulfate responds to the identity tests under
codeine, as well as to that for sulfate. Specific
rotation. — Not less than —112.5° and not more
than —115°, when determined in a solution con-
taining the equivalent of 2 Gm. in 100 ml. and
calculated to the anhydrous basis. Acidity. —
Not more than 0.3 ml. of 0.02 N sodium hydrox-
ide is required to neutralize a solution of 500 mg.
of codeine sulfate in 15 ml. of water, using methyl
red T.S. as indicator. Loss on drying. — Not over
12 per cent, when dried at 105° for 3 hours.
Residue on ignition. — The residue from 500 mg.
is negligible. Readily carbonizable substances. —
A solution of 10 mg. of codeine sulfate in 5 ml.
of sulfuric acid has no more color than matching
fluid S. Morphine. — This is performed as de-
scribed under Codeine. N.F.

Uses. — The medicinal properties of this salt
are those of the alkaloid codeine (q.v.). [v]

The usual dose is 30 mg. (approximately Y
grain) but from 15 mg. to 60 mg. (approxi-
mately K to 2 grains) is commonly prescribed,
both orally and subcutaneously.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

CODEINE SULFATE TABLETS.
N.F.

[Tabellae Codeinae Sulfatis]

"Codeine Sulfate Tablets contain not less than
93 per cent and not more than 107 per cent of
the labeled amount of (CisH2iN03)2.H2S04.-
5H20." U.S.P.

Usual Sizes. — 15, 30, and 60 mg. (approxi-
mately %, }4, and 1 grain).

COLCHICINE. U.S.P., B.P., LP.

[Colchicina]

H2
CH30^^\C-

CH,0

CH3O

II
HC

I
HC =

■C
I
CH- NH-CO-CHi

C=0

I
=C-0CH3

"Colchicine is an alkaloid obtained from Col-
chicum autumnale Linne (Fam. Liliacea)."
U.S.P.

"Caution — Colchicine is extremely poisonous."
U.S.P.

LP. Colchicinum. Fr. Colchicine. Ger. Kolchizin;
Colchicin. Sp. Colchicina.

Pelletier and Caventou first isolated colchicine
in 1820. The alkaloid occurs in various species of
Colchicum, in Gloriosa superba (see Part II), in
species of Merendera (Fourment and Roques,
Bull. sc. Pharmacol., 1928, 35, 408), and in
Androcymbium gramineum of Southern Sahara
(Perrot, Compt. rend. acad. sc, 1936, 202, 1088).

In Colchicum autumnale colchicine is found in

352

Colchicine

Part I

concentrations of 0.3 to 0.9 per cent. Because the
alkaloid is so readily hydrolyzed to colchiceine
by dilute acids, extraction of seeds and corm is
effected by means of alcohol. The extract is con-
centrated, diluted with water to precipitate fats
and resins, the mixture filtered, and the filtrate
extracted with chloroform. The chloroform solu-
tion is evaporated to a syrupy consistence, after
which alcohol is added to dissolve the precipitate
that forms. On cooling the solution to 0°, crys-
tals of colchicine containing two molecules of
chloroform of crystallization separate; a suspen-
sion of the crystals in water is treated with steam
to expel the chloroform and the aqueous solution
is evaporated, under vacuum, to obtain a yellow,
varnish-like residue of colchicine. Crystallization
of the residue from ethyl acetate yields pale
yellow or colorless crystals of the alkaloid.

Though many investigators have studied the
problem intensively, the structural formula of
colchicine has not been definitely established.
Present evidence strongly suggests that colchi-
cine is a methoxylated tricyclic condensed ring
compound containing two seven-membered rings,
a keto and an a-enol ether group, with its nitrogen
a part of an acetamide group (Cook and Loudon,
Quarterly Rev., 1951, 5, 99; see also Dewar,
Nature, 1945, 155, 141, 479).

On hydrolysis of colchicine with dilute acids,
methyl alcohol is produced and the demethylated
derivative colchiceine results; the latter has but
¥200 to Mo the activity of colchicine (Biochem. J.,
1938, 32, 1207). The presence of colchiceine
may be detected by the green color produced
with ferric chloride in chloroform solution. Colchi-
ceine, which is acetyltrimethylcolchicinic acid,
may by more vigorous hydrolysis with strong
acids be converted to trimethylcolchicinic acid.

In purifying U.S. P. colchicine for biological
studies Horowitz and Ullyot (Science, 1952, 115,
216) found in it about 4 per cent of desmethyl-
colchicine, as well as minor amounts of other
constituents. They believe that the desmethylcol-
chicine is identical with Compound C, one of
several new constituents of colchicum seed iso-
lated by Santavy and Reichstein (see under
Colchicum Seed Constituents). In another sam-
ple of colchicine Raffauf, Farren and Ullyot
(J.A.C.S., 1953, 75, 3854) found about 1.5
per cent of an alkaloid apparently identical with
Santavy and Reichstein's Compound B; no des-
methylcolchicine was found in the second sample.

Description. — "Colchicine occurs as pale yel-
low, amorphous scales, or powder. It is odorless
or nearly so, and darkens on exposure to light.
One Gm. of Colchicine dissolves in 25 ml. of
water, and in about 220 ml. of ether. It is freely
soluble in alcohol and in chloroform." U.S.P. The
B.P. specifies that the melting point of colchicine,
after drying it over sulfuric acid for 24 hours, is
between 153° and 157°.

On exposure to sunlight or ultraviolet light
colchicine is converted to isomeric compounds
called lumicolchicines (Grewe and Wulf, Chem.
Ber., 1951, 84, 621).

In a study of the solubility of colchicine in
water, Loudon and Speakman (Research, 1950,

3, 583) found that the anhydrous form decreased
in solubility with increase in temperature, while
the reverse was observed with the sesquihydrate ;
they claim that the solubility given by the U.S.P.
and B.P. can be obtained only if crystals of
the hydrated alkaloid are absent.

Standards and Tests. — Specific rotation. —
The specific rotation, determined in a solution
containing 100 mg. of colchicine in each 10 ml.,
calculated on an anhydrous basis, is between
—410° and —435°. Identification. — (1) A lemon
yellow color is produced on mixing 1 mg. of col-
chicine with a few drops of sulfuric acid; on
adding a drop of nitric acid the color changes to
greenish blue, this rapidly becoming reddish and
finally yellow or almost colorless; upon now
adding an excess of sodium hydroxide T.S. a red
color forms. (2) A garnet red color is formed
on adding 1 drop of ferric chloride T.S. to 1 ml.
of a 1 in 20 solution of colchicine in alcohol.
Loss on drying. — Not over 3 per cent, when dried
at 105° for 3 hours. Residue on ignition. — The
residue from 100 mg. is negligible. Chloroform. —
No odor of phenylisocyanide is apparent on heat-
ing 10 mg. of colchicine with 2 ml. of sodium
hydroxide T.S. and 1 drop of aniline. Colchiceine.
— No color results on adding 2 drops of ferric
chloride T.S. to 5 ml. of a 1 in 100 solution of
colchicine; on heating the mixture it becomes
brownish red. then brownish black. U.S.P.

Vanderkleed and E'we (Proc. P. Ph. A., 1916,
p. 279) found that some commercial samples
of colchicine contain chloroform of crystalliza-
tion. This not only interferes with the melting
point determination, but inasmuch as the amount
of chloroform present is sometimes over 20 per
cent it constitutes an adulteration.

Incompatibility. — Because of the ease with
which colchicine is hydrolyzed by dilute acids to
the relatively inactive colchiceine, solutions of the
alkaloid should be adjusted to neutrality to avoid
decomposition.

Uses. — Colchicine is a therapeutic agent
whose specificity for gouty arthritis has been
known for centuries but whose mode of action
is still unknown. Colchicine may be given by
oral or intravenous routes (Gutman and Gu,
Am. J. Med., 1952, 13, 744). There is no avail-
able information regarding therapeutic blood
levels. The drug is obviously well absorbed from
the gastrointestinal tract since its therapeutic
effects are promptly noted after oral administra-
tion. Because most toxic symptoms are referable
to the gastrointestinal tract and kidneys, it has
been assumed that these two systems are con-
cerned with excretion of the drug. The therapeu-
tic and toxic doses of the drug seem to be fairly
close to each other since early signs of toxicity
appear frequently at the same time as the thera-
peutic action is noted.

Gout. — A brief description of clinical gout
is needed to discuss even the theoretical pharma-
codynamics of colchicine. Gout is a disease
believed to be due to an inborn error in the
metabolism of purines. Purine compounds are
formed by the degradation of certain proteins
in the body and also are synthesized by the body

Part I

Colchicine

353

from simple nitrogen and carbon containing sub-
stances. The end product of purine metabolism
is uric acid, which is excreted in the urine. Clini-
cally, gout is manifested by recurrent attacks of
acute arthralgia. The natural course of the dis-
ease is one of chronicity, characterized by more
and more frequent and severe acute attacks and
finally a state of chronic arthritis with gross
deposition of urates in the joint tissues as well
as other connective tissue. The disease is also
characterized by an elevated serum uric acid level.
Since colchicine is effective in treating the acute
attacks of gout, it seems logical to assume that
it must in some way affect uric acid metabolism.
All evidence is either negative in nature or pre-
sumptive. Colchicine has no measurable or pre-
dictable influence on serum uric acid levels and
does not increase the urinary excretion of the
urates. It is assumed that in some unknown way
it influences the chemical pathway used by the
body to produce uric acid. Since uric acid is the
end product of nucleoprotein metabolism it is
of interest that colchicine has a known inhibitory
effect on cellular mitosis in numerous plant and
animal cells. Whether this action causes its
anti-gout effect is only conjecture.

The sole clinical usefulness of colchicine is
the management of the different stages of gout.
In attacks of acute gouty arthralgia, it is usually
given by mouth according to the following sched-
ule. An initial dose of 1 mg. is given and followed
every two to four hours with 0.5 to 0.65 mg. until
(a) relief of the arthralgia occurs or (b) toxic
symptoms occur. Either or both of these end
points will be reached at a total dose of from
6 to 8 mg. of the drug. There may be a latent
period between the onset of the therapeutic effect
and the toxic manifestations and vice versa.
Therefore, it is imperative to limit the total
number of tablets that a patient may use in a
course of treatment so that severe and dangerous
toxicity does not occur. Colchicine has two other
indications in gout. First, it may be used to abort
an impending attack of acute gout (Talbott et al.,
J.A.M.A., 1938, 110, 1977). Patients frequently
recognize the prodromal symptoms warning of
an impending attack. When this pattern is known,
the prompt ingestion of 0.5 to 1 mg. of colchi-
cine every two hours for a total dose of 3 to 4
mg. will frequently abort the attack and also
not cause distressing gastrointestinal symptoms.
It is advisable for patients subject to frequent
attacks to carry several tablets of the drug with
them at all times. Second, colchicine is useful
in reducing the recurrences of acute attacks.
Here it is used in various dosage schedules.
Cohen {Am. J. Med. Sc, 1936, 192, 488) ad-
vises 0.5 mg. three times daily for one week in
every four. Talbott recommends one or two tab-
lets a week continuously. Gutman advises 0.5
to 1.5 mg. every night or every other night
depending on the patient's needs. No toxicity
has resulted from these schedules.

It should be emphasized that colchicine is not
of benefit in any of the other varieties of arth-
ritis (Lockie, Ann. Int. Med., 1939, 13, 755)
and its specificity for gout is such that a thera-

peutic trial of the drug may be of considerable
diagnostic help in confusing clinical pictures
where the serum uric acid level does not confirm
the diagnosis of gout. It should also be remem-
bered that other measures must be used ade-
quately to manage the gouty patient. Thus, dietary
restrictions and the use of uricosuric agents, as
salicylates or probenecid, are also therapeutic
adjuncts in the management of gout.

Intravenous Use. — Recently the intravenous
administration of colchicine in doses of 0.65 mg.
every 3 to 6 hours has been reported to have
resulted in prompt therapeutic benefit with mini-
mal gastrointestinal symptoms (Suttenfield,
Geriatrics, 1951, 6, 96). This mode of therapy
has not been widely used or confirmed. However,
an aqueous solution containing 0.6 mg. of colchi-
cine, 1 Gm. of sodium iodide and 1 Gm. of so-
dium salicylate in 20 ml., given intravenously,
has been advocated with varying degrees of en-
thusiasm in the past. (See Sodium Salicylate and
Iodide with Colchicine Injection, N.F.)

Action. — By growing Colchicum autumnale
plants in an atmosphere containing carbon dioxide
labeled with radioactive carbon- 14, Geiling and
his associates (Walaszek et al., Science, 1952,
116, 225) extracted and isolated carbon-14-la-
beled colchicine and five other related alkaloids.
Back and Walaszek {Fed. Proc, 1952, 11, 320),
working with this labeled colchicine, reported
that the maximum concentration following ad-
ministration to mice was found in the spleen and
liver, with variable amounts in the organs of
excretion — the kidney and liver. In tumor-bearing
mice, there was considerable labeled colchicine
in the tumor but none in the spleen. Injections
of tumor homogenates or a lipid fraction derived
therefrom caused the normal mouse to behave
like the tumor-bearing mouse in storing no col-
chicine in the spleen {ibid., 1953, 12, 377);
the intestine showed a much greater concentration
in these animals than in the normal animals.
Urinary excretion in humans (Wolaszek et al.,
ibid., 1954, 13, 414), after intravenous injection
of 3 mg. of labeled colchicine, accounted for
70 to 97 per cent of the carbon-14 in 48 hours.
In 4 cases with neoplastic disease, 3.9 to 6 per
cent of the labeled colchicine was excreted un-
changed in the urine while 3 normal individuals
excreted 15.6 to 46.7 per cent unchanged; in
2 gouty patients the values were 3.6 and 4.7
per cent. Using colchicine labeled in the acetyl
group only a considerable portion of the carbon-14
appeared in the expired carbon dioxide.

Beck {Arch. exp. Path. Pharm., 1932, 165,
208) found that in rabbits sensitized to horse
serum preliminary treatment with colchicine les-
sened or entirely prevented the arthritis which
ordinarily follows the injection of horse serum
into joints. Colchicine has been used in animals
as a stressing agent in the sense of this term
used by Selye (see under Cortisone). In small
doses it causes a release of adrenal cortical
steroids; the prevention of serum reactions might
be mediated by this action. However, an increase
in 17-hydroxycorticosterone in the blood follows
a variety of toxic or traumatic stimuli and this

354

Colchicine

Part I

action of colchicine is probably nonspecific.
Dixon and Maiden (/. Physiol., 1908, 38, 50)
showed that it is an active stimulant of unstriped
muscle, increasing intestinal and uterine contrac-
tions and bronchial tonus. After large doses there
is a fall of blood pressure, apparently due to an
effect upon the blood capillaries. On the other
hand Ferguson (/. Pharmacol., 1952, 106, 261),
using highly purified colchicine, observed that
the usual response of the circulation when at
least 5 mg. per Kg. was injected intravenously
into cats was a slow rise in blood pressure;
subsequent doses, however, failed to raise blood
pressure. Ferguson states that the validity of
older work on pharmacology is in doubt because
of the finding that even U.S. P. colchicine is
contaminated with other alkaloids (see above);
his report provides information on the general
pharmacology of colchicine. Injected into rabbits
it causes erythroblasts and erythrocytes with
diffuse or punctate basophilia to appear in the
blood, as well ,as a marked reduction in the
number of leukocytes, followed in a few hours
by a marked increase above the norm, an effect
which may last for several days (Beck, loc. cit.).
While some have compared this action to that
of foreign protein therapy, the findings of Beck
of a cumulative effect of small doses repeated
daily would seem to put it in a distinct category.
A few attempts to treat leukemia with colchicine
have given inconclusive results (see Kneedler,
J.A.M.A., 1945, 129, 272).

Mitosis. — In 1935, Dustin found that colchi-
cine arrested cellular mitosis in the metaphase.
This finding has been confirmed by several in-
vestigators (Allen, Am. J. Anat., 1937, 61, 321
and Bureau and Vilter, Compt. rend. soc. biol.,
1939, 132, 558). Levine and Silver (Proc. S. Exp.
Biol. Med., 1947, 65, 54) confirmed the arrest
in terminal cases of human cancer. The effects
upon mitosis are well marked in the vegetable
as well as the animal kingdom and are utilized
by biologists for the purpose of producing changes
in genetic behavior with marked alteration of
specific characters. Guyer and Claus (Proc. Exp.
Biol. Med., 1939, 42, 565) found that — presum-
ably through its action on mitosis — colchicine
markedly increases the susceptibility of cancer
cells to the x-ray. A large experimental literature
has appeared but no significant clinical use of
this observation has been made. Nelson (Arch.
Dermat. Syph., 1951, 63, 440) described marked
but incomplete destruction of basal and squamous
cell epitheliomas.

Miller and Fischer (/. A. Ph. A., 1946, 35, 23)
have by colchicine treatment of seeds of species
of Datura induced polyploidy in the plants with a
concomitant marked increase in their content of
alkaloids. Rowson (Quart. J. P., 1945, 18, 175,
185) obtained the same effects not only in
Datura species but also in species of Atropa and
Myoscyanus as well. Polyploidy in mints may
be similarly induced but Sievers et al. (J. A. Ph.
A., 1945, 34, 225) found such abnormal plants
to contain only traces of oil. [v]

Toxicology. — The usual toxic signs are
nausea, vomiting, abdominal cramps, and diarrhea.
It is usually advisable to prescribe camphorated

opium tincture in 4 ml. doses after each bowel
movement to control the diarrhea and cramps
(Bauer et al., New Eng. J. Med., 1944, 231, 681).
Usually if the drug is stopped at the end points
outlined, no serious reactions result. The lethal
dose of colchicine has been estimated at 65 mg.
but much smaller doses have caused death. One
fatality occurred after a total dose of 7 mg. (Mac-
Leod and Phillips, Ann. Rheumat. Dis., 1947, 6,
224). Severe toxicity is manifested by severe
diarrhea, generalized vascular damage, and kidney
damage with hematuria and oliguria. Severe de-
hydration and hypotension ensue. There is no
specific antidote known. Brown and Seed (Am. J.
Clin. Path., 1945, 15, 189) reported 3 cases with
advanced carcinoma treated with 13 to 29 mg.
of colchicine each over a period of 7 to 64 days.
There was temporary decrease in the size of the
tumor in 1 case but aplastic anemia and peripheral
neuritis developed in 2 cases. Sternberg and
Ferguson (Fed. Proc, 1952, 11, 429) studied the
so-called fat-nephrosis in several species of ani-
mals following toxic doses (0.5 mg. per kilogram
of body weight) of colchicine. Similar fat deposits
in the proximal nephron are also produced by
carbon tetrachloride and by phosphorus poisoning.
For further remarks on toxicology see under Col-
chicum Seed.

Dose. — The usual dose is 0.5 mg. (approxi-
mately Vno grain) by mouth every y2 to 1 hour
for 6 to 8 doses. The maximum safe dose is usually
0.5 mg. and the total dose in 24 hours seldom
exceeds 4 mg. The drug is usually discontinued
when gastrointestinal symptoms appear. As much
as 0.65 mg. is given slowly in a single intrave-
nous dose. (v.s.)

Storage. — Preserve "in tight, fight-resistant
containers." U.S.P.

Off. Prep.— Colchicine Tablets, U.S.P.; So-
dium Salicylate and Iodide with Colchicine Injec-
tion, N.F.

COLCHICINE TABLETS. U.S.P. (LP.)

[Tabellae Colchicine]

"Colchicine Tablets contain not less than 90
per cent and not more than 110 per cent of the
labeled amount of C22H25NO6." U.S.P. The LP.
limits are the same.

LP. Tablets of Colchicine; Compressi Colchicini.
Sp. Tabletas de Colchicina.

Assay. — A representative sample of powdered
tablets, equivalent to about 50 mg. of colchicine,
is macerated with portions of petroleum benzin
to remove lubricants, the mixture filtered, and
the filtrate discarded. The residue is heated with
alcohol and this solution filtered through the paper
used in the preceding filtration. The alcoholic
solution is evaporated to expel the alcohol, the
residue then heated with chloroform to dissolve
the colchicine fraction of the residue, this mixture
filtered, and the chloroform evaporated from the
filtrate. After heating the residue with two por-
tions of alcohol to expel the chloroform, the
colchicine is dried at 105° for 16 hours. U.S.P.

Usual Sizes. — M20 and Moo grain (approxi-
mately 0.5 and 0.6 mg.).

Part I

Colchicum, Liquid Extract of 355

COLCHICUM CORM. B.P.

Colchici Cormus

Colchicum Corm is the corm of Colchicum
autumnale L., collected in early summer, de-
prived of its coats, sliced and dried at a tempera-
ture not exceeding 65°; the dried corm contains
not less than 0.25 per cent of the alkaloids of
colchicum corm. B.P.

Meadow Saffron Corm; Colchicum Root. Tubera Col-
chici; Colchici Radix. Fr. Bulbe (racine) de colchique.
Ger. Zeitlosenknollen; Colchicumzwiebel; Zeitlosenwurzel.
Sp. Bulbo de colchico.

Colchicum corm was not admitted to N.F. X,
after many years of official recognition in either
the U.S.P. or N.F.; it is official in the B.P.,
which no longer recognizes the seed. For account
of the botany and chemistry of this drug see
under Colchicum Seed.

The medicinal virtue of the corm depends
much upon the season at which it is collected.
The proper period for its collection is from the
early part of June, when it has usually attained
perfection, to the middle of August.

The corm is often used in the fresh state in
the countries where it grows; it is likely to be
injured in drying, unless the process is care-
fully conducted. The usual treatment is to cut the
corm, as soon as possible after it has been dug
up, into thin transverse slices, which are spread
out separately upon paper or perforated trays
and dried with a moderate heat. Unless it is
sliced and dried quickly after removal from the
ground it begins to vegetate, with significant
changes in its composition taking place. During
desiccation it loses, on the average, 70 per cent
of its weight.

The recent corm of C. autumnale resembles
that of the tulip in shape and size, and is covered
with a brown membranous coat. Internally it is
solid, white and fleshy, and, when cut trans-
versely, yields, if mature, an acrid milky juice.
There is often a small lateral projection from its
base, which is the bud for the development of a
new plant; this bud is frequently broken off in
drying. When dried, and deprived of its external
membranous covering, the corm is of an ash-
brown color, convex on one side, and somewhat
flattened on the other, where it is marked by a
deep groove extending from the base to the sum-
mit. As found in commerce, it is always in the
dried state, sometimes in segments made by
vertical sections of the corm, but generally in
transverse, reniform or longitudinal ovate slices.

For information concerning Colchicum autum-
nale and the constituents of both the corm and
seed of the plant see under Colchicum Seed.

Description. — "Unground Colchicum Corm.
— Unground Colchicum Corm usually occurs as
reniform transverse slices or as ovate longitudinal
slices from 2 to 5 mm. in thickness. The flat
surfaces are yellowish white to pale yellowish
orange, slightly roughened and of a crystalline ap-
pearance under a hand lens. The epidermal sur-
face is pale brown to dusky yellowish orange and
finely wrinkled. The fracture is short and mealy.

"Powdered Colchicum Corm. — Powdered Col-
chicum Corm is weak yellowish orange; has a

slight odor and a bitter, acrid taste. Starch grains
are numerous, single or 2- to 6-compound, the
individual grains varying from spherical or ovoid
to polygonal, from 3 to 30 microns in diameter,
and marked with a triangular or star-shaped cen-
tral cleft. Tracheae are few and with spiral or
scalariform thickenings. There are also occa-
sional fragments of epidermal cells with thin
walls." N.F. IX. The B.P. description is essen-
tially the same.

Standards and Tests.— The B.P. limits
acid-insoluble ash to 0.5 per cent, and foreign
organic matter to 2.0 per cent.

Assay. — The B.P. assay commences with
continuous extraction of 20 Gm. of powdered
colchicum corm with 90 per cent alcohol; the
resulting solution of alkaloids is evaporated to
dryness on a water bath. The residue is dis-
solved in 20 per cent w/v solution of sodium
sulfate (the alkaloids are soluble in water and in
aqueous solutions generally) and the resulting
liquid is shaken out with ether to remove oil
which has been salted-out by the sodium sulfate.
From the oil-free solution colchicine is extracted
with chloroform after alkalinizing the aqueous
liquid with sodium hydroxide. The chloroform
extract is evaporated to dryness, traces of chloro-
form are expelled with the aid of alcohol, and
the impure residue is weighed after drying over
phosphorus pentoxide in a vacuum. This residue
is extracted with water to dissolve the alkaloids,
and any insoluble matter is finally weighed, after
drying as before. The difference in weight of
the two residues represents the weight of the
alkaloids of colchicum corm.

For a discussion of other methods of assaying
colchicum corm, see Trupp (Bull. N.F. Com.,
1939, 7, 339).

Uses. — The medicinal properties of this drug
are precisely the same as those of colchicum seed
(q. v.), but the latter is somewhat less variable
and was for that reason once given preference
for internal administration; at present colchicine,
or a standardized tincture or fluidextract, is em-
ployed. Colchicum corm was given in doses of
130 to 300 mg. (approximately 2 to 5 grains).

Off. Prep. — Liquid Extract of Colchicum,
B.P.

LIQUID EXTRACT OF COLCHICUM.
B.P.

Extractum Colchici Liquidum

Liquid Extract of Colchicum contains 0.3
per cent w/v of the alkaloids of colchicum corm
(limits, 0.27 to 0.33). B.P. The N.F. IX recog-
nized, under the title Colchicum Corm Fluidex-
tract, a slightly more potent preparation,
requiring it to yield, from each 100 ml., not less
than 300 mg. and not more than 400 mg. of
anhydrous colchicine.

To prepare the liquid extract, the B.P. ex-
hausts colchicum corm, in moderately fine
powder, with 70 per cent alcohol, reserving the
first 600 ml. of percolate. The alcohol is removed
from the remainder of the percolate, the residue
is evaporated to a soft extract under reduced
pressure at a temperature not above 60° and

356 Colchicum, Liquid Extract of

Part I

dissolved in the reserved liquid. After determin-
ing the content of alkaloids in the liquid it is
adjusted to the required strength with 70 per
cent alcohol, set aside at least 24 hours, after
which it is filtered, if necessary.

Liquid extract of colchicum is not intended
to be used as a dosage form of colchicum corm:
it is used only to prepare tincture of colchicum
(B.P.).

Off. Prep.— Tincture of Colchicum, B.P.

TINCTURE OF COLCHICUM. B.P.

Tinctura Colchici

Tincture of Colchicum contains 0.03 per cent
w/v of the alkaloids of colchicum corm (limits,
0.027 to 0.033. B.P. The tincture is prepared by
diluting liquid extract of colchicum with sufficient
70 per cent alcohol to produce 10 volumes of
tincture. B.P.

The Strong Colchicum Corm Tincture, of
N.F. IX, was over four times as potent as the
B.P. tincture, being required to yield, from each
100 ml., not less than 120 mg. and not more than
160 mg. of anhydrous colchicine.

The dose of the B.P. tincture is from 0.3 to
1 ml. (approximately 5 to 15 minims).

COLCHICUM SEED. N.F, LP.

Colchici Semen

"Colchicum Seed is the dried ripe seed of
Colchicum autumnale Linne (Fam. Liliacece).
Colchicum Seed yields not less than 0.45 per
cent of colchicine." N.F. The LP. requires not
less than 0.5 per cent of colchicine.

Meadow-Saffron Seed. Semen Croci Pratensis. Fr.
Colchique; Semence de colchique. Ger. Zeitlosensamen;
Herbstzeitlosensamen. It. Colchico. Sp. Semilla de
colchico.

Colchicum autumnale, often called meadow-
saffron, is a perennial plant, the leaves of which
appear in spring, and the flowers in autumn.
Its underground portion consists of an ovoid
corm growing several inches below the surface.
In the latter part of summer, a new corm begins
to form at the lateral inferior portion of the old
one, which receives the young offshoot in its
bosom and embraces it half round. The new
plant sends out rootlets from its base, and is
furnished with a radical spathe, which is cylin-
drical, tubular, cloven at top on one side, and
half under ground. In September, from two to
six flowers, of a lilac or pale-purple color, emerge
from the spathe. unaccompanied by leaves. The
corolla consists of a tube from 10 to 12 cm. long,
concealed for two-thirds of its length in the
ground, and of a limb divided into six segments.
The flowers perish by the end of October, and
the rudiments of the fruit remain under ground
until the following spring, when they rise upon
a stem above the surface, in the form of a 3-lobed,
3-celled capsule. The leaves of the new plant
appear at the same time, so that in fact they
follow the flower instead of preceding it. The
leaves are radical, spear-shaped, erect, numerous,
about 12 cm. long, and 2.5 cm. broad at the base.

In the meantime, the new corm has been in-
creasing at the expense of the old one, which
then decays, while the former, after attaining
its full growth, sends forth shoots, and in its
turn decays. The old corm in its second spring,
and a little before it decays, sometimes puts
forth one or more small conns, which are the
sources of new plants. The usual method of
propagating colchicum is by planting the corms
about August or September in deep rich soil,
about 2 or 3 inches below the surface and about
3 inches apart in the row (Drug. Circ, 1912,
p. 134). Most of the commercial supplies of the
drug are in normal times imported from Leg-
horn. Italy. Yugoslavia and Hungary.

The seeds of the meadow-saffron ripen in sum-
mer, and should be collected about the end of
July or beginning of August. They never reach
maturity in plants cultivated in a dry soil or
in confined gardens.

C. autumnale is a native of temperate Europe
and of northern Africa, growing in moist pas-
tures and meadows. Attempts have been made
to introduce its culture into this country, but
with no great commercial success, though small
quantities of the corm, of apparently good qual-
ity, have entered commerce. The flowers possess
activity similar to those of the corm. Niemann
(Pharm. Acta Heh., 1933. 8, 92) found the alka-
loidal content of the fluidextract of the flowers
to be 0.806 per cent.

Description. — "Unground Colchicum Seed is
ovoid or irregularly globular in shape, amphi-
tropous. minutely pointed at the hilum. and
with a distinct beak or caruncle approximately
opposite the hilum; from 2 to 3 mm. in diameter
and, when fresh, has a tendency to cohere in
small clumps. It is tough and of bony hardness
finely pitted and weak reddish brown to dark
brown externally and pale yellow, yellowish gray
or light brown internally. Colchicum Seed when
crushed is nearly odorless, and has a bitter and
acrid taste." N.F. For histology see N.F. X.

"Powdered Colchicum Seed is dark yellowish
brown to moderate brown. It consists of frag-
ments of endosperm comprised of cells with
thick porous walls, the cells containing oil
globules and aleurone grains, and fragments of
seed coat composed of parenchyma with brownish
walls and dark brown pigment cells. Starch
grains and spiral vessels occur sparingly." N.F.

Standards and Tests. — Foreign organic mat-
ter.— Not over 1 per cent. Acid-insoluble ash. —
Not over 1 per cent. N.F. The LP. limits total
ash to 5.0 per cent, and foreign organic matter
to 2.0 per cent.

Assay. — A 15-Gm. portion of colchicum seed,
in moderately fine powder, is digested at 60° to
70° with an aqueous solution of lead subacetate.
the latter precipitating the gums, tannins, and
coloring matter which would otherwise dissolve
in the aqueous solution along with the colchicine
and. also, liberating the alkaloid from any of its
salts which may be present. The mixture is
filtered and an aliquot portion of the filtrate
taken; from this portion the lead is precipitated
with sodium phosphate and, after filtration, the

Part I

Colchicum Seed Fluidextract 357

colchicine in an aliquot portion of this filtrate is
extracted by means of chloroform. A test for
completeness of extraction is made with iodine
T.S. The combined chloroform extracts are
evaporated to dryness and the residue, after
addition of alcohol to it followed by evaporation,
is dried for 16 hours at 105°. This impure residue
is heated with a mixture of chloroform, 0.1 N
sulfuric acid, and water to dissolve the colchicine
and, after evaporating the chloroform, the mix-
ture is filtered and the residue washed with
water. This residue is dissolved with alcohol and
ether, the solution transferred to the container
in which the first alkaloidal residue was weighed,
and the solvent evaporated. After drying the
residue for 16 hours at 105°, the weight of it is
deducted from the weight of the impure alkaloidal
residue, and the difference is calculated to col-
chicine. N.F.

Constituents. — The predominant principle of
C. autumnale, both corm and seed, is the alkaloid
colchicine, which is itself official and is described
under that title. While for a long time it was
supposed that colchicine was the sole alkaloidal
constituent, recent work has clearly demon-
strated the presence of other alkaloids, at least
in the seed and probably also in the corm. San-
tavy and Reichstein (Helv. Chim. Acta., 1950,
33, 1606) isolated four substances, in addition
to colchicine; these they called Compounds B, C,
G, and /, respectively. Compound B is a
7V-f ormyldesacetylcolchicine ; Compound C dif-
fers from colchicine only in having a hydroxyl
group in place of a methoxy group in colchicine;
Compound G is either a homolog or an isomer
of colchicine; Compound J is probably an isomer
of colchicine. In the course of purifying a sample
of colchicine, Horowitz and Ullyot (Science, 1952,
115, 216) found in it about 4 per cent of des-
methylcolchicine, which they believe to be
identical with the Compound C of Santavy and
Reichstein; in purifying another sample Raffauf,
Farren and Ullyot (J.A.C.S., 1953, 75, 3854)
failed to find desmethylcolchicine but instead
found about 1.5 per cent of an alkaloid appar-
ently identical with Compound B.

Uses. — For account of the therapeutic uses
and physiologic actions of colchicum see under
Colchicine. Mixtures of colchicum preparations
with hydragogue cathartics, or with methyl sali-
cylate (J.A.M.A., 1915, March 20, p. 1016) have
disappeared from common use. In preparing
dosage formulations of colchicum it should be
kept in mind that colchicine readily undergoes
hydrolytic decomposition; in general, acids or
alkalies, especially at elevated temperatures,
alter colchicine. Under various conditions col-
chicine may be decomposed into colchiceine,
colchicinic acid, and various allied products.
Whether these derivatives of colchicine possess
the therapeutic virtues of the natural alkaloid
is uncertain, but Fuehner (Arch. exp. Path.
Pharm., 1913, 72, 228) has shown that colchiceine
is very much less toxic than colchicine. When
taken internally in therapeutic dose, colchicum
usually produces no other symptoms than abdom-
inal pain and diarrhea. In some rare cases it

is said to give rise to copious diuresis or diapho-
resis instead of purging.

Toxicology. — When larger amounts are
given, there is profuse, watery and bloody diar-
rhea and there may be also vomiting. With these
symptoms there may be some depression, which
seems to be due to the gastrointestinal irritation
with the loss of fluid and electrolyte rather than
to the direct action of the poison. In an overdose,
it may produce dangerous and even fatal effects.
Excessive nausea and vomiting, abdominal pains,
purging and tenesmus, great thirst, sinking of
the pulse, coldness of the extremities, and gen-
eral prostration, with occasional symptoms of
nervous derangement, such as headache, delirium,
and stupor, are among the results of its poisonous
action. A latent period of several hours precedes
the onset of symptoms. A peculiarity of its in-
fluence is that when its dose is increased beyond
a certain point there is not a corresponding in-
crease in the rapidity of the fatal issue. This is
probably because it kills not by a direct influence
upon the heart or the nervous system, but by
causing gastro-enteritis ; or a toxic oxidation prod-
uct may require time to form. On post-mortem
examination the alimentary mucous membrane is
found much inflamed. Intravenous administra-
tion also causes abdominal symptoms because it
is excreted into the gastrointestinal tract. Excre-
tion by the kidneys results in hematuria and
oliguria. The severity of the shock syndrome
arises from the fact that colchicine is a capillary
poison as well as from the loss of fluids with the
diarrhea. As little as 6 mg. of colchicine has
proved fatal but individuals have survived larger
doses. In the treatment of poisoning, the usual
measures for shock — rest, mild warmth, intrave-
nous saline, glucose and plasma, morphine and
atropine for the abdominal pain, and stimulants
such as caffeine, strychnine, etc., as necessary —
are just as important as gastric lavage and the
use of demulcent drinks. Dilute tannic acid solu-
tion has been advocated for the lavage and large
doses of activated charcoal may be beneficial.

Dose. — Colchicum seed and corm have been
given in doses of 130 to 300 mg., repeated every
4 or 6 hours until its effects are obtained. At pres-
ent, the crude drugs are probably never adminis-
tered, and their dosage forms only rarely, because
colchicine has proved to be so much more reliable
and otherwise satisfactory.

Off. Prep. — Colchicum Seed Fluidextract,
Colchicum Seed Tincture, N.F.

COLCHICUM SEED FLUIDEXTRACT.

N.F.

Fluidextractum Colchici Seminis

"Colchicum Seed Fluidextract yields, from each
100 ml., not less than 400 mg. and not more
than 500 mg. of anhydrous colchicine." N.F.

Fluidextractum Colchici.

Extract the fatty matter from colchicum seed,
in moderately coarse powder, by percolation with
petroleum benzin; reject this percolate. Prepare
the fluidextract from the dried, defatted drug by

358 Colchicum Seed Fluidextract

Part I

Process A, as modified for assayed fluidextracts
(see under Fluidextracts), using a menstruum of
2 volumes of alcohol and 1 volume of water.
Macerate the drug during 48 hours, and perco-
late at a moderate rate. Adjust the liquid to
contain, in each 100 ml.. 450 mg. of anhydrous
colchicine and 56 per cent, by volume, of
C2H5OH. N.F.

Alcohol Content. — From 53 to 58 per cent,
by volume, of C2H5OH. N.F.

Colchicum seed fluidextract is representative
of the activity of the drug from which it is pre-
pared but its dosage is not capable of as flexible
a variation as the less potent tincture. The usual
dose of the N.F. fluidextract is 0.2 ml. (approxi-
mately 3 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

COLCHICUM SEED TINCTURE.
X.F. (LP.)

Tinctura Colchici Seminis

"Colchicum Seed Tincture yields, from each
100 ml., not less than 40 mg. and not more than
50 mg. of anhydrous colchicine." N.F. The LP.
Tincture of Colchicum contains 0.036 to 0.044
per cent w/v of colchicine.

Fr. Teinture de colchique. Gcr. Zeitlosentinktur. It.
Tintura di colchico. Sp. Tintura de colchico; Tintura
de semilla de colchico.

Prepare the tincture from 100 Gm. of colchi-
cum seed, in moderately coarse powder, by
Process P as modified for assayed tinctures (see
under Tinctures), using a menstruum of 2 vol-
umes of alcohol and 1 volume of water. Adjust
the tincture to contain, in each 100 ml., 45 mg.
of colchicine. N.F.

Alcohol Content. — From 59 to 63 per cent,
by volume, of C2H5OH. N.F.

This tincture is representative of colchicum
and may be given whenever that drug is indi-
cated.

The N.F. usual dose is 2 ml. (approximately
30 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

COLLODION. U.S.P.

[Collodium]

"Collodion contains not less than 5 per cent, by
weight, of pyroxylin." U.S.P.

Sp. Colodion.

To 40 Gm. of pyroxylin, contained in a suit-
able bottle, add 250 ml. of alcohol; after shaking
the mixture thoroughly add 750 ml. of ethyl
oxide and again shake until solution occurs. Set
the well-stoppered bottle aside until the liquid
becomes clear. Decant the clear liquid from any
sediment that may be present and transfer at
once to tight containers. Caution — Collodion is
highly flammable. U.S.P.

Acetone has been used as a solvent for pyrox-
ylin, and collodion so prepared is also on the
market.

Description. — "Collodion is a clear, or slightly
opalescent, syrupy liquid. It is colorless or slightly
yellowish, and has the odor of ether. The specific
gravity of Collodion is not less than 0.765 and not
more than 0.775." U.S.P.

Standards and Tests. — Identification. — (1)
A transparent, tenacious film forms on exposing
to the air a thin layer of collodion; this film burns
rapidly and with a yellow flame. (2) A viscid,
stringy mass of pyroxylin is produced on adding
an equal volume of water to pyroxylin. Acidity. —
The liquid separated from a mixture of collodion
with an equal volume of water is not acid to
litmus. U.S.P.

Assay. — About 10 ml. of collodion is weighed,
warmed on a water bath, 10 ml. of water added
dropwise, and the mixture dried at 105° for 4
hours; the residue of pyroxylin is weighed. U.S.P.

Alcohol Content. — From 22 to 26 per cent,
by volume, of C2H5OH. U.S.P.

When applied to a dry surface, the ether of
collodion quickly evaporates, and a transparent
film is left, having a high degree of adhesiveness
and contractility. Because of the volatility of
ether, collodion must be kept in bottles well stop-
pered. If volatilization does occur, the liquid
thickens and becomes too viscous to use; the
thickened liquid sometimes contains acicular crys-
tals. The addition of a mixture of 3 volumes of
ether and 1 volume of alcohol will generally re-
store the collodion to its original condition.

Uses. — Collodion is used in medicine topically
for its mechanical properties and to hold some
medications locally in contact with skin. In sur-
gery it is employed to hold together the edges of
incised wounds, to keep dressings in place, and
to seal sterile wounds. It should be remembered
that while it protects the underlying tissues from
external contamination, it also prevents proper
drainage of possible exudate and may induce sec-
ondary infection by localizing contaminants. Col-
lodion is applied locally to the part, and the rigid
film contracts. When a flexible, non-contracting
film is preferred, the official flexible collodion
should be used. Collodion may be employed in
some skin diseases for its protective effect on an
irritated surface, such as in herpes zoster and
herpes simplex, and sometimes may be used to
hold active drugs locally, as chrysarobin in psori-
asis, or tar in localized eczematous patches. In
general, however, the medicated collodions of this
type may not be as effective as planned because
much of the drug is held by the vehicle, and does
not exercise its characteristic action (Berry and
Goodwin, Quart. J. P., 1937, 23). Salicylic acid
in 10 to 20 per cent strength in collodion is com-
monly used for keratolytic effect in corns and
warts (see Salicylic Collodion).

Storage. — Preserve "in tight containers, at a
temperature not above 30°, remote from fire."
U.S.P.

Off. Prep.— Flexible Collodion, U.S.P.

FLEXIBLE COLLODION. U.S.P., B.P.

[Collodium Flexile]

Collodium Elasticum. Fr. Collodion ilastique. Ger.
Elastisches Kollodium. It. Collodio elastico. Sp.
Colodion flexible.

Part I

Colocynth 359

Weigh 20 Gm. of camphor, 30 Gm. of castor
oil and sufficient collodion to make 1000 Gm. into
a dry, tared bottle and shake the stoppered bottle
until the camphor is dissolved. U.S. P.

Alcohol Content. — From 21 to 25 per cent,
by volume, of C2H.3OH. U.S.P.

The B.P. prepares this collodion by immersing
16 Gm. of pyroxylin in 240 ml. of 90 per cent
alcohol, then adding 30 Gm. of colophony (rosin),
20 Gm. of castor oil, and enough solvent ether to
make 1000 ml.; after solution is effected the prod-
uct is set aside for deposit to settle, the clear
liquid subsequently being decanted.

The contractility of the collodion film has long
been felt as a drawback to its use simply for the
purposes of protection. Various substances — in-
cluding glycerin, turpentine and elemi — have been
suggested to overcome this tendency but castor
oil is probably as useful as any and also imparts
a degree of flexibility and elasticity (see Col-
lodion).

Storage. — Preserve "in tight containers, at a
temperature not above 30°, remote from fire."
U.S.P.

Off. Prep.— Salicylic Collodion, U.S.P.

COLOCYNTH. N.F.

Colocynth Pulp, Bitter Apple, [Colocynthis]

"Colocynth is the dried pulp of the unripe but
full-grown fruit of Citrullus Colocynthis (Linne)
Schrader (Fam. Cucurbitaceoe.) ." N.F.

Bitter Gourd. Colocynthidis Pulpa; Fructus Colocynthidis.
Fr. Coloquinte; Pulpe de coloquinte. Ger. Koloquinthen ;
Koloquinthenapfel; Purgierguiken; Teufelsapfel.

Citrullus Colocynthis is an animal plant whose
herbaceous stems, beset with rough hairs, trail
upon the ground, or rise upon neighboring bodies,
to which they attach themselves by their numer-
ous tendrils. The leaf blades, which stand alter-
nately on long petioles, are triangular, many-cleft
or parted and variously sinuated, obtuse, hairy,
of a fine green color on the upper surface, rough
and pale on the under. The flowers .are yellow,
and appear singly at the axils of the leaves. The
fruit is a globular berry, of the size of a small
orange, yellow and smooth when ripe, and con-
tains, within a hard, coriaceous rind, a white,
spongy pulp, enclosing numerous ovate, com-
pressed, white or brownish seeds.

The plant is a native of Asia and Africa. The
drug is obtained from both wild and cultivated
plants. It is said to be cultivated in Spain, the
island of Cyprus, Morocco and in the neighbor-
ing countries, and even to have been collected
in Japan. The bulk of the supplies to the United
States is collected in the Anglo-Egyptian Sudan
and shipped from Cairo. That from the maritime
plain between the mountains of Palestine and the
Mediterranean and from Cyprus is chiefly shipped
from Jaffa, and is known as Turkish colocynth. It
is said to be of superior quality. The fruit is
gathered in autumn, when it begins to become
yellow, and, having been peeled, is dried quickly
in a stove or in the sunshine. Thus prepared, it is
imported from the Levant. Much of the Egyptian
colocynth is broken with most of the seeds re-
moved and the pulp compressed. Colocynth has

been grown in New Mexico, but, according to
Sayre, the American colocynth is less active.

As found in commerce, colocynth occurs in two
forms, one as the official pulp, another as "bitter
apples," the latter occurring as peeled whitish,
globular berries, from 6 to 7 cm. in diameter, very
light and spongy, and abounding in seeds which
constitute three-fourths of the fruit.

It is estimated that every 100 pounds of colo-
cynth fruit will yield 30 pounds of pulp and about
70 pounds of seeds. Although Tunmann {Sudd.
Apoth.-Ztg., 1907, p. 503) stated that the seeds
do not contain medicinally active constituents,
Francis (Proc. A. Ph. A., 1906, p. 336) claimed
that if the seeds are first deprived of their fixed
oil with benzin, dried and then extracted with
75 per cent alcohol, the extract is almost as active
as the official product.

Description. — "Ungroand Colocynth occurs
as light, spongy, easily broken pieces; light yel-
lowish orange to pale yellow, with occasional small
patches of darker epicarp. The fruits, before re-
moval of seed, are nearly globular, from 4 to 10
cm. in diameter with 3 large lenticular cavities
between the 3 carpels, hence being easily separable
longitudinally into 3 parts. The seeds are ovoid,
compressed, strong brown to weak yellowish
orange. Colocynth has a slight odor and an in-
tensely bitter taste." N.F. For histology see
N.F. X.

"Powdered Colocynth is weak yellowish orange
to yellowish gray. It is characteristically flaky,
and consists chiefly of fragments of the paren-
chyma and vascular bundles." N.F.

Standards and Tests. — Epicarp and seed. —
Colocynth contains not more than 5 per cent of
seed and not more than 2 per cent of epicarp. In
the powder characteristic stone cells are few or
absent (epicarp and seed), as are also aleurone
grains and globules of fixed oil (seed). Acid-
insoluble ash. — Not more than 4 per cent. Pe-
troleum benzin extractive. — Not more than 2 per
cent. N.F.

Constituents. — Power and Moore (Trans.
Chem. Soc, 1910, 17, 99) found in colocynth
an alkaloidal principle which has a violent purga-
tive effect, but this is not the only active prin-
ciple of the crude drug, because both ether and
chloroform extracts of the resin, when free from
the alkaloidal principle, were still purgative. They
found also alpha-elaterin, but none of the active
beta-elaterin. The)* stated that the substance re-
ferred to by the older writers as colocynthin (or
citrullin), and believed to be a glycoside, is a mix-
ture of the alkaloid and a crystallizable alcohol,
citrullol. For tests for identification of colocynthin
see David (Pharm. Ztg., 1928, 73, 525).

Uses. — The pulp of colocynth is a powerful
drastic, hydragogue cathartic, producing copious
watery evacuations within two to three hours and,
when given in large doses, violent griping, pros-
tration, and sometimes bloody discharges, with
dangerous inflammation of the bowels. Death has
resulted from \l/2 teaspoonfuls of the powder.
In the management of poisoning, the stomach
should be washed with dilute tannic acid solution
followed by large quantities of albuminous drinks.
Stimulants, such as brandy, and opiates and

360 Colocynth

Part I

atropine are indicated. Dehydration and loss of
electrolytes should be corrected, parenterally, if
necessary. Even in moderate doses it sometimes
acts with much harshness, and it is therefore
seldom prescribed except as an adjuvant to other
cathartics. It is excreted in the urine and milk;
it should not be prescribed for nursing women. It
was formerly used to evacuate dropsical effusions
and as a revulsant.

Usual dose, 120 mg. (approximately 2 grains).

COLOCYNTH EXTRACT. N.F.

Bitter Apple Extract

"One Gm. of the Extract represents 4 Gm. of
colocynth." N.F.

Fr. Extrait de coloquinte. Ger. Koloquinthenextrakt.
It. Estratto di coloquintide.

Prepare the extract from colocynth, in coarse
powder, by percolation and evaporation, using 4
volumes of alcohol and 1 volume of water as the
menstruum; macerate the drug during 24 hours,
and percolate at a moderate rate. Evaporate the
percolate to dryness, reduce the residue to a fine
powder, and mix it thoroughly, if necessary, with
sufficient dry starch to make the extract weigh
one-fourth of the weight of colocynth taken. N.F.

The chief, if not exclusive, use of this extract
is in the preparation of the compound extract.
The N.F. usual dose is 30 mg. (approximately
x/2 grain).

Storage. — Preserve "in tight, light-resistant
containers, preferably at a temperature not above
30°." N.F.

COMPOUND COLOCYNTH EXTRACT.
N.F.

Fr. Extrait de coloquinte compose. Ger. Zusammen-
gesetztes Koloquinthenextrakt.

Mix 160 Gm. of colocynth extract, 140 Gm.
of ipomea resin, in fine powder, 650 Gm. of aloe,
in fine powder, and 50 Gm. of cardamom seed, in
fine powder. N.F.

This extract is an energetic cathartic, possess-
ing the activity of its three purgative ingredients,
with comparatively little of the drastic character
of the colocynth and ipomea.

Dose, as a laxative, 60 to 125 mg. (approxi-
mately 1 to 2 grains) ; as a purgative, 300 to 600
mg. (approximately 5 to 10 grains).

Off. Prep. — Compound Mild Mercurous Chlo-
ride Pills, N.F.

CONESSINE HYDROBROMIDE. LP.

Conessini Hydrobromidum

C24H4oN2.2HBr.

Conessine Hydrobromide is the hydrobromide
of an alkaloid obtained from the seeds of Holar-
rhena antidysenterica. It contains not less than
67.5 per cent and not more than 69.0 per cent of
C24H40N2. LP.

Holarrhena antidysenterica (Roxb.) Wall is a
small tree growing in India; its bark, variously
known as kurchi, conessi bark, and by other
names, has long been used in that country in the
treatment of amebic dysentery. The bark, and
also the seeds, contain a number of alkaloids, of

which conessine (which has also been called
wrightine from an old botanical name for the tree
from which it is obtained) is the most important.
For further information concerning the bark, and
its other alkaloids, see Conessi Bark, in Part II.

The structure of conessine includes four hy-
drogenated, carbocyclic rings, to which a ring
containing one nitrogen atom is attached. For
information concerning the isolation of conessine
see Bertho, Arch. Pharm., 1939, 277, 237.

Description. — Conessine hydrobromide occurs
as a white, microcrystalline powder, odorless, and
having a very bitter taste. It is soluble in water;
slightly soluble in alcohol; very slightly soluble
in ether. Conessine hydrobromide melts at about
340°, with decomposition.

Standards and Tests. — Identification. — (1)
A yellowish-green color, changing to bluish-green,
is produced when a drop of a mixture of equal
parts of sulfuric acid and nitric acid is added to
about 5 mg. of finely powdered conessine hydro-
bromide. (2) The base isolated in the assay, after
recrystallization from acetone, melts between
123° and 125°. (3) Conessine hydrobromide re-
sponds to tests for bromide. Specific rotation. —
Not less than +6° and not more than +7°, when
determined in a 5 per cent w/v aqueous solution,
at 20°. Clarity and color of solution. — A 2 per
cent w/v aqueous solution is clear and colorless.
Loss on drying. — Not over 1 per cent, when dried
at 100°. Residue on ignition. — Not over 0.1 per
cent. LP.

Assay. — About 1 Gm. of conessine hydro-
bromide is dissolved in 50 ml. of water, alkalinized
with dilute ammonia, and extracted with portions
of 50, 50, 25, and 25 ml. of light petroleum (boil-
ing range 40° to 60°). The light petroleum ex-
tracts are collected in a flask containing anhydrous
potassium carbonate, allowed to stand 3 hours,
and a 100-ml. portion is evaporated on a water
bath in a tared flask, dried and weighed. The
residue represents two-thirds of the weight of
C24H40N2 in the weight of the sample taken. LP.

Uses. — Conessine hydrobromide is used in the
treatment of amebic dysentery in place of emetine
hydrochloride, over which it has the advantage
of oral efficacy but the disadvantage of severe
although infrequent neuropsychiatric effects. For
discussion of the actions of other alkaloids of
Conessi Bark see under this title in Part II.
Amebicidal action, in vitro, was reported by
Henry and Bron (Lancet, 1928, 1, 108); in cul-
tures Piette (Ann. pharm. franc, 1950, 8, 402,
410) reported it to be effective in concentrations
of 1:71,000 to 1:45,000, compared with effective
concentrations of emetine hydrochloride of 1 :300,-
000 to 1:200.000. Following oral administration
of 500 mg. daily for 5 days none of the drug was
found in the feces, and urinary excretion was
small, prolonged and variable, being about 10 per
cent of the dose over a period of 15 days (Piette,
ibid., 316).

In amebiasis, Acton and Chopra (Indian Med.
Gaz., 1936, 6) reported good results with a bis-
muth-iodide-mixed-kurchi-alkaloid salt. Leake
(J.A.M.A., 1932, 98, 195) concluded, however,
that the combination was inferior to emetine hy-
drochloride. Among numerous reports from tropi-

Part I

Congo Red 361

cal areas, Crosnier et al. {Bull. mem. soc. d. hop.
Paris, 1949, #9/10, 386) reported cure in 89
per cent of 128 cases of acute amebiasis, includ-
ing 12 cases passing cysts, with an initial dose
of 500 mg. or less, and a total dose of 5 to 6 Gm.
in 2 weeks. Some cases required a second course;
of 44 retreated cases 9 remained infected. The
drug was recommended for patients intolerant to
emetine, or those with emetine-resistant amebiasis.
Seguier et al. {Med. trop., 1949, 9, 99) reported
good, and prompt, results in acute (primary or
relapse) cases treated with 100 mg. of the hydro-
chloride or hydrobromide 5 times a day for 5
days, then 3 times daily for 7 days; results in
subacute cases were poor, and in amebic hepatitis
the drug was ineffective. Lesser toxicity with the
hydrobromide than with either the hydrochloride
or the base has been claimed (Porte, Med. trop.
Marseilles, 1950, 10, 116). Moretti {Bull. soc.
path, exotique, 1949, 42, 132), however, observed
good response in amebic hepatitis, as did also
Porte {Trop. Dis. Bull, 1950, 47, 993) in pre-
suppurative hepatitis. For Trichomonas vaginalis
vaginitis, Sicard et al. {Presse med., 1950, 58,
853) successfully used a glycerin suppository,
having a pH of 4, containing 200 mg. of conessine
hydrobromide and 500 mg. of sulfanilamide, along
with acid douches.

Toxicology. — Restlessness, insomnia, vertigo,
tinnitus and muscular tremors occur particu-
larly with doses of more than 500 mg. daily
(Durieux et al, World Med. Abstr., 1948, 4, 355).
Crosnier et al. {loc. cit.) used calcium gluconate
and a barbiturate to minimize these symptoms
during therapeutic use. Out of 322 patients, 3
cases with hallucinations, amnesia and mania
were described by Crosnier {Presse med., 1949,
57, 1107); promethazine was found useful in
preventing these reactions. Soulage and Porte
{Med. trop. Marseilles, 1949, 9, 1059) reported
that promethazine controlled the insomnia fre-
quently associated with adequate doses of cones-
sine hydrochloride.

Dose. — The usual dose of conessine hydro-
bromide is 100 mg. (approximately lyi grains)
5 times daily by mouth for 5 to 7 days, then 3
times daily for 7 days. The maximum dose in 24
hours should not exceed 500 mg., and the total
dose in a course should not exceed 6 Gm.

Storage. — Preserve in a well-closed container.
LP.

CONGO RED. U.S.P.

Rubrum Congo

which has been previously diazotized at both
amine groups, with two molecules of 1-amino-
naphthalene-4-sulfonic acid (naphthionic acid)
and converting the water-insoluble reaction prod-
uct to the disodium salt, which is soluble in water.

Description. — "Congo Red occurs as a dark
red or reddish brown powder. It is odorless and
decomposes on exposure to acid fumes. Its solu-
tions have a pH of about 8 to 9.5. One Gm. of
Congo Red dissolves in about 30 ml. of water. It
is only slightly soluble in alcohol." U.S.P.

Standards and Tests. — Identification. — (1)
A blue precipitate results on addition of acid to
a solution of congo red. (2) The red brown color
of a dilute solution of congo red changes to yellow
upon addition of bromine T.S. (3) Sulfur dioxide
is evolved on adding a slight excess of diluted
hydrochloric acid to an alkaline solution of congo
red which has been boiled for 10 minutes. Loss on
drying. — Not over 3 per cent, when dried at 105°
for 4 hours. Residue on ignition. — Employing
congo red which has been dried at 105° for 4
hours, the sulfated ash (consisting of sodium
sulfate) is not less than 20 per cent and not more
than 24 per cent of the sample taken. Sensitive-
ness.— Addition of a dilute solution of hydro-
chloric acid to a dilute solution of congo red
changes its red color to violet; the red color is
restored when a dilute solution of sodium hydrox-
ide is subsequently added. U.S.P.

Uses. — Congo red has found many diagnostic
and therapeutic uses, of which the most important
is in the diagnosis of amyloidosis (Bennhold,
Deutsches Arch. klin. Med., 1923, 142, 32). In
the presence of this disease the dye disappears
from the blood more rapidly than it does in nor-
mal humans. It has also found use in estimating
blood volume (Keith et al, Arch. Int. Med.,
1915, 16, 547), in determining the functional ca-
pacity of the reticuloendothelial system (Takeda,
Jap. J. Exper. Med., 1930, 8, 433), in differential
diagnosis of the nephri tides (Barker and Snell,
/. Lab. Clin. Med., 1930, 16, 262), as a hemo-
static agent (Wedekind, Munch, med. Wchnschr.,
1930, 77, 2049), as an antidote for roentgen sick-
ness (Arons and Sokoloff, Am. J. Roentgen., 1939,
41, 834), as an antitoxic substance against the
toxins of diphtheria and botulinus as well as
against curare and strychnine (Hanzlik and Butt,
/. Pharmacol, 1928, 33, 260), in the treatment
of streptococcic septicemia (Green, /. Indiana
M. A., 1937, 30, 527), in the treatment of per-
nicious anemia (Barker, Am. J. Med. Sc, 1937,
194) and as a vital stain (Bennhold, loc. cit.).

S03Na

Direct Red.

Congo red, which is sodium diphenyldiazo-bis-
alphanaphthylamine sulfonate, was the first direct
dye for cotton to be synthesized. It may be pre-
pared by coupling benzidine, H2NC6H4.C6H4NH2,

SO3N0.

Diaz et al. {Rev. din. espan., 1948, 30, 365)
reported good results in therapy of infectious
rheumatism with congo red. They used a 1 per
cent solution in doses varying from 5 to 10 ml.,
given slowly intravenously to prevent reaction.

362 Congo Red

Part

Injections were given on alternate days for 40
days. Treatment may be repeated after a rest
period of 3 weeks. A disodium salt of Congo red
and streptomycin was used successfully in experi-
mentally produced tuberculosis by Pescetti and
Destefanis (Minerva Medica, 1952, 43, 189).
Because of phagocytosis of congo red, the anti-
biotic is able to penetrate into and concentrate
in foci of infection, whereas streptomycin alone
is unable to do so. The same investigators adminis-
tered the combination of drugs to two patients
with tuberculous meningitis and found that the
preparation was selectively fixed in the inflamed
meninges and that streptomycin levels as high as
8 to 10 micrograms per ml. were produced in the
cerebrospinal fluid following a dose of 0.5 Gm.
of the antibiotic given 24 hours after a similar
initial dose. The fluid becomes progressively red
after 2 days, the color being directly proportional
to the concentration of dye in the fluid (ibid.,
1953, 44, 369).

Toxicology. — The dye, usually injected as
a 1 per cent aqueous solution, is commonly con-
sidered to be free from toxicity and entirely safe
to use but several clinicians have observed various
reactions, and even sudden death, to follow in-
travenous injection of congo red. Selikoff and
Bernstein (Quarterly Bulletin of Sea View Hos-
pital, Staten Island, N. Y., 1946, 8, 131) reviewed
the literature and reported six cases of severe
systemic reactions, including two deaths. Later,
Selikoff (personal communication, November
1949) observed another instance of sudden death
and learned of at least six other fatalities fol-
lowing intravenous administration of the dye;
various brands of the dye had been used in the
cases. The incidence of reactions is very small
when it is realized that in one hospital alone thou-
sands of such injections are given. The cause of
the reactions is not certain; Selikoff suggests that
because the reactions are observed in patients
who have previously had injections of the dye
that a sensitizing azoprotein, formed by the reac-
tion of congo red with the patient's own serum,
may be responsible. He observed in one patient
who had a severe reaction to congo red the third
time he received the dye intravenously a skin
sensitivity to congo red incubated with his own
serum, but not to congo red by itself. Caution is
advised especially in injecting patients who have
previously had the dye, as well as in those who are
in the arteriosclerotic age group, even if these
have had no injections of the dye previously.

Because flocculation of congo red may occur in
isotonic sodium chloride solution, it is advisable
to use water for injection as the solvent for congo
red when it is used intravenously (Richardson
and Dillon, Am. J. Med. Sc, 1939, 198, 73).
Centrifuging a solution of congo red at 1500
revolutions per minute for 5 minutes has been
recommended as a means of clearing the solution
of particles; the supernatant liquid is removed
with a hvpodermic syringe and injected (Brit.
M. J., 1949. 2, 1230).

Dose. — The usual dose is 100 to 200 mg. in-
travenously (approximately \]/2 to 3 grains).

Storage. — Preserve "in tight containers."
U.S.P.

CONGO RED INJECTION. U.S.P.

[Injectio Rubri Congo]

"Congo Red Injection is a sterile solution of
congo red in water for injection. It contains not
less than 95 per cent and not more than 110 per
cent of the labeled amount of C32H--NuXa206S2."
UJSJ*.

The pH of the injection is required to be be-
tween 7.0 and 9.0; the injection responds to
identification tests under Congo Red.

Assay. — A volume of injection equivalent to
about 200 mg. of congo red is evaporated to dry-
ness and the residue of congo red is dried at 105°
for 4 hours and weighed.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." U.S.P.

Usual Size. — 100 mg. (approximately \Yi
grains) in 10 ml.

COPPER.

Cuprum

Cu (63.54)

Fr. Cuivre. Ger. Kupfer. It. Rame. Sp. Cobre.

Since articles of copper were made as long as
6000 years ago it is probably the first metal to
be extensively used by man. It was first called
cyprium, from its discovery on the island of
Cyprus by the Romans, but later came to be
known as cuprum.

Copper is found native in several localities in
the United States. Its ores include chalcopyrite,
CuFeS2; chalcocite, CU2S; cuprite, CU2O; mela-
conite, CuO; and malachite, Cu(OH)2.CuCO"3.
The United States is the leading producer of
copper, though nearly every country produces
some of the element. The sulfide ores of cop-
per are the most important sources of copper.

The metallurgy of sulfide ores begins with
concentration by grinding, washing with water,
and flotation. Following this the ore is roasted
to drive off a part of the sulfur and then smelted,
whereupon a matte, consisting principally of sul-
fides of copper and iron, settles out. This is
mixed with some silica and heated in a converter
in which the iron separates as a slag of ferrous
silicate and the copper is eventually converted
to the element which is poured into molds, yield-
ing blister copper, so named from the fact that
blisters form on the surface from the gases
escaping while the metal solidifies. This blister
copper is refined by electrolysis.

Properties. — Copper possesses a characteris-
tic reddish-brown color in reflected light, but
thin layers show a green color in transmitted
light. It crystallizes in the cubic system and its
density usually varies between 8.92 and 8.95 al-
though exceptions are observed under certain
conditions of treatment of the metal. At about
900° it begins to volatilize and at 1083° it
fuses. Near its melting point copper is brittle
enough to be powdered. Upon heating and then
slowly cooling the metal is brittle, but if cooled
rapidly a soft, malleable and ductile product is
obtained. It colors the Bunsen flame green.
Copper is an exceedingly good conductor of

Part I

Cupric Sulfate 363

electricity. Exposed to the atmosphere, polished
surfaces tarnish slightly.

Its combinations are numerous and important.
Although at least four oxides are said to be
known, two of them are of particular importance,
namely, red cuprous oxide, CU2O, and black cupric
oxide, CuO. The important copper salts are usu-
ally cupric compounds. With metals copper
forms numerous alloys, of which that with zinc,
called brass, and that with tin, called bronze,
are the most useful.

Biochemical Role. — Copper is a constituent
of all tissues of the animal organism. It is essen-
tial for growth of plants, and is concerned in
the formation of chlorophyll. In the blue pigment
hemocyanin, found in the blood of Mollusca and
Crustacea and which functions like hemoglobin
in animals, copper is the metal component rather
than iron. Copper is absorbed in the intestinal
tract from food, which supplies about 2 mg.
daily (Jones et al., J. Lab. Clin. Med., 1947, 32,
387); it is stored in the liver (about 0.8 mg. per
100 Gm.). The blood of man contains about
0.14 mg. per 100 ml.; most of this is in the red
blood cells but some is bound to protein in the
serum (Sachs et al., Arch. Int. Med., 1937, 60,
982). In most iron-deficiency states the amount
of copper in both blood and liver tends to vary
inversely with concentration of iron (Hahn and
Fairman, /. Biol. Chem., 1936, 113, 161). Copper
is present in urine to the extent of about 0.1 mg.
per liter, and in milk to about the same degree.
Most of the ingested copper appears in feces.

Copper is essential for utilization of iron in
synthesis of hemoglobin (Summerson, J.A.M.A.,
1940, 114, 2301); it is not known how the cop-
per acts and the amount required is very small —
perhaps 0.1 mg. per kilogram of body weight
(see Acta med. Scandinav., 1944, 118, 84, 87,
92, 163). Knowledge of this fact has led to
popularization of combinations of iron and cop-
per (about 4 per cent of the mixture) for
treatment of hypochromic anemias (see Cupric
Sulfate). Castle pointed out, however, that there
is no deficiency of copper in the blood of most
hypochromic anemia patients and also that there
are traces of copper present in most iron prepara-
tions; therefore, it is not to be expected that
copper will be of any material value in treating
these cases {Trans. Stud. Coll. Phys., 1937, 7,
129). In some infants on an exclusive milk diet,
copper deficiency may be present (Elvehjem
et al, Am. J. Dis. Child., 1937, 53, 785). De Vries
(Nederland. Tijdschr. v. Geneesk., 1952, 96,
611) described 8 patients with anemia refractory
to iron therapy who responded when copper was
administered simultaneously. Van Wyk et al.
(Bull. Johns Hopkins Hosp., 1953, 93, 41) com-
pared the anemia produced in dogs by iron defi-
ciency with that resulting from copper deficiency.
The latter was characterized by a low erythrocyte
count, by normochromic and normocytic indices,
and by absence of the normoblastic hyperplasia
and of the hemoglobin deficient normoblasts
characteristic of the iron deficiency state. It was
concluded that, besides its role in the formation
of hemoglobin, copper is essential for normal
maturation of erythrocytes. An abnormal bone

formation resulting from copper deficiency was
also described.

The possible deleterious influence of the con-
tinued ingestion of considerable quantities of
copper has been debated. Huber (/. Pharmacol.,
1918, 11, 303) found that while there was a
tendency for copper to deposit in the liver he
was not able to detect, either during life or by
post-mortem examination, any evidence of in-
jury to the health of animals from prolonged
administration of salts of copper. Mallory (Arch.
Int. Med., 1926, 37, 336; Am. J. Path., 1931, 7,
351) maintained, on the other hand, that there
was evidence of injurious effect from continued
use of foods containing copper. Sheldon (Lancet,
1934, 2, 1031) found no evidence for clinically
deleterious effects (hemochromatosis) of copper.

In addition to the aminoaciduria found by
Uzman and Denny-Brown (Am. J. Med. Sc,
1953, 226, 645) to be characteristic of patients
(and their relatives) with Wilson's hepatolenticu-
lar degeneration-cirrhosis of the liver and de-
generation of the lenticular and caudate nuclei
of the brain, an increase in the copper content
of the brain, liver and urine has also been ob-
served (Spillane et al., J. Clin. Path., 1952, 5,
16). Administration of dimercaprol increased the
urinary excretion of copper. Gubler et al. (Fed.
Proc, 1953, 12, 415) noted that chronic manga-
nese poisoning produces a similar syndrome in
humans; however, feeding copper and/or manga-
nese to rats produced no histological lesions in
the brain although body levels of the element(s)
were increased. Beneficial effects, insofar as
the neurological symptoms were concerned, fol-
lowed treatment with dimercaprol in 2 cases of
Wilson's syndrome (Hornbostel, Schweiz. med.
Wchnschr., 1954, 84, 7); there was no change in
total serum copper and degree of aminoaciduria,
although there was increase in urinary copper ex-
cretion. A copper-protein complex in blood serum,
related to Pi-globulin, was studied by Keiderling
(Klin. Wchnschr., 1950, 28, 460). In Wilson's
syndrome, Wintrobe et al. (Proc. Assoc. Am.
Physic, 1954) reported that 7 per cent of the
serum copper was ionized while 93 per cent was
present as ceruloplasmin (a copper-protein com-
plex, formed in the fiver, which upon electropho-
resis moves as an a-globulin). Administration of
dimercaprol, but not of Versene, caused a de-
crease in the amount of this protein complex
in the blood; an increase in the amount of the
complex was found in cases of schizophrenia and
also when a-globulin in the blood was increased.

Copper is not toxic in the same sense that lead,
mercury or nickel are toxic. It does not cause
stippling of red blood cells, but a blue line may
appear at the margin of the gums. Many of
the soluble salts of copper, when taken in large
quantity, may give rise to evidence of gastro-
enteritis (see under Cupric Sidfate). Vomiting
is usually so prompt that systemic poisoning does
not occur. H

CUPRIC SULFATE. N.F. (B.P.)

Copper Sulfate, [Cupri Sulfas]

"Cupric Sulfate contains not less than 98.5 per

364 Cupric Sulfate

Part I

cent and not more than 104.5 per cent of CuSO-t.-
5H20." N.F. The B.P. requires not less than 98.5
per cent, and not more than the equivalent of
101.0 per cent, of CuSC^.SH-O.

B.P. Copper Sulphate; Cupri Sulphas. Blue Vitriol;
Blue Stone; Blue Copperas. Cuprum Sulfuricum; Cuprum
Vitriolatum. Fr. Sulfate de cuivre ; Couperose bleue;
Vitriol bleu. Ger. Kupfersulfat ; Schwefelsaures Kupfe-
roxyd; Kupfervitriol. It. Solfato di rame. Sp. Sulfato de
cobre; Sulfato Cuprico.

Copper sulfate is commercially prepared by
several methods. One of these consists in roasting
sulfide ores of copper in air, the product being
digested with sulfuric acid to dissolve the copper
oxide while leaving the iron oxide unaffected.
The resulting solution is concentrated to crystal-
lize the copper sulfate. Another method is to
dissolve scrap copper in dilute sulfuric acid.

Description. — "Cupric Sulfate occurs as deep
blue, triclinic crystals, or as blue, crystalline
granules or powder. It has a nauseous, metallic
taste and effloresces slowly in dry air. Its solu-
tions are acicf to litmus paper. One Gm. of
Cupric Sulfate dissolves in 3 ml. of water, in
about 500 ml. of alcohol, and very slowly in
3 ml. of glycerin. One Gm. dissolves in about
0.5 ml. of boiling water." N.F.

Standards and Tests. — Identification. — A
1 in 10 solution of cupric sulfate responds to tests
for copper, and for sulfate. Alkalies and alkaline
earths. — After precipitating the copper from a
solution containing 2 Gm. of cupric sulfate in
100 ml. of water with hydrogen sulfide. 50 ml. of
the filtrate obtained from the mixture yields not
more than 3 mg. of residue. N.F.

The B.P. requires, as a limit test for zinc and
lead, that an aqueous solution of copper sulfate,
to which ammonia and potassium cyanide have
been added, shall produce no opalescence, and
not more than a slight darkening, on the addi-
tion of sodium sulfide solution. A limit test for
iron specifies that the amount of precipitate ob-
tained with ammonia, after ignition, shall not be
in excess of 0.14 per cent.

Assay. — About 1 Gm. of cupric sulfate, dis-
solved in water, is reduced by potassium iodide
in an acetic acid medium with liberation of
iodine, this being titrated with 0.1 N sodium thio-
sulfate. Each ml. of 0.1 N sodium thiosulfate
represents 24.97 mg. of CuS04.5H20. N.F.

Incompatibilities. — Solutions of fixed alkali
hydroxides precipitate copper ion as blue copper
hydroxide, which upon standing or heating turns
black. This precipitation is either prevented or
reduced by citrates, tartrates, salicylates, glycerin,
sugar and other organic substances. Ammonium
hydroxide and ammonium carbonate first produce
a precipitate of copper hydroxide or carbonate
which dissolves in excess of these substances
forming a deep blue solution characteristic of
copper ammines. The fixed alkali carbonates
precipitate copper carbonate of variable compo-
sition; phosphates precipitate copper phosphate;
borax produces an insoluble compound; arsenites
precipitate green copper arsenite in neutral solu-
tion; tannic acid and vegetable astringents are
precipitated; albumin is coagulated by copper
sulfate; soluble iodides reduce the copper, and

then precipitate it as cuprous iodide with simul-
taneous liberation of iodine.

Uses. — While copper may be an important
element in the body (see under Copper) the
sulfate is comparatively little employed as a
constitutional remedy. It is sometimes used in
the treatment of anemia. It owes its therapeutic
value chiefly to its irritant, astringent, and anti-
septic properites. In doses of 300 mg., in 1
per cent solution, copper sulfate is a prompt and
active emetic and may be used to evacuate the
stomach in various forms of poisoning, especially
in phosphorus poisoning, where it not only causes
vomiting but also acts as a chemical antidote
through formation of a layer of copper phosphide
on articles of phosphorus. This dose may be re-
peated but if vomiting does not occur gastric
lavage is essential to remove the copper. A 1
per cent solution is beneficial for phosphorus
burns of the skin (Bull. War Med., 1944, 5, 85) ;
a 4 per cent concentration in soap is also effective
(McCartan and Fecitt, Brit. M. J., 1945, 2,
316).

As a general disinfectant it is of only moderate
power; a solution of 0.5 to 1 per cent will destroy
most vegetative bacteria within one or two hours;
against sporulating organisms it is inefficient. On
the other hand, it is extremely active against
Bacillus typhosus and B. coli; Gildersleeve (Am.
J. Med. Sc, 1905, 139, 757) found that one
part per million will destroy the typhoid germ
within a period of three hours. Its antiseptic
powers are greatly reduced by the presence of
proteins. Strips of copper foil in suspensions of
V. cholerae in distilled water destroyed all the
vibrios in half an hour (Bose and Chakraborty,
see Trop. Dis. Bull., 1949, 46, 827) but in the
presence of protein the copper failed. Cupric
sulfate is also highly poisonous to- algae and is
employed (1:1,000,000 concentration) for ridding
ponds and swimming pools of these organisms.
It is a good fungicide; 1 or 2 per cent solutions
have been used for ion transfer with the electrical
current in epidermophytosis (Freis. Arch. Dermat.
Syph., 1946, 53, 34) and stockings have been
impregnated with copper sulfate (/. Lab. Clin.
Med., 1944, 29, 606). Benedek (Urol. Cutan.
Rev., 1951, 55, 539) used 5 per cent of copper
sulfate, 5 per cent of chloral hydrate, 78 per cent
of glycerin and 1 per cent of sodium lauryl sulfate
in distilled water twice daily in cases of tinea
capitis; it was an effective epilator but it did not
destroy either M . audouini or lanosum.

For its astringent and stimulating effect con-
tinuous soaks of 1 in 150 solution have been used
in the treatment of tropical and other indolent
ulcers of the skin (Med. J. Australia, 1938, 1,
348) and various chronic conditions of the mucous
membranes. Subconjunctival injections of a 1
per cent solution, with 4 per cent procaine, have
been used in the treatment of trachoma. A 0.25
to 0.5 per cent solution is a stimulant collyrium
in conjunctivitis and styes. In 0.1 to 1 per cent
solution it has been used in urethritis and vagi-
nitis; daily douches with 0.1 to 0.2 per cent
solution are effective for trichomonas vaginalis in-
festations. Actinomycotic lesions have been infil-
trated with a 1 per cent solution. Retention

Part I

Coriander

365

enemas of a 1:5000 solution have been used for
amebic dysentery (De Rivas, Internat. Clin.,
1938, 1, 220) and also for chronic bacillary
dysentery. Hunter et al. (Trans. Roy. Soc. Trop.
Med. Hyg., 1952, 46, 201) found an ointment of
copper oleate 95.5 per cent effective as a protec-
tive during an 8-hour test period in rice paddies
against cercariae of the bird schistosome; it was
more effective than dimethyl phthalate or benzyl
benzoate.

Cupric sulfate is occasionally employed inter-
nally in small doses as a gastrointestinal astrin-
gent and antiseptic, but its value is very
questionable. Oral doses of 15 to 60 mg. three
times daily have been prescribed for blasto-
mycosis. lS

Toxicology. — Soluble salts of copper, when
taken in poisonous doses, produce the following:
a coppery taste in the mouth; nausea and vomit-
ing; violent pain in the stomach and bowels; fre-
quent black and bloody stools; small, irregular,
sharp, and frequent pulse; fainting; burning
thirst; difficulty of breathing; cold sweats; pau-
city of urine, and burning pain in voiding it;
violent headache; muscular cramps, convulsions,
and finally death. The best antidote is potassium
ferrocyanide, 600 mg. (approximately 10 grains)
in water, which forms insoluble copper ferro-
cyanide. Soap and alkalies are also antidotal. If
the antidote cannot be procured immediately
large quantities of albuminous substances, as milk
or white of eggs, should be given mixed with
water, which act favorably by forming copper
caseinate and copper albuminate, respectively,
but those compounds should be evacuated as
soon as possible by vomiting and purging. Should
vomiting not take place, the stomach tube should
be employed.

For discussion of chronic copper poisoning see
under Copper.

Dose. — The dose as an astringent is 16 mg.
(approximately l/i grain) ; as an emetic, 300 mg.
(approximately 5 grains) in warm water, re-
peated in fifteen minutes if necessary, but not
oftener than once; for nutritional anemia in in-
fants— 3 mg. (approximately Via grain) daily in
milk or fruit juice, in adults— 5 to 10 mg. (ap-
proximately Vn to % grain) three times daily in
capsules. As a stimulant wash, the solution may
contain 0.5 to 1.5 per cent of cupric sulfate.

Storage. — Preserve "in tight containers."
U.S.P.

CORIANDER. N.F., B.P.

Coriander Seed, [Coriandrum]

"Coriander is the dried ripe fruit of Corian-
drum sativum Linne (Fam. Umbelliferce). Cori-
ander yields not less than 0.25 ml. of volatile
coriander oil from each 100 Gm. of drug." N.F.
The B.P. definition is similar; not less than 0.3
per cent v/w of oil is required.

Coriander Fruit. Fructus Coriandri. Fr. Coriandre;
Fruit de Coriandre. Ger. Koriander; Koriandersamen;
Stinkdillsamen. It. Coriandro. Sp. Fruto de cilantro.

Coriander is listed in the Ebers papyrus and
was mentioned in the writings of Pliny and Cato,
the latter describing its cultivation.

Coriandrum sativum is an annual plant, with
an erect branching stem rising about two feet,
and furnished with compound leaves, of which
the upper are thrice ternate, with linear pointed
leaflets, the lower pinnate, with the pinnae cut
into irregular serrated lobes like those of parsley.
The flowers are white or rose-colored, and in
compound terminal umbels; the fruit globular,
and composed of two concavo-convex mericarps.
C. sativum is a native of the Mediterranean and
Caucasus regions, but at present grows wild in
most parts of Europe, having become naturalized
in consequence of its extended cultivation. The
flowers appear in June, and the fruit ripens in
August. It has a singular fact that all parts of the
fresh plant possess a mousy odor, when bruised,
while the fruit becomes fragrant by drying. This
is the official portion.

Coriander is cultivated in England, India, Asia
Minor, northern Africa and the United States.
The plants are propagated from seeds sown in the
spring. In August and early September, when the
fruits are ripe, the plants are mowed down, par-
tially cured in the field and dried under cover.
The fruits are then thrashed out and cleaned. In
1952 there were imported into the U. S. A. 2,761,-
047 pounds of coriander. The shipments came
from French Morocco, Rumania, Netherlands,
Czechoslovakia and Yugoslavia. During and since
World War II, a considerable domestic supply
has been obtained from plants cultivated in many
sections of the United States.

Description. — "Unground Coriander occurs
as usually coherent mericarps. The cremocarps
are nearly globular, from 2 to 5 mm. in diameter;
externally weak yellowish orange to moderate
yellowish brown, frequently with a purplish red
blush. The apex has 5 small sepals and a short
stylopodium; each mericarp has 5 prominent,
straight, longitudinal secondary ribs and 4 indis-
tinct, undulate primary ribs. The mericarps are
easily separated and are deeply concave on the
commissural surface. Coriander has a fragrant
odor and an aromatic, characteristic taste." N.F.
For histology see N.F. X.

"Powdered Coriander is moderate yellowish
brown. It consists chiefly of endosperm and ligni-
fied tissues of the pericarp; calcium oxalate crys-
tals are numerous, and up to 10 \i in diameter,
mostly in rosette aggregates, either isolated or in
aleurone grains. The fibers are irregularly curved
and have thick, lignified walls and numerous
simple pits. Numerous globules of fixed oil and
a few fragments of yellow vittae, associated with
elongated polygonal, epidermal cells are also
present. Hairs and reticulate parenchyma are
absent." N.F.

Standards and Tests. — Foreign organic mat-
ter.— Not over 5 per cent. Acid-insoluble ash. —
Not over 1.5 per cent. N.F. The B.P. limits for-
eign organic matter at 2 per cent, and acid-insolu-
ble ash at 1.5 per cent.

Assay. — The volatile oil in 200 Gm. of cori-
ander, preferably whole or coarsely comminuted,
is determined by the official Volatile Oil Deter-
mination. N.F.

Constituents. — The aromatic taste and odor
of coriander depend on a volatile oil (see Cori-

366

Coriander

Part I

ander Oil) which may be separated by distilla-
tion. The amount of oil present is generally in
the proportion of 0.25 to 0.5 per cent but Ram-
stad {Chem. Abs., 1944, 38, 218), analyzing seed
obtained from test plots of coriander grown in
Norway, found between 1.4 and 1.7 per cent of
essential oil; he also reported finding 12 to 12.4
per cent of fixed oil, 6.3 to 7 per cent of aqueous
extract, and 5.5 to 6.5 per cent of ash.

Uses. — Coriander is a rather feeble aromatic
and carminative. It is almost exclusively employed
in combination with other medicines, either to
mask their taste, to render them acceptable to the
stomach, or to correct the griping qualities of
rhubarb or senna.

Dose, 0.3 to 1 Gm. (approximately 5 to 15
grains).

Off. Prep.— Coriander Oil, U.S. P., B.P.; Com-
pound Tincture of Rhubarb, B.P.

CORIANDER OIL. U.S.P. (B.P.)

[Oleum Coriandri]

"Coriander Oil is the volatile oil distilled with
steam from the dried ripe fruit of Coriandrum
sativum Linne (Fam. Umbelliferai) ." U.S.P. The
B.P. recognizes oil distilled from the same source.

B.P. Oil of Coriander. Fr. Essence de coriandre. Ger.
Korianderol. Sp. Esceiuia de Cilaniro.

The amount of oil obtainable from coriander
by steam distillation is generally in the proportion
of 0.25 to 0.5 per cent, though substantially
greater yields are often reported. Corianders of
Russian, Czechoslovakian and German origin are
said consistently to average 0.8 to 1 per cent of
oil, while coriander grown on test plots in Norway
vielded 1.4 to 1.7 per cent of the oil (Ramstad,
Chem. Abs., 1944, 38, 218).

Description. — "Coriander Oil is a colorless
or pale yellow liquid, having the characteristic
odor and taste of coriander. One volume of Cori-
ander Oil dissolves in 3 volumes of 70 per cent
alcohol." U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 0.863 and not more than 0.875.
Optical rotation. — Not less than +8° and not
more than +15° in a 100-mm. tube. Refractive
itidex. — Not less than 1.4620 and not more than
1.4720, at 20°. Heavy metals. — The oils meets the
requirements of the test for Heavy metals in
volatile oils. U.S.P.

The B.P. description of the oil is the same as
that of the U.S.P.

Constituents. — Coriander oil contains from
45 to 65 per cent of coriandrol, C10H17OH, a
terpene tertiary alcohol now known to be identi-
cal with d-linalool; it also contains alpha- and
beta-pinene, cymene, terpinene, geraniol, borneol
and decyl aldehyde.

Coriander oil has been extensively adulterated
with colorless rectified orange oil, which can be
detected by its insolubility in 90 per cent alcohol,
pure coriander oil being soluble. Cedarwood oil
and turpentine have also been used as adulterants.

Uses. — The oil has the medicinal properties of
the fruit, and, like the aromatic oils generally,
may be used to mask the taste or correct the

nauseating or griping properties of other medi-
cines.

Dose, 0.06 to 0.2 ml. (approximately 1 to 3
minims).

Storage. — Preserve "in well-filled, tight con-
tainers and avoid exposure to excessive heat."
U.S.P.

Off. Prep. — Aromatic Cascara Sagrada Fluid-
extract, U.S.P., B.P.; Senna Syrup, N.F., B.P.;
Compound Orange Spirit, U.S.P.

CORN OIL. U.S.P.

Oleum Maydis

"Corn Oil is the refined fixed oil expressed from
the embryo of Zea Mays Linne (Fam. Gram-
inea)r U.S.P.

Maize Oil; Oil of Maize. Fr. Huile de Mais. Ger.
Maisol. Sp. Aceite de Maxz.

In the manufacture of starch, glucose, hominy,
and other corn products the germ or embryo of
Zea Mays L. is almost entirely separated from the
rest of the kernel, a circumstance to which corn
oil owes its extensive utilization today. The con-
tent of oil in the germ is nearly 50 per cent, in
the whole kernel from 3 to 6.5 per cent.

Two processes for separating the germ from the
corn — degermination — are in use. The wet proc-
ess is employed in the manufacture of starch and
glucose; the dry process in producing flour, meal,
hominy, etc. In the former process (see also
Starch) the cleaned corn is soaked in large vats
with water containing 0.2 per cent sulfurous acid
for 30 to 40 hours; the corn is then drained and
passed through an attrition mill which shreds the
kernels and loosens the germs which are floated
off on water along with starch, from which sepa-
ration is made by use of perforated reels. The
washed germs are passed through moisture ex-
pellers and then into steam-heated, rotary driers
where the moisture content is reduced to 5 per
cent or less. The dried germ is reduced to a coarse
meal, which is transferred to steam-heated tem-
perers and then to expellers; the resulting oil is
passed through a slowly rotating screen to remove
the coarser part of the "press foots" and then
through paper in a filter press. In the dry process
the corn is sprayed with water or treated with
steam until it has a moisture content of about
20 per cent, after which it is passed into a de-
germinating machine consisting of a tapering drum
revolving within a casing of the same shape; the
germs are loosened by cone-shaped protuberances
on the drum and casing and pass through perfora-
tions in the machine. Expression of oil is finally
effected as in the wet process. In recent years
extraction of the oil by means of solvents has
also been employed.

The crude corn oil is refined by treatment with
dilute caustic soda to neutralize free acids, then
bleached with fuller's earth or activated carbon,
deodorized in a vacuum deodorizer with steam,
and finally chilled to separate waxy components
which would otherwise separate out and give the
oil an objectionable appearance.

Description. — "Corn Oil is a clear, fight yel-
low, oily liquid. It has a faint, characteristic odor

Part I

Corticotropin Injection 367

and taste. Corn Oil is slightly soluble in alcohol.
It is miscible with ether, with chloroform, with
benzene, and with petroleum benzin." U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 0.914 and not more than 0.921.
Cottonseed oil. — 5 ml. of oil is mixed, in a test
tube, with 5 ml. of a mixture of equal volumes of
amyl alcohol and a 1 in 100 solution of sulfur in
carbon disulfide and the mixture gently warmed
until the carbon disulfide is expelled: on immers-
ing the tube to one-third its depth in a boiling,
saturated solution of sodium chloride, no reddish
color develops within 15 minutes. Free fatty acids.
— Not more than 2 ml. of 0.02 N sodium hydrox-
ide is required for neutralization of 10 Gm. of
corn oil. Iodine value. — Not less than 102 and not
more than 128. Saponification value. — Not less
than 187 and not more than 193. Solidification
range of fatty acids. — Between 14° and 20°. Un-
saponifiable matter. — Not more than 1.5 per cent.
U.S.P.

Constituents. — Corn oil, classified as a semi-
drying oil, is reported by Jamieson (Vegetable
Oils and Fats) to contain 43.4 per cent oleic acid,
39.1 per cent linoleic acid, 7.3 per cent palmitic
acid, 3.3 per cent stearic acid, 0.4 per cent
arachidic acid, and 0.2 per cent lignoceric acid as
the acid components of the glycerices present.
Also occurring in the oil are very small quantities
of various phosphatides, carbohydrates, coloring
matter, etc. The wax which separates from corn
oil on chilling is not stearin, as has been supposed,
but esters of ceryl and myricyl alcohols.

Uses. — Corn oil finds extensive use as the
solvent or vehicle for several vitamin containing
products, notably synthetic oleovitamin D (vios-
terol in oil), and oleovitamin A and D. It is also
employed by some manufacturers as a solvent for
injections of diethylstilbestrol, estrogenic sub-
stances, progesterone, menadione and other com-
pounds requiring a vegetable oil vehicle. Corn
oil has been employed as a source of unsaturated
fatty acids in the treatment of eczema (see Un-
saturated Fatty Acids, Part II).

Most of the corn oil produced in the United
States is used for edible purposes; it is employed
as a salad and cooking oil and in the manufacture
of some lard substitutes.

Storage. — Preserve "in tight containers, and
avoid exposure to excessive heat." U.S.P.

CORTICOTROPIN INJECTION.

U.S.P.

ACTH Injection, Adrenocorticotropin Injection,
Corticotrophin Injection

"Corticotropin Injection is a sterile preparation
of the principle or principles derived from the
anterior lobe of the pituitary gland of mammals
used for food by man, which exert a tropic influ-
ence on the adrenal cortex. It possesses a potency
of not less than 80 per cent and not more than
125 per cent of that stated on the label in U.S.P.
Corticotropin Units. It may contain a suitable
antibacterial agent.

"Note. — Corticotropin Injection is for adminis-
tration intramuscularly or subcutaneously unless

its label indicates that it may be given intrave-
nously, in which case its potency also is deter-
mined by the assay method involving intravenous
injection." U.S.P.

Acthar (Armour). Solacthyl (Squibb).

The existence in the anterior lobe of the pitui-
tary of a hormonal principle or principles which
stimulate secretion by the adrenal cortex was the
outcome of an early observation that atrophy of
the adrenal caused by hypophysectomy was favor-
ably influenced by injection of certain extracts
of the anterior pituitary. In 1943, Li et al. (J. Biol.
Chem., 1943, 149, 413) and Sayers et al. (ibid.,
1943, 149, 425) obtained from swine and sheep
pituitary glands, respectively, substances which
exhibited a high degree of activity in stimulating
the adrenal cortex; these substances were found
to be sulfur-containing proteins with a molecular
weight of about 20,000. Fishman (ibid., 1947,
167, 425) also described a method for preparing
a potent product from pig pituitary glands, which
source appears to be richer in the active prin-
ciple^) than the glands from either beef or sheep.
Such preparations, sometimes called "crude"
corticotropin, are commonly prepared by extrac-
tion of pituitary glands with acetone and hydro-
chloric acid, followed by fractional precipitation
technics employing the salting-out principle and
adjustment to the pH at the isoelectric point of
the protein (pH 4.7).

That the activity of the corticotropin referred
to in the preceding may not be dependent on the
whole of the very complex molecule which it
represents was first suggested by Li (Conference
on Metabolic Aspects of Convalescence, Josiah
Macy, Jr. Foundation, 1948, 17, 114), whose ex-
periments indicated that a peptide product ob-
tained by partial hydrolysis of "crude" cortico-
tropin retained its ability to stimulate the adrenal
cortex in hypophysectomized rats; the average
size of the peptide fragments in the hydrolyzed
material corresponded to a chain length of about
8 amino acid molecules (Fed. Proc, 1949, 8, 219).
Brink et al. (J.A.C.S., 1950, 72, 1040) found that
a pepsin digest of corticotropin prepared from
pig pituitaries was active in maintaining the re-
mission obtained by previous treatment with
corticotropin of patients afflicted with rheumatoid
arthritis; the active hydrolysis products were
small enough in molecular dimensions to be
dialyzable. Astwood et al. (Bull. New Eng. M.
Center, 1950, 12, 2) reported on the high potency
of a glacial acetic acid extract of pork pituitaries.
An active non-protein fraction derived from sheep
pituitary glands was described by Geschwind et al.,
Science, 1950, 111, 625. The presence of at least
four active substances, with molecular weights
ranging from about 410 to about 2800, was indi-
cated by the chromatographic experiments of Li
et al. (J. Biol. Chem., 1951, 190, 317). By peptic
digestion technics Lesh et al. (Science, 1950, 112,
43) produced a material about 150 times as active
as crude corticotropin extracts, the range of
molecular weight being between 2500 and 10,000.
Astwood et al. (J.A.C.S., 1951, 73, 2969) found
that adsorption on oxycellulose of the active prin-
ciple (s) from a glacial acetic acid extract of

368 Corticotropin Injection

Part I

pituitary glands yielded a product having 100
U.S. P. units of activity per mg. Even this mate-
rial is not a pure hormone; it is a water-soluble,
colorless, non-volatile organic compound of mod-
erate molecular weight, with no distinctive ab-
sorption band in the ultraviolet region. No carbo-
hydrate, sulfur, phosphorus, or heavy metal and
little, if any, lipid is present. Since activity can
be destroyed by pepsin, trypsin, or carboxy-
peptidase the presence of one or more peptide
linkages is indicated. Since esterification inacti-
vates the substance carboxyl groups are present.
Its solubility in organic acids, and its adsorption
on cation exchange resins suggests the presence
of a basic group.

Under the title Purified Corticotropin the
X.X.R. recognizes one prepared by the adsorption
of corticotropin from a dilute acetic acid solution
on oxycellulose and the subsequent elution of the
adsorbed material with dilute hydrochloric acid.
This method, according to X.X.R., yields a prod-
uct having 10 to 40 times the adrenocorticotropic
activity of an equivalent weight of corticotropin.
For details of preparation see Fisher and Thomp-
son, Endocrinology, 1953. 52, 496, and also White,
J.A.C.S., 1953, 75, 503. Since adsorption on
oxycellulose appears to remove only noncortico-
tropic-active material, including that which is
believed to be responsible for inactivation of
corticotropin on intramuscular injection (see
under Assay), the trend is to produce purified
corticotropin, which in effect increases the yield
of intramuscularly-active material from pituitaiy
approximately 3-fold. Purified corticotropin is
sometimes referred to in the literature as high-
potency corticotropin and as ACTX-corticotropin
and corticotropin A to distinguish it from "crude"
or ACTH-corticotropin.

Peptic hydrolysates of "crude"' corticotropin,
containing relatively small molecules having cor-
ticotropic activity, are also available; these have
been variously referred to as ACTH-peptide,
ACTIVE, ACTIDE-corticotropin, and as cortico-
tropin B.

All of the corticotropins referred to above have
the same qualitative action on the adrenal cortex;
they differ only in their quantitative effects.

Biochemical evidence (see under Assay) sug-
gests that there are several forms or "subtypes"
of corticotropin; thus. White and Fierce (J.A.C.S.,
1953, 75, 245) by a chromatographic procedure
obtained evidence of the existence of three active
corticotropins. While two corticotropins, desig-
nated corticotropin A and corticotropin B, have
been referred to above, it is not apparent at this
writing that both of these are true "subtypes." It
does appear, however, that the ^.-corticotropin
separated by Li et al. (J. Biol. Chem., 1955. 213,
171, 187) and the ^-corticotropin isolated by Bell
(J.A.C.S., 1954. 76, 5565) are ultimate "sub-
types"; both of these physiologically active con-
stituents, which were separated from extracts of
sheep and hog pituitary glands, respectively, and
neither of which is a pepsin digestion product,
have a molecular weight of about 4500 and con-
tain 39 amino acid groups. It is very significant.
however, that in the course of isolating P-cortico-
tropin Bell separated also smaller quantities of

seven other distinct proteins of equally high
corticotropin activity. It is apparent that much
remains to be learned about the ultimate com-
ponents of the product commonly referred to as
corticotropin and recognized in the U.S. P. as
corticotropin injection.

Description. — "Corticotropin Injection is a
colorless or light straw-colored liquid, or a soluble
amorphous solid obtained by drying such liquid
from the frozen state. It is odorless or has the
odor of an antibacterial agent. The pH of Cortico-
tropin Injection in liquid form or after reconsti-
tution from the solid state is between 3.0 and 7.0."
U.S.P. It is intended that the U.S. P. monograph
for Corticotropin Injection will recognize both
"crude" and purified corticotropin.

Standards and Tests. — The U.S.P. provides
separate biological tests for limit of thyrotropin
activity, oxytocin activity, vasopressin activity,
and of depressor substances. For information con-
cerning these see U.S.P. XV.

Assay. — Following the rather cumbersome
method of measuring the effect of anterior pitui-
tary extracts on the size and histology of the
adrenal cortex of the hypophysectomized rat
(Collip et al., Lancet, 1933. 2, 347) the improved
method developed by Savers et al. {Endocrinology,
1948. 42, 379; and modified by Munson et al.
(/. Clin. Endocrinol., 1948, 8, 586) greatly facili-
tated purification of extracts of the pituitary
gland. This assay method utilizes the depletion
of the ascorbic acid content of the adrenal cortex
in hypophysectomized rats following injection
of the pituitary extract as a measure of the
effectiveness of the latter. This is the basis of
the U.S.P. assay, quantitative evaluation being
achieved through comparison with the effect pro-
duced by U.S.P. Corticotropin Reference Stand-
ard; the activity of 1 mg. of the standard is
designated 1 U.S.P. Unit, which is equivalent also
to 1 International Unit.

It has been observed that there is a marked
diminution in the clinical effect of "crude" cor-
ticotropin when it is injected intramuscularly or
subcutaneously compared to when it is injected
intravenously; on the other hand, the clinical
effect of purified corticotropin (v.s.) is practically
the same regardless of the route of administra-
tion. The difference appears to be due to some
extravascular inactivation (Wolfson, Arch. Int.
Med., 1953. 92, 108). possibly enzymatic in
nature, of "crude" corticotropin when it is in-
jected intramuscularly; such extravascular in-
activation does not occur with purified cortico-
tropin. Since both types of corticotropin are in
common use it is apparent that a special problem
arises in evaluating the clinical potency of both
products because of the difference in activity of
"crude"' corticotropin, depending on its route of
administration. The following illustrations will
indicate the magnitude of the difference. If a
preparation of "crude" corticotropin and another
of purified corticotropin are assayed by the intra-
venous method (using rats) and are adjusted to
identical potencies they will produce in humans
identical clinical effects when administered intra-
venously; if they are administered intramuscu-
larly or subcutaneously the clinical effect of the

Part I

Corticotropin Injection 369

purified corticotropin will not be any less than
when it was administered intravenously but the
effect of the "crude" corticotropin will be less
than one-third of its activity when administered
intravenously. On the other hand, if the prepara-
tions of "crude" and purified corticotropin are
adjusted to identical potencies after assay by
intramuscular injection (in rats) they will pro-
duce identical clinical effects in humans when
administered intramuscularly or subcutaneously
but when administered intravenously the clinical
effect of the "crude" corticotropin preparation
will be 3 or 4 times that of the purified cortico-
tropin preparation. It is for this reason that the
U.S. P. provides a subcutaneous and an intra-
venous method for the assay of corticotropin; as
defined, U.S. P. corticotropin injection "is for ad-
ministration intramuscularly or subcutaneously
unless its label indicates that it may be given
intravenously, in which case its potency also is
determined by the assay method involving intra-
venous injection." Also, the N.N.R. states: "For
the convenience of physicians, the potency of
purified corticotropin is expressed in terms of
clinical activity equivalent to a specified number
of U.S. P. units of corticotropin, so that treatment
may be changed from corticotropin to purified
corticotropin without gross adjustments in dosage
requirement. ... As the dosage of purified cor-
ticotropin is expressed in clinical equivalents of
U.S. P. units of corticotropin, it should be em-
ployed in the same dosage as corticotropin when
administered intramuscularly or subcutaneously.
If administered by the intravenous route, three
clinical equivalents of purified corticotropin must
be administered to obtain the same range of clini-
cal activity as obtained with each U.S. P. unit of
corticotropin."

In humans the reduction in the number of
eosinophilic polymorphonuclear leukocytes in
blood (Thorn et al, J.A.M.A., 1948, 137, 1005),
and the increase in urinary excretion of 17-keto-
steroids (Renold et al., J. Clin. Endocrinol., 1952,
12, 763) have been used as criteria for evaluating
the activity of anterior pituitary extracts in indi-
viduals having normal adrenocortical function.

Long-acting Corticotropin Preparations.
— Several investigators have prepared long-acting
corticotropin injections through combination with
various substances (see Wolfson et al., Proc. Sec-
ond Clinical ACTH Conf., Mote, Vol. 2, 1951,
p. 1; Raben et al., J. A.M. A., 1952, 148, 844;
Fletcher and Williams, Lancet, 1952, 2, 1228).
One of the most promising of such preparations
is obtained by combining zinc phosphate or zinc
hydroxide in aqueous solutions of corticotropin at
a pH close to neutrality, so that about 99 per cent
of the total activity is precipitated; by various
biochemical and clinical tests such a preparation
was found effective for from 1 to 3 days and ap-
peared to be more active and stable than the regu-
lar corticotropin injection (Homan et al., Lancet,
1954, 1, 541; Greene and Vaughan-Morgan, ibid.,
543; Ferriman and Anderson, ibid., 545).

Action. — The action of corticotropin is to
stimulate the synthesis and release of the physio-
logically active steroids from adrenal cortex;
various aspects of this general action are discussed

here but reference should also be made to the
monograph on Cortisone Acetate.

Pituitary-Adrenal Axis. — The relation be-
tween the pituitary and adrenal glands was first
demonstrated experimentally by Smith (J. A.M. A.,
1927, 88, 159), who showed that atrophy of the
adrenal cortex followed hypophysectomy in the
rat and was prevented by implantation of rat
pituitary tissue subcutaneously. Subsequently sev-
eral investigators (Evans et al., Science, 1932,
75, 442; Anselmino et al., Klin. Wchnschr., 1933,
12, 1944; Houssay et al., Rev. soc. argent, biol.,
1933, 9, 262; Collip et al., Lancet, 1933, 2, 347)
independently observed adrenal cortical hyper-
trophy following injection of extracts of the an-
terior lobe of the hypophysis.

The development of a simple assay method
for the corticotropic principle, by Sayers et al.,
(Endocrinology, 1948, 42, 379), which is based
on the decrease of ascorbic acid and also of cho-
lesterol in the adrenal cortex of hypophysecto-
mized rats following injection of an active extract
of the hypophysis made possible rapid advances
in purifying extracts for physiological evaluation
and therapeutic trial. Likewise, the recognition of
the development of blood eosinopenia (Wolfson
and Fajans, New Eng. J. Med., 1952, 246, 1000),
and of the increase in urinary 17-ketosteroids
(Renold et al., J. Clin. Endocrinol., 1952, 12,
763) and of 17-hydroxycorticosteroids in urine
(Reddy et al., Metabolism, 1952, 1, 511) and in
blood plasma (Perkoff et al., Arch. Int. Med.,
1954, 93, 1) facilitated evaulation of such extracts
in clinical medicine.

In man with normal adrenals, corticotropin
causes all the effects produced by administration
of adrenal steroids (see under Cortisone Acetate,
Desoxycorticosterone Acetate and also Testoste-
rone). In animals, as already mentioned, hypo-
physectomy results in atrophy of the adrenal
cortex. Stress causes an increase in the weight of
the adrenal cortex, a decrease in cholesterol,
ascorbic acid and sudanophilic (fat-staining) ma-
terial in the normal animal but not in the animal
without a pituitary gland. Like the adrenalecto-
mized animal, the hypophysectomized animal is
abnormally sensitive to any stress (Baird et al.,
Am. J. Physiol., 1933, 104, 489; Corey and Brit-
ton, ibid., 1939, 126, 148). Three mechanisms of
regulation seem to exist : humoral, sympatho-
adrenal and neurohumoral.

Regulation. — Sayers and Sayers (Recent
Progress in Hormone Research, 1948, 2, 81)
showed that corticotropic action was inversely
proportional to adrenal corticoid action. In other
words, as the concentration of corticoid in the
blood stream decreased the corticotropic action
increased and vice versa. Hypertrophy of the
remaining gland follows unilateral adrenalectomy.
The prolonged administration of cortisone results
in atropy of the adrenal cortex (Ingle et al., Anat.
Rec, 1938, 71, 363). Increased corticotropic
action in response to stress is inhibited by the
administration of cortisone (O'Donnell et al.,
Arch. Int. Med., 1951, 88, 28). Direct action of
cortisone on the cells of the anterior pituitary has
been alleged (Sayers, Physiol. Rev., 1950, 30,
241). Without denying the importance of this

370 Corticotropin Injection

Part I

mechanism, the increase in corticotropic action
of the blood of rats in a few seconds after intra-
venous injection of histamine (Gray and Munson,
Endocrinology, 1951, 48, 471) or the stimulation
of a sensory nerve (Long, Colloquia on Endo-
crinology, Wolstenholme, Vol. 4, London, 1952,
p. 139) suggests another more rapid mechanism
of regulation.

Long suggested that the rapid response to stress
was mediated by epinephrine, since the response
of the adrenal demedullated animal was delayed.
The application of epinephrine to transplants of
anterior pituitary tissue in the anterior chamber
of a rabbit's eye produced a rapid eosinopenia
which was interperted as evidence of corticotropic
action (Long and Fry, Recent Progress in Hor-
mone Research, 1951, 7, 75), as it parallels the
decrease in adrenal ascorbic acid. However, the
delayed response of demedullated animals, with or
without a sympathectomy, was not confirmed
(Recant et al., J. Clin. Endocrinol., 1950, 10,
187; Vogt, Colloquia on Endocrinology, Wolsten-
holme, Vol. 4, London. Churchill, 1952, p. 154;
Pickford and Vogt, /. Physiol, 1951, 112, 133).
Because of availability and simplicity, epinephrine
came into wide use as a test of the functional
status of the pituitary-adrenal axis. But this test
had to be abandoned because eosinopenia follow-
ing an injection of epinephrine may be due to
factors other than an increase in adrenal steroids.
Eosinopenia was produced by epinephrine both
in patients with Addison's disease and in patients
following bilateral adrenalectomy. In cases where
corticotropin failed to cause a decrease in circu-
lating eosinophils, epinephrine did cause a de-
crease. Despite an eosinopenia following intra-
venous injections of epinephrine, Nelson et al.,
(J. Clin. Endocrinol., 1952, 12, 936) found no
change in the blood concentration of 17-hydroxy-
corticosteroids in normal subjects or in patients.
Furthermore, the changes in urinary steroid
excretion produced in individuals with normal
adrenal glands by corticotropin may not appear
after epinephrine (Jeffries et al., ibid., 924).
Hence, eosinopenia alone is not an adequate cri-
terion of corticotropic action because it may occur
without activation of the adrenal cortex. The
mechanism of regulation of the pituitary-adrenal
axis is not quite so simple.

Further studies implicated the hypothalamus in
the regulation. Lesions in the hypothalamus may
prevent the usual response to stress (Harris,
Physiol. Rev., 1948, 28, 139; Hume, /. Clin. Inv.,
1949, 28, 790). Electrical stimulation of the
hypothalamus has caused evidences of cortico-
tropic action (Harris, Philos. Trans., B, 1947,
232, 385), whereas stimulation of the pituitary
itself did not. The results observed following cut-
ting of the stalk of the pituitary gland have been
most variable and careful study has shown that
the blood vessels are arranged like a portal sys-
tem (Popa and Fielding, /. Anat., 1930, 65, 88)
connecting the sinusoids in the pars distalis of
the hypophysis to the vascular plexus on the
brain stem (Wislocki and King, Am. J. Anat.,
1936, 58, 421; Green, ibid., 1951, 88, 225). In
transplantation experiments, Harris and Jacob-
sohn (Colloquia on Endocrinology, Wolstenholme,

Vol. 4, London, 1952, p. 115) found that this vas-
cular connection was essential to normal pituitary
cytology and the functioning of transplants. How-
ever, Cheng et al. and Fortier observed normal
response to stress of transplants in the anterior
chamber of the eye by the criteria of change in
adrenal ascorbic acid (Am. J. Physiol., 1949, 159,
426) and eosinopenia (Colloquia on Endocrin-
ology, p. 124) respectively. It seems probable
that all three mechanisms operate : humoral, sym-
pathoadrenal and neuro-humoral.

Cellular Source of Corticotropin. — The
cell type which produces corticotropin is in dis-
pute, although most evidence indicates the baso-
philic cells to be responsible. An increase in baso-
phils in the pituitary has been reported in patients
with Addison's disease (Swann, Physiol Rev.,
1940, 20, 493). Cushing's syndrome shows baso-
philic adenoma or hyperplasia of the pituitary
(Cushing, Bull. Johns Hopkins Hosp., 1932, 50,
137). In starved animals showing adrenal hyper-
plasia, D'Angelo et al. (Endocrinology, 1948, 42,
399) observed an increase in the number of
basophils in the pituitary. However, in the rat
with one adrenal removed and hyperplasia of the
remaining gland, increase in acidophilic cells has
been reported (Finerty and Briseno-Castrejon,
ibid., 1949, 44, 293). Pearse (Colloquia on Endo-
crinology, Wolstenholme, Vol. 4, London, 1952,
p. 1) called attention to the unknown significance
of the staining reaction of these cells. With fluo-
rescein-tagged antisera against hog corticotropin,
only the basophilic cells of hog pituitary tissue
slices were stained (Marshall, /. Exp. Med., 1951,
94, 21). After prolonged administration of corti-
cotropin in humans an increase in the basophils,
Crooke's hyaline cytoplasmic changes and baso-
philic stippling were observed (Golden et al, Proc.
S. Exp. Biol. Med., 1950, 74, 45.5; Laqueur,
Science, 1950, 112, 429). In leukemic children
treated with corticotropin an increase in pituitary
basophils and basophilic stippling of the chromo-
phobe cells has been observed.

Action on the Adrenal Gland. — Histological
study of the adrenal cortex in man (O'Donnell
et al, Arch. Int. Med., 1951, 88, 28) after corti-
cotropin shows first a decrease in sudanophilic
material and an enlargement of the cells of the
outer fascicular layer. Following more prolonged
use of corticotropin, there is less lipid in all layers
of the adrenal cortex, hypertrophy of the fascicu-
lar and reticular layers and a broader and ill-
defined glomerulosa layer. Similar changes were
observed in cases of leukemia and nephrosis.

Corticotropin causes a rapid decrease in the
concentration of ascorbic acid in the adrenal cor-
tex. On repeated doses, ascorbic acid remains low
for some time but eventually increases in spite
of continued doses of corticotropin. The signifi-
cance of ascorbic acid in the adrenal or its
decrease after corticotropin is unknown (Lowen-
stein and Zwemer, Endocrinology, 1946, 39, 63).
In scurvy the depleted liver glycogen is not cor-
rected by corticotropin (McKee et al, ibid., 1949,
45, 21) nor is there any abnormality in the uri-
nary corticoids in patients with scurvy (Daugha-
day et al, J. Clin. Endocrinol, 1948, 8, 244).
In the normal human after a few doses of cortico-

Part I

Corticotropin Injection 371

tropin there is an increase in the ascorbic acid
found in the blood and the urine (Beck et al,
Proc. Second Clinical ACTH Conf., Mote, Vol 1,
1951, p. 355). In scorbutic animals there is no
ascorbic acid in the adrenal to be depleted follow-
ing a dose of cortocotropin, but the adrenal cho-
lesterol concentration decreases as usual (Long,
Fed. Proc, 1947, 6, 461).

Cholesterol is found in greater concentration
in the adrenal gland — 5 per cent of the wet weight
of the resting gland — than in any other tissue,
including even the brain. After corticotropin the
level of adrenal cholesterol decreases (Sayers et
al., Yale J. Biol. Med., 1944, 16, 361) at the
time that the effect of adrenal corticoids is mani-
fest (Sokoloff et al, Am. J. Path., 1951, 27, 706).
In hypophysectomized animals the level of adrenal
cholesterol is often greater than normal, and it
does not decrease in response to stress (Sayers
et al., Endocrinology, 1945, 37, 96). It is proba-
bly a precursor of the physiologically active
corticoids (Hechter et al., Recent Progress in
Hormone Research, 1951, 6, 215).

Considerable information on the effect of corti-
cotropin on steroids has accumulated. It stimu-
lates both synthesis (Hechter et al., loc. cit.;
Haynes et al., Science, 1952, 116, 690) and re-
lease of hydrocortisone (Kendall's compound F)
and corticosterone (compound B) in particular
(60 per cent of total steroid recovered), an un-
identified mineralocorticoid, androgens, estrogens
and progesterone, or their precursors. Both hydro-
cortisone and cortisone have been identified in
the adrenal venous blood of dogs following
administration of cortocotropin, and also in di-
alysates of peripheral blood; also present are 11-
dehydrocortiscosterone (compound A) and 11-
desoxycorticosterone. In human urine, a-ketolic
corticoids are increased after corticotropin; these
are formaldehydogenic or reducing corticoids,
especially tetrahydrocortisone, tetrahydrohydro-
cortisone, hydrocortisone and cortisone (Dobriner
et al., Proc. Second Clinical ACTH Conf., Mote,
Vol. 1, 1951, p. 65). Studies of adrenal glands
perfused with either cholesterol or acetate show
an increase in conversion to hyrocortisone after
corticotropin, and also from acetate by adrenal
slices. Extensive studies by Hechter et al. and
others involving perfusion of various steroids or
incubation with homogenates of adrenal glands
(McGinty et al, Science, 1950 112, 506; Hayano
et al, J. Biol. Chem., 1951, 193, 175; Savard
et al, Endocrinology, 1950, 47, 418) and mito-
chondrial fractions of adrenal tissue (Sweat,
J.A.C.S., 1951, 73, 4056) may be briefly sum-
marized as follows: corticotropin seems to stimu-
late oxygenation at carbon atom 11 prior to
formation of the progestrone type of steroid.
Desoxycorticosterone is probably not a natural
substance, but an active mineralocorticoid has
been recognized (Simpson et al, Lancet, 1952, 2,
226) which is more active on electrolyte metabo-
lism than either cortisone, hydrocortisone, corti-
costerone or desoxycorticosterone (see aldosterone
or electrocortin, under Desoxycorticosterone
Acetate).

In human urine following administration of
corticotropin there is also an increase in 17-

ketosteroids (Dobriner et al, loc. cit.; Lieberman
et al, Fed. Proc, 1950, 9, 196). These include
compounds with oxygen at carbon atom 11, such
as 11-hydroxyandrosterone, 11-hydroxyetiocho-
lanolone and 11-ketoetiocholanolone, and also
steroids without oxygen at carbon atom 11, such
as androsterone and etiocholanolone. By contrast,
cortisone therapy increases only ll-hydroxy-17-
ketosteroids. The precursors of the ll-desoxy-17-
ketosteroids are thought to be 17-hydroxycorti-
costerone (Reichstein's compound S) and 17-
hydroxyprogesterone, since feeding of these ste-
roids labeled with radioactive carbon-14 isotope
results in labeled androsterone and etiocholano-
lone. As mentioned under cortisone, a biologically
active androgen is found in the urine of bilaterally
adrenalectomized, castrated men after adminis-
tration of cortistone, hydrocortisone or corticoste-
rone. Dehydroisoandrosterone, a 17-ketosteroid, is
probably formed by the adrenal since it is found
in the urine of castrated men (Callow and Callow,
Biochem. J., 1940, 34, 2 76) and women (Hirsch-
mann, /. Biol. Chem., 1940, 136, 483), normal
women (Callow and Callow, Biochem. J., 1938,
32, 1759) and, in large quantity, in patients with
adrenal tumors (Crooke and Callow, Quart. J.
Med., 1939, 8, 233). It is not a metabolite of
testosterone (Landau et al, Endocrinology, 1951,
48,489).

Estrone (Beall, Nature, 1939, 144, 76) and
progestrone (Beall and Reichstein, ibid., 1938,
142, 479) have been isolated from ox adrenals,
and increased estrogenic action is found in the
urine of certain cases with adrenal tumors (Bur-
rows et al, Biochem. J., 1937, 31, 950; Frank,
J.A.M.A., 1937, 109, 1121; Mason and Kepler,
/. Biol. Chem., 1945, 161, 235). After cortico-
tropin (Nathanson et al.,Proc. Second Clin. ACTH
Conf., Mote, Vol. 1, 1951, p. 54), urinary estrone,
estradiol and estriol were increased in 3 females,
one of whom was found to have atrophic ovaries,
but not in 2 men. In the discussion of this paper,
Paschkis reported increased estrogenic action in
the urine of 2 males after corticotropin. After ad-
ministration of desoxycorticosterone, pregnanediol,
which is the urinary excretory product of proges-
terone, is increased in the urine (Horwitt et al,
J. Biol. Chem., 1944, 155, 213). After cortico-
tropin (Dobriner et al, loc. cit.) or a major sur-
gical operation (Zimmermann and Wojack,
/. Clin. Endocrinol, 1952, 12, 972), but not after
cortisone, pregnanolone, which is a reduction
product of progesterone, is increased in the urine.

Thorn et al. (New Eng. J. Med., 1953, 248,
588) concluded that corticotropin stimulates syn-
thesis and release of hydrocortisone (see also
Conn et al, Science, 1951, 113, 713) and corti-
costerone, and also steroids with mineralocorticoid.
androgenic, estrogenic and progestational action.

Action on Other Tissues. — In general, the
action of corticotropin is similar to that of cor-
tisone or hydrocortisone unless the adrenal cortex
is incapable of responding to stimulation. It has
no known action other than through the adrenal
cortex. Mineralocorticoid action is also produced
probably by release of an unidentified steroid,
since neither cortisone nor hydrocortisone exert
as much action by usual routes of administration

372 Corticotropin Injection

Part I

as is observed after corticotropin. However, the
intravenous administration of either hydrocor-
tisone or cortisone at the rate of 12 mg. per hour
produces complete suppression of urinary sodium
excretion. Furthermore, corticosterone or 11-
desoxycorticosterone are more active in electrolyte
metabolism than cortisone.

In contrast to the trivial action of cortisone on
blood cholesterol concentration, corticotropin pro-
duces a sharp decrease in cholesterol esters on
the third to fifth day of use (Conn et al, J. Lab.
Clin. Med., 1950, 35, 504). In Addison's disease
this does not occur. Cholesterol may serve as a
precursor of adrenal corticoids. On prolonged ad-
ministration of corticotropin, the moderate rise in
blood cholesterol ester concentration observed
after cortisone occurs (Adlersberg et al, J. A.M. A.,
1950, 144, 909). Wolf son et al. (J. Lab. Clin.
Med., 1950. 36, 1005) suggest that this is due to
depression of thyroid function.

Following parenteral administration, cortico-
tropin produces t the same changes of the skin as
cortisone (it is to be noted, however, that cor-
ticotropin is not active when applied topically).
In persons with normal adrenal function, cortico-
tropin often causes darkening of the skin whereas
in the bronzed skin of Addison's disease cortisone
causes a decrease in melanin pigmentation (Mc-
Cracken and Hall, J. Clin. Endocrinol., 1952, 12,
923). Contamination of corticotropin preparations
with the melanophore principle — intermedin — of
the hypophysis has been suggested as the causa-
tive factor but the action of this hormone on
human skin is unknown. On the electroencephalo-
gram and the psychic status corticotropin and
cortisone have the same action but cortisone
markedly increases the electroshock threshold in
the rat and corticotropin has only a slight effect
(Woodbury. /. Clin. Endocrinol., 1952, 12, 924).
Corticotropin stimulates the formation of corti-
coids by the placenta (DeCourcy et al., Nature,
1952, 170, 494); both cortisone and hydrocorti-
sone have been isolated from the placenta.

Absorption. — Corticotropin is given parenter-
ally only. As measured by the eosinophil response,
the effect of 25 U.S. P. units intramuscularly of
corticotropin (crude) is maximum at 4 to 6 hours
and subsides within 8 to 12 hours. To maintain
continuous action, 10 to 25 units must be injected
every 6 to 8 hours. Development of resistance is
experienced, particularly with the crude prepara-
tion. This seems to be due to inactivation at the
injection site since the preparation is still effective
intravenously in these cases. With more purified
preparations, resistance does not develop and
furthermore the effective dose is likewise much
less. After intravenous injection, corticotropin
disappears rapidly from the blood. After a dose
of 50 to 100 units, over a period of 30 to 60 min-
utes, the corticotropin activity of blood plasma is
markedly increased but it does not persist for 2
hours after injection (Savers et al., J. Clin.
Endocrinol., 1949, 9, 593). Corticotropin is in-
activated quickly (Greenspan et al., Endocrinol-
ogy, 1950, 46, 261; Pincus et al., J. Clin. En-
docrinol, 1952. 12, 920). In rats, Richards and
Sayers (Proc. S. Exp. Biol. Med., 1951, 77, 87)
found 40 per cent of the dose in the extracellular

water (including blood plasma) of the body and
20 per cent in the kidneys after 5 minutes. After
15 minutes, only traces remained in the extra-
cellular fluid but 15 per cent was still found in
the kidneys (see also Sonenberg et al., Endo-
crinology, 1951, 48, 148). Transient fixation in
the adrenal cortex was demonstrated in rats with
iodine-131-labeled corticotropin. There is no
information on the metabolism or excretion of
corticotropin.

The injection of 25 units slowly intravenously
over an 8-hour period produces an action similar
to that of 100 to 150 units of crude corticotropin
intramuscularly daily or 35 to 50 units of the
purified corticotropin intramuscularly daily in
equal portions every 6 to 8 hours (Gordon et al.,
Proc. Second Clinical ACTH Con}., Mote, Vol. 2,
1951, p. 30; Renold et al, New Eng. J. Med.,
1951, 244, 796). For an 8-hour injection period
intravenously, 20 U.S. P. units produces a maxi-
mum response. If 20 units is given over a longer
period of time a greater effect is obtained. Injec-
tion of a highly purified extract in a repository
dosage form has been tried successfully; the slow
prolonged absorption and the minimal tissue in-
activation produce a maximum effect. With this
long-acting gel dosage form, the maximum effect
is seen at 15 to 18 hours and action extends
beyond 24 hours. This gives the desired con-
tinuous stimulation of the adrenal gland but
cumulation of action is also a problem and the
difference between an effective and a toxic dose
becomes quite narrow. Some patients requiring
large doses of cortisone and experiencing untoward
effects may be managed with small doses of the
gel dosage form; typical dosage is 10 to 20 U.S.P.
units daily, or even every other day. Resistance
to the gel is rarely if ever encountered.

Therapeutic Uses. — Corticotropin injection
and repository corticotropin injection are used
for the same purposes in therapeutics as cortisone
acetate or hydrocortisone; the former prepara-
tions, however, cannot serve as replacement ther-
apy for adrenocortical secretion in patients with-
out adrenal glands or with diseased adrenal glands
since such patients are unable to respond to
corticotropic substances. Minor differences in
action remain to be fully evaluated. Corticotropin
needs to be administered parenterally; it acts
more rapidly than cortisone acetate, whether this
is given parenterally or orally. Corticotropin is
effective in instances of hypopituitarism, and it
does not cause atrophy of the suprarenal cortex,
as with prolonged use of cortisone or hydrocor-
tisone. On prolonged use allergic sensitization
develops to this protein-like corticotropic mate-
rial in some patients, with resultant decrease in
efficacy of the preparation. Insofar as cortico-
tropin increases formation of other suprarenal
hormones with androgenic and other actions there
are differences in the therapeutic effects of cor-
ticotropin as compared with those of cortisone or
hydrocortisone. Virilism, edema, hypertension,
etc., are perhaps more frequently associated with
corticotropin therapy. For a discussion of the
therapeutic applications of corticotropin see the
table and discussion under Cortisone Acetate.

Diagnostic Test for Adrenocortical In-

Part I

Corticotropin Injection 373

sufficien'CY. — Corticotropin is used to demon-
strate adrenocortical insufficiency in patients for
whom a clinical diagnosis is not definite, or to
recognize acute failure of cortical function in
patients with severe injury or infection, or to
distinguish between primary and secondary cor-
tical insufficiency. In this test corticotropin is
employed to stimulate the adrenal gland (Thorn
et al, J. Clin. Endocrinol., 1953, 13, 604). All
urine is collected and stored in a refrigerator dur-
ing the 24 hours preceding the test and a blood
eosinophil count is made just before the injection
of corticotropin, either as 25 units of repository
corticotropin injection given intramuscularly or
as 25 units of corticotropin injection given intra-
venously, after dilution with 500 ml. of sodium
chloride injection, slowly over a period of 8 hours.
The blood eosinophil count is repeated 8 to 10
hours after the intramuscular injection or after
the start of the intravenous infusion. The urine
is again collected for 24 hours after commencing
the injection. If spontaneous or cortisone-therapy-
induced adrenal atrophy is suspected, the injection
of corticotropin and the collection of urine and
determination of blood eosinophil count should
be repeated on the second and even the third day
since time may be required for an atrophic gland
to respond to stimulation (Renold et al., J. Clin.
Inv., 1952, 31, 657). The criteria of normal
adrenocortical function are: (a) a decrease in the
blood eosinophil count at 10 hours of 85 per cent
or more; (b) an increase in urinary 17-hydroxy-
corticoids (Reddy et al., Metabolism, 1952, 1,
511) of 10 to 15 mg. in the first 24 hours or about
20 mg. during the second 24 hours; and (c) a less
consistent and hence less diagnostic increase in
urinary 17-ketosteroids (Zimmermann, Ztschr.
physiol. Chem., 1935, 233, 257) of 4.4 (range,
0.9 to 19) mg. during the first 24 hours or 8.7
(range, 4.7 to 16) mg. during the second day.
These average figures were derived from study of
35 subjects. In 35 patients with Addison's disease
the decrease in eosinophil count was 30 per cent or
less and no significant increase in either 17-hy-
droxysteroids or 17-ketosteroids occurred (Thorn
et al., J. Clin. Endocrinol., 1953, 13, 604). In
cases of hypopituitarism or of adrenal atrophy
due to cortisone therapy, the response was poor
on the first day but approached normal after the
third daily injection. To be significant, the initial
eosinophil count must be at least 100 per cu. mm.
of blood; otherwise the errors incident to this
counting method prevent a valid interpretation of
the result of this test. Numerous counting meth-
ods have been recommended; seven procedures
are employed {J. A.M. A., 1953, 153, 1067; see
also reviews by Wright et al., Arch. Int. Med.,
1953, 92, 365 and Spiers, Blood, 1952, 7, 550).
Careful and consistent technic is essential with
this procedure. A normal excretion of 17-hydroxy-
corticoids or a normal concentration in the blood
plasma prior to the administration of cortico-
tropin excludes adrenocortical hypofunction from
the diagnosis. Chemical determination of the
conjugated and free 17-hydroxycorticoids depends
on extraction with butanol from acidified urine
and development of a color with a phenylhydra-
zine-sulfuric acid reagent. In cases of adreno-

cortical hyperfunction an increase in urinary ex-
cretion of 17-ketosteroids is often found but there
may be no increase in 17-hydroxycorticoid excre-
tion. The subcutaneous injection of epinephrine
(0.2 mg.) often causes a decrease in the eosinophil
count but it will not increase the excretion of
17-keto- or 17-hydroxy-corticosteroids in the urine
of normal or abnormal cases. Changes in eosino-
phils are nonspecific with epinephrine; they may
be related to the presence of allergic disorders, and
typical decreases in the eosinophil count have
been observed in adrenalectomized persons.

Toxicology. — With prolonged use of large
doses of corticotropin the same untoward effects
arise as in the case of cortisone, i.e., hyperadreno-
corticism (Cushing's syndrome) and, on discon-
tinuing use, hypoadrenocorticism (Addison's dis-
ease). The manifestations of Cushing's syndrome
are more frequent with the more sustained action
of the intramuscular repository dosage forms;
with slow intravenous injection of the small yet
effective doses during a period of 8 hours daily
there is less tendency to untoward effects. The
retention of sodium and water and the effects of
excessive androgenic action (acne and hirsutism")
are more marked with corticotropin than with
cortisone. As soon as the desired clinical improve-
ment is obtained the dose should be decreased.
On doses exceeding 100 units daily untoward
effects are common. In rats, adrenal hemorrhages
have been produced by excessive doses (Ingle,
Ann. Int. Med., 1951, 35, 652) but the continuous
intravenous injection for 10 days of therapeutic
doses in the human show no evidence of perma-
nent damage from overstimulation of the adrenal
gland. In impure preparations, significant vaso-
pressor and antidiuretic action arising from the
posterior lobe of the hypophysis may cause un-
toward effects. Most commercial and all official
preparations available have been amazingly free
of other pituitary hormones.

Allergic reactions occur especially with less
purified preparations. Immediate reactions in-
clude pruritus, urticaria, wheezing, angioneurotic
edema and rarely anaphylaxis (Wilson, Lancet,

1951, 2, 478). Delayed reactions include fever
and malaise (Renold et al., J. Clin. Endocrinol.,

1952, 12, 763) and are rare. Patients with adrenal
insufficiency, who often receive corticotropin as
a diagnostic test of adrenal function, react more
violently to any stress, including corticotropin,
and especially when given intravenously. However,
Thorn et al. experienced only 6 severe reactions
among several thousand doses. Two of these were
delayed responses in patients with Addison's dis-
ease. Three Addison's disease cases had severe
urticaria. One case experienced urticaria when
corticotropin was given at the end of a prolonged
course of cortisone therapy. All of these cases had
received corticotropin previously without unto-
ward effects and 3 received the highly purified
dosage form subsequently without incident. Pre-
cautions and contraindications are discussed under
cortisone. An immediate anaphylactoid reaction
to bovine corticotropin, terminating fatally 8 days
later, was reported by Hill and Swinburn {Lancet,
1954, 1, 1218).

Withdrawal of corticotropin, particularly after

374 Corticotropin Injection

Part I

prolonged use, must be conducted slowly to avoid
adrenal insufficiency. The daily dose should be
decreased slowly. A decrease of 5 units in each
dose daily every 3 to 5 days is a safe procedure
and the interval should also be lengthened, viz.,
from 6 to 8 and then 10 and 12 hours, etc. Adrenal
insufficiency is much less of a problem than after
prolonged employment of cortisone.

Dose. — The usual dose is 10 U.S. P. units intra-
muscularly every 6 hours for 4 doses daily or,
highly diluted with sodium chloride or 5 per cent
dextrose injection, by continuous intravenous in-
fusion over a period of 8 hours once daily; the
range of the total daily dose is 10 to 100 units. In
action the effect of 20 units of corticotropin in-
jection intravenously over a period of 8 hours
resembles that of 25 to 33 units given 3 or 4 times
daily intramuscularly or 7 units of repository
corticotropin injection administered intramuscu-
larly daily.

Labeling. — "Label Corticotropin Injection
which is recommended for use by intravenous
administration td show the potency found by the
intravenous method of assay as well as that found
by the subcutaneous method of assay." U.S.P.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass."
U.S.P.

Usual Sizes.— 200 U.S.P. Units in 5 ml. of
solution, and 10, 15, 25, and 40 U.S.P. Units in
the dry form.

REPOSITORY CORTICOTROPIN
INJECTION. U.S.P.

Corticotropin Gel

"Repository Corticotropin Injection is cortico-
tropin injection prepared in a vehicle which favors
prolongation of the therapeutic effect. It possesses
a potency of not less than 80 per cent and not
more than 125 per cent of that stated on the
label in U.S.P. Corticotropin Units. It may con-
tain a suitable antibacterial agent." U.S.P.

This dosage form of "purified" corticotropin is
commonly prepared in an aqueous medium con-
taining approximately 20 per cent of gelatin and
approximately 30 per cent of propylene glycol,
with 0.5 per cent of phenol added as an antibac-
terial agent. The solution is stable at room tem-
perature. It may solidify below room tempera-
ture but is readily liquefied by placing the con-
tainer in warm water.

Description. — "Repository Corticotropin In-
jection is a colorless or light straw-colored liquid
which may be quite viscid at room temperature.
It is odorless or has an odor of an antibacterial
agent." U.S.P.

The various requirements specified by the
U.S.P. for Corticotropin Injection are applicable
also to this dosage form.

Uses. — Repository corticotropin injection,
which is commonly prepared from "purified" cor-
ticotropin, has the actions described under Cortico-
tropin Injection. As mentioned there, this long-
acting gel dosage form produces maximum effect
in 15 to 18 hours, with action extending beyond
24 hours. Since the purified form of corticotropin
is used in preparing the gel there is little extra-

vascular inactivation of corticotropin, as is the
case when "crude" corticotropin is injected intra-
muscularly or subcutaneously.

Because of the difference in behavior of "crude"
and "purified" preparations of corticotropin when
used intramuscularly and when they are used
intravenously, and the possibility that confusion
may arise because of this difference, it is impera-
tive that users of corticotropin preparations recog-
nize which type of preparation is being used and
clearly understand the basis of standardization of
the preparation in order that proper dosage may
be established. The nature and magnitude of the
differences involved are explained in the mono-
graph on Corticotropin Injection, under Assay.
To minimize confusion the repository injection is
labeled in terms of clinical activity, as explained
in that monograph.

Toxicology. — For untoward effects, contra-
indications and precautions see under Cortico-
tropin Injection.

The usual dose of repository corticotropin in-
jection is 10 U.S.P. units intramuscularly (not
intravenously) daily, with a range of 10 to 100
U.S.P. units.

Labeling. — "Label Repository Corticotropin
Injection to indicate that it is not recommended
for intravenous administration." U.S.P.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass."
U.S.P.

Usual Sizes. — 5 ml. vials containing 10, 20,
or 40 U.S.P. units per ml.

CORTISONE ACETATE. U.S.P., LP.

CH20C0CH,
CO

"Cortisone Acetate is 21-acetoxy-17a-hydroxy-
3:11 :20-triketopregnene-4." LP.

Cortogen Acetate (Schering) ; Cortone Acetate {Sharp &
Dohme).

The hormone cortisone is one of the 28 or more
steroid components of the adrenal cortex (see
Adrenal Cortex Injection). It was isolated inde-
pendently by several groups of investigators (see
under History) and thus came to have such desig-
nations as Kendall's compound E, Winters teiner's
compound F, and Reichstein's substance Fa. Cor-
tisone is 17-hydroxy-ll-dehydrocorticosterone,
also called t^-pregnene-17o.,21-diol-3,ll,20-trione;
it differs from desoxycorticosterone. another offi-
cial adrenal cortex hormone, in having an oxygen
atom at the number 11 carbon atom instead of
two hydrogen atoms and also in having a hy-
droxyl group at the number 17 carbon atom
instead of a hydrogen atom.

Cortisone cannot be obtained in adequate
amounts from adrenal glands and must be pro-
duced by processes of synthesis from other ma-

Part I

Cortisone Acetate

375

terials. For a time it was made solely by a 32-step
synthesis from desoxycholic acid (Sarett, /. Biol.
Chem., 1946, 162, 630). Various other partial
syntheses of cortisone have been reported, start-
ing with such plant steroids as diosgenin, ergos-
terol, stigmasterol and hecogenin (J.A.C.S., 1951,
73, 4052, 5513). Starting with progesterone it is
possible by introduction of oxygen at carbon atom
11 through microbiological oxygenation using
molds of the Mucorales order to form lla-hy-
droxyprogesterone (J.A.C.S., 1952, 74, 1871),
which may be subsequently converted to cor-
tisone by nonbiological organic procedures (ibid.,
1953, 75, 1286). A total synthesis of cortisone,
starting with a condensation of benzoquinone and
ethoxypentadiene, has been reported by Sarett
et al. (J.A.C.S., 1952, 74, 4974); this synthesis
has practical possibilities.

Cortisone is used in medicine in the form of
the acetate ester, being esterified at the number
21 carbon atom; the ester has the advantage of
enhanced stability and, possibly, of prolonged
pharmacologic activity.

Description. — "Cortisone Acetate is a white
or practically white, odorless, crystalline powder.
It is stable in air and, when tested by the method
for Class la, melts at about 240° with some de-
composition. Cortisone Acetate is insoluble in
water. One Gm. dissolves in about 350 ml. of
alcohol, in 4 ml. of chloroform, in 30 ml. of
dioxane, and in 75 ml. of acetone." U.S.P.

The solubility of cortisone acetate has been
reported by Macek et al. (Science, 1952, 116,
399) to be as follows: in water, 0.02 mg. per ml.;
in human plasma, 0.16 mg. per ml.; in human
synovial fluid, 0.36 mg. per ml. The correspond-
ing solubilities of the free alcohol form of cor-
tisone are 0.28 mg., 0.75 mg., and 0.56 mg., per
ml., respectively, in the liquids mentioned.

Standards and Tests.— Identification. — (1)
A solution of cortisone acetate in alcohol, alka-
linized with tetramethylammonium hydroxide,
produces a red color with an alcohol solution of
triphenyltetrazolium chloride. (2) On heating a
methanol solution of cortisone acetate with a
sulfuric acid solution of phenylhydrazine a yellow
color is produced. (3) On saponifying cortisone
acetate with alcoholic potassium hydroxide T.S.,
then acidifying with sulfuric acid and heating, the
odor of ethyl acetate is observable. Specific rota-
tion.— Not less than + 208° and not more than
+ 217°, when determined in a dioxane solution
containing 100 mg. in 10 ml. and calculated on
the dried basis. Absorptivity. — The absorptivity
(1%, 1 cm.) at 238 mn, determined in a methanol
solution containing 0.01 mg. of cortisone acetate
in each ml. but calculated on the dried basis, is
390 ± 10. Loss on drying. — Not over 1 per cent,
when determined by drying in vacuum. Residue on
ignition. — The residue from 100 mg. is negligible.
Hydrocortisone. — A solution of 5 mg. of cortisone
acetate in 2 ml. of sulfuric acid is colorless at
first, becoming yellow in about a minute, but
remains free from green fluorescence when ex-
amined in reflected light (hydrocortisone becomes
yellow almost at once and shows a green fluo-
rescence). U.S.P.

Action. — The steroid cortisone has many and

striking physiological and pharmacological actions.
It is probably not the main endocrine substance
fabricated by the suprarenal gland but it is useful
in replacement therapy of adrenal insufficiency.
The dramatic relief of symptoms produced by
cortisone therapy of rheumatoid arthritis and
other hitherto intractable diseases led to its trial
for every symptom or disease recognized by man.
The extent of its effect on metabolism transcends
that of any previously known drug. Although cor-
tisone cures nothing, its marked anti-inflammatory,
antiallergic, and metabolism-modifying actions in
pharmacological doses are very useful, when care-
fully utilized, in a variety of diseases.

History. — Since Addison described the disease,
which now bears his name, characterized by de-
struction of the adrenal gland, there has been a
continuous interest in the function of this en-
docrine organ. Epinephrine was eventually isolated
from the medullary portion of the adrenal, and
this hormone came into general therapeutic use
as a sympathomimetic agent. The hyperfunction-
ing of the adrenal cortex in Cushing's syndrome,
and also the interrelation of the pituitary gland
and the adrenal cortex, have long been recog-
nized. The preparation of an active extract of
adrenal cortex, which maintained life and health
in adrenalectomized animals and also in patients
with Addison's disease, completed the demonstra-
tion of the essentiality of the cortical portion of
the adrenal. The relationship of the adrenal gland
to the syndrome of adaptation to stresses known
as the "alarm reaction" has been described (Selye,
/. Clin. Endocrinol., 1946, 6, 117), and the re-
semblance of certain common human diseases to
this reaction noted.

The adrenal cortex contains many steroid com-
pounds (see Adrenal Cortex Injection). These
steroids are sometimes classified according to
three general physiological actions which they pro-
duce: the mineralocorticoids, such as desoxycorti-
costerone, which are concerned with electrolyte
and fluid balance; the glucocorticoids, such as
cortisone, which have to do principally with
carbohydrate metabolism; the steroids, such as
testosterone, which are involved chiefly in protein
anabolism. Cortisone, independently identified as
a constituent of adrenal cortex by Kendall's group
(/. Biol. Chem., 1936, 114, 613), by Reichstein
(Helv. Chim. Acta, 1936, 19, 1107), and by Win-
tersteiner and Pfiffner (/. Biol. Chem., 1936, 116,
281), fails to maintain life in adrenalectomized
animals but it improves the ability of such ani-
mals to perform muscular work (Mason et al.,
ibid., 1936, 114, 613).

Following Hench's observations that pregnancy
(Proc. Mayo, 1938, 13, 161) and jaundice from
biliary obstruction or hepatitis (Ann. Int. Med.,
1934, 7, 1278) are potent antagonists of rheuma-
toid arthritis, he speculated that release of an
adrenocortical hormone may provide the amelio-
rating influence and on the recommendation of
Kendall tried the latter's compound E (cortisone)
on a patient with severe rheumatoid arthritis.
The rapid and striking improvement in the clinical
manifestations of the disease observed not only
in this patient but also in 13 others is now well
known (Hench et al., Proc. Mayo, 1949, 24, 181)

376

Cortisone Acetate

Part I

and has provided the stimulus for a most com-
prehensive program of research. The comparable
results obtained with adrenocorticotropic hormone
from anterior pituitary, known as corticotropin,
has resulted in a parallel investigation of that
compound.

The experimental and clinical studies with cor-
tisone and corticotropin which have been reported
are so numerous that it is impossible to refer to
more than a few of them in this work. Thom and
his associates (New Eng. J. Med., 1953. 248, 232,
284. 325. 369. 414. 588. 632; ibid., 1950. 242,
$24) have performed an excellent service in
organizing most of the data; reference may also
be made to Dorfman and Ungar's Metabolism of
Steroid Hormones, 1953. to the monograph on
Mechanism of Corticosteroid Action in Disease
Processes, published in Ann. N. Y. Acad. Sc,
1953. 56, 623-814. and to the review of Lieber-
man and Teich. Pharm. Rev., 1953. 5, 282-380.

Absorption. Intermediary Metabolism and
Excretion. — Absorption. — Since absorption of
the drug depends to a considerable extent on its
method of administration this subject is discussed
in the section on Routes of Administration.

Intermediary Metabolism. — Cortisone is prob-
ably a precursor or a metabolite of the chief
glycocorticoid of the adrenal cortex. It has been
found in both hog and beef adrenal tissue, in
normal human urine, in human placenta, and in
perfusates of corticotropin-treated adrenal glands
of animals. That acetate may serve as a precursor
has been demonstrated by conversion of carbon-
14-labeled acetate by hog adrenal tissue to hydro-
cortisone and cortisone. Cortisone is not found in
adrenal venous blood (Reich et al., J. Biol. Chem.,
1950, 187, 411) or in the peripheral blood of ani-
mals (Savard et al., Endocrinology, 1952. 50,
366). whereas hydrocortisone (compound F) is
found in both places and is the principal form
found in adrenal perfusates (Hechter et al., Re-
cent Progress in Hormone Research, 1951. 6, 215 ).
After intravenous injection cortisone disappears
rapidly from blood: in the dog 90 per cent dis-
appeared within 10 minutes. Based on analyses
of 17-hydroxycorticosteroids. cortisone is found
to disappear rapidly on perfusion through the
liver (Hechter et al., J. Clin. Endocrinol., 1952.
12, 935) but only slightly on passing through
muscle or kidney (Nelson. Tr. Third Conf. Ad-
renal Cortex, Josiah Macy Jr. Found.. 1952. p.
89). Based on assavs measuring glycogen deposi-
tion. Paschkis et al (Fed. Proc, 1951. 10, 101)
found that muscle, brain and liver brei inactivated
cortisone, but Louchart and Jailer (/. Clin. Endo-
crinol., 1951. 11, 771) did not observe inactivation
in blood, muscle or brain slices.

Excretion. — Xo information is available con-
cerning fecal excretion of cortisone. Urinary ex-
cretion is difficult to evaluate because of the pres-
ence of endogenous steroids. In Addison's disease
administration of cortisone results in an increase
in urinary 17-ketosteroids and of formaldehydo-
genic and reducing corticosteroids (Daughadav
et al., J. Clin. Endocrinol., 1948. 8, 166: Talbot
et al, J.Biol. Chem., 1945. 160, 535: Heard et al.,
ibid., 1946. 165, 699). In persons with normal
adrenal function large doses of cortisone result in

similar products in the urine (Sprague et al., Arch.
Int. Med., 1950, 85, 199) but the increased excre-
tion may not persist on continued administration.
On the relatively smaller dose of 50 to 100 mg.
of cortisone daily, the 17-ketosteroids in the urine
of the normal human actually decrease as a re-
sult of suppression of endogenous adrenal func-
tion. Androsterone and etiocholanolone. which in
the female are derived only from the adrenal, dis-
appear from the urine. The steroids are present
in the urine as glucuronides and ethereal sulfates,
and also as an unidentified conjugate (Cohen.
/. Biol. Chem., 1951. 192, 147: Lieberman and
Dobriner, Recent Progress hi Hormone Research.
1948, 3, 71). Steroids without oxygen at carbon
atom 11 do not increase in the urine. In the
female with acne and hirsutism as a result of large
doses of cortisone, androgenic activity is found in
the urine. In castrated, bilaterally adrenalecto-
mized patients with metastatic carcinoma of the
prostate, urinary androgen excretion parallels
the dose of cortisone even in large doses but the
amount of biologically active androgen present is
much less than that present in the urine of a nor-
mal male. Hydrocortisone administration produces
more androgen in the urine than does cortisone.
Small amounts of many other degradation prod-
ucts of cortisone have been identified in the urine
but the total accounts for only a small fraction of
the dose of cortisone administered. The fate of
most of a dose of cortisone is unknown.

Action on Metabolism. — Carbohydrate. — Cor-
tisone is capable of correcting the abnormalities
in carbohydrate metabolism in adrenal insuffi-
ciency, these including a subnormal fasting-blood-
sugar concentration, a decreased concentration of
glycogen in the liver but not in muscle, a decrease
in urinary nitrogen excretion, a high respiratory
quotient (indicating combustion of carbohydrate
rather than of fat), and an abnormal sensitivity
to insulin (Thom et al., J. Clin, /fro., 1940. 19,
813; Long et al., Endocrinology, 1940. 26, 309).
Cortisone stimulates gluconeogenesis from pro-
tein, carbohydrate (Welt et al., J. Biol. Chem.,
1952. 197, 57) and fat (Kinsell et al., J. Clin.
Endocrinol., 1952. 12, 945). It also inhibits the
utilization of carbohydrate in the body, as shown
by a decrease in the respiratory quotient and other
findings. The exact site of action, as on hexokinase.
etc.. remains to be determined.

Protein. — Cortisone corrects the decreased ni-
trogen excretion of adrenal insufficiency and in-
creases the excretion in normal persons. Studies
utilizing radioactive nitrogen-15-labeled glycine
indicate both stimulation of protein catabolism
and inhibition of anabolism (Hoberman. Yale J.
Biol. Med., 1950. 22, 341). although the net effect
can be minimized by ingestion of a high carbo-
hydrate or protein and potassium diet. Cortisone
causes increased excretion of uric acid in urine
(Sprague et al., Arch. Int. Med., 1950. 85, 199)
due to greater renal clearance rather than to in-
creased production.

Lipids. — The action of cortisone in fat metab-
olism requires further clarification. In Addison's
disease it causes a decrease in the respiratory
quotient and an increase in the concentration of
ketones in the blood, suggesting increased oxida-

Part I

Cortisone Acetate

377

tion of fat or increased conversion of fat to carbo-
hydrate (Thorn et al, Trans. A. Am. Phys., 1949,
62, 233). Animal studies are contradictory (Stoerk
and Porter. Proc. S. Exp. Biol. Med., 1950, 74,
65; Welt and Wilhelmi, Yale J. Biol. Med., 1950,
23, 99). In normal rats (Levin and Farber, Proc.
S. Exp. Biol. Med., 1950, 74, 758) and rabbits
(Kobernick and More, ibid., 602) it causes lipemia
and fatty infiltration of the liver. In various dis-
eases in humans Adlersberg et al. (J. Clin. Endo-
crinol., 1951, 11, 67) reported a questionable rise
in blood cholesterol and esters and also in phos-
pholipid, with a sharp decrease in the content of
neutral fat in blood serum.

Mucopolysaccharides. — The elevated levels of
mucopolysaccharides in blood serum, observed in
certain diseases, are variously influenced follow-
ing cortisone therapy. In acute disseminated lupus
erythematosus there is a decrease in hexosamine
concentration (Boas and Reiner, ibid., 890). In
rheumatic fever a decrease in the levels of glu-
cosamine-, non-glucosamine-, and albumin-poly-
saccharides accompanies clinical remission (Shetlar
et al., J. Lab. Clin. Med., 1952, 39, 372). In tissue
cultures derived from embryonic tissue or healing
wounds cortisone inhibits synthesis of chondroitin
sulfate (Layton, Proc. S. Exp. Biol Med., 1951,
76, 596). Injection into the synovial space in
cases of rheumatoid arthritis results in an in-
creased degree of polymerization of the hyaluronic
acid (Duff et al, J. Lab. Clin. Med., 1951, 38,
805); following systemic administration the
spreading action of hyaluronidase is inhibited
(Opsahl, Yale J. Biol. Med., 1949, 21, 255). This
latter action is due to an alteration in the sub-
strate rather than a direct antagonism of steroid
and enzyme (Seifter et al., Ann. N. Y. Acad. Sc,
1953, 56, 693). Systemic action also inhibits
absorption of a dye from the synovial space of
normal animals.

Enzymes. — Cortisone increases the concentra-
tion of blood serum glucuronidase (Cohen, ibid.,
1951, 44, 558). In animal studies the arginase
content of liver and kidney is increased by this
steroid (Kochkakian and Robertson, /. Biol.
Chem., 1951, 190, 481), while in the adrenalec-
tomized rat the depressed amino acid oxidase
activity of liver and the proline oxidase of kidney
are restored to normal (Umbreit, Ann. N. Y.
Acad. Sc, 1951, 54, 569). The gastric secretion
of pepsinogen is increased by cortisone (v.i.). It
is not known whether these effects are directly on
the enzyme or a result of alteration in the access
of substrate or of co-factors to the cells.

Inorganic Elements. — In adrenal insufficiency,
the characteristic and clinically significant loss of
sodium chloride and the retention of potassium is
best corrected by desoxycorticosterone ; cortisone
possesses about one-thirtieth to one-fiftieth of the
activity of desoxycorticosterone in reversing this
phenomenon in man and animals (Thorn et al.,
Science, 1941, 94, 348). Some cases of Addison's
disease can be maintained satisfactorily with a
high salt diet and 12.5 to 25 mg. of cortisone
daily while some patients following adrenalectomy
for hypertension do well on a high sodium chlo-
ride intake and 37.5 to 50 mg. of cortisone daily
(Thorn et al., Ann. Int. Med., 1952, 37, 972).

However, most cases of adrenal insufficiency re-
quire desoxycorticosterone to regulate electrolyte
metabolism. Actually, therapy of Addison's dis-
ease with a combination of cortisone and desoxy-
corticosterone may result in less retention of
sodium chloride than when the latter steroid is
used alone (Thorn et al., Trans. A. Am. Phys.,
1949, 62, 233). The action of cortisone is con-
ditioned considerably by the status of adrenal
function, the dose of desoxycorticosterone in use,
and the duration and route of cortisone adminis-
tration. Prolonged use of cortisone in these cases
of insufficiency results in retention of sodium
chloride (Sprague et al., Arch. Int. Med., 1950,
85, 199). Intramuscular injection of cortisone is
more effective in this respect than oral adminis-
tration. Intravenous injection of cortisone has an
action equal to that of desoxycorticosterone. De-
creased excretion of potassium may be related in
some patients to rapid storage of glycogen in the
liver as a result of cortisone therapy; under these
circumstances inorganic phosphorus may also be
retained.

In the individual with normal adrenal function
the action of cortisone on electrolytes is complex
and variable. Initially, a retention of sodium chlo-
ride and a loss of potassium is seen (Sprague et al.,
loc. cit.) which diminishes on continued use. An
increased excretion of phosphate and calcium is
usual (Eliel et al., Proc. Second ACTH Confer-
ence, Vol. 1, Mote, 1951, p. 196). The sum of
these several effects is a depletion of potassium
and phosphate in the cells of the body and a
migration of sodium into the cells. Prolonged use
of large doses of cortisone induces the changes
found in Cushing's syndrome of hyperadreno-
corticism (Wilson et al., J. Clin. Inv., 1940, 19,
701), i.e., hypochloremia and hypokalemia and
metabolic alkalosis in the blood, loss of potassium
and phosphate from the muscle cell, with or
without an increase in intracellular sodium.
Testosterone antagonizes this loss of potassium,
phosphate and calcium by its anabolic action on
protoplasm (Bartter et al., Pituitary- Adrenal
Function, A.A.A.S., 1950, p. 109). A decrease in
urinary magnesium concentration has been ob-
served and less blood serum iron reported (Cart-
wright et al, I. Clin. Inv., 1951, 30, 161).

Water. — The disturbance in water and electro-
lyte balance in Addison's disease was the first to
receive attention (Gaunt et al, Physiol. Rev.,
1949, 29, 281) because of the dry, inelastic skin
and other signs of dehydration in these patients.
Harrop {Bull Johns Hopkins Hosp., 1936, 59,
11) concluded that loss of sodium resulted in
hypotonicity of extracellular fluid with passage of
water into the cells of the body (see also Harrison
and Darrow, J. Clin. Inv., 1938, 17, 77). How-
ever, water and electrolyte changes are not always
parallel (Gaunt, /. Clin. Endocrinol, 1946, 6,
595). Swingle et al. {Am. J. Physiol, 1934, 108,
144) observed a greater shift in fluid than could
be explained on the basis of osmotic changes re-
sulting from loss of salt. Thorn and his associates
studied the volume and water content of the easily
accessible red blood cells and found that cell
volume increased and hemoglobin concentration
decreased in adrenal insufficiency. Harrop had

378

Cortisone Acetate

Part I

observed shrinkage of red blood cells, increased
hemoglobin concentration and excess water excre-
tion following use of adrenal cortical extract in
patients with Addison's disease. Cortisone exerts
the same action. This metabolic abnormality is
the basis of the "water-load test" in the diagnosis
of adrenal insufficiency (Robinson et al., Proc.
Mayo, 1941, 16, 577). In other words, in adrenal
insufficiency water is stored in the cells of the
body and does not reach the kidneys for excretion.
Other possible mechanisms for the failure to
excrete water seem to be excluded. The appear-
ance of the usual dilution of blood following the
ingestion of water (Slessor, /. Clin. Endocrinol.,

1951, 11, 700) and the failure to excrete fluid
administered intravenously (Lewis, Proc. Roy.
Soc. Med., 1952, 45, 63) indicate that poor ab-
sorption from the gastrointestinal tract is not the
explanation. Diuresis following cortisone therapy
occurs without a correlated change in renal glo-
merular filtration rate (Burston and Garrod, Clin.
Sc, 1952, 11, 12,9) and water excretion may not
improve despite restoration of normal glomerular
filtration with desoxycorticosterone. The sugges-
tion of increased antidiuretic hormone activity in
blood serum (Birnie et al., Endocrinol., 1950, 47,
1) and urine (Slessor, loc. cit.) due to increased
sensitivity of the tissues to such a hormone or to
decreased ability to inactivate it is questionable
because of several observations. Cases of Addi-
son's disease show normal sensitivity to the anti-
diuretic action of vasopressin injection; adminis-
tration of cortisone does not alter this response
(Chalmers and Lewis, Lancet, 1951, 2, 1158).
The diuresis in response to cortisone does not
occur in the absence of the pituitary gland in ani-
mals (Gaunt et al., Am. J. Physiol, 1937, 120,
532) or patients (Garrod and Burston, Clin. Sc,

1952, 11, 113). The theory that excessive renal
tubular reabsorption of water in adrenal insuffi-
ciency explains the failure to excrete water seems
unlikely since a decrease in the specific gravity of
the urine has been observed during failure of
diuresis. Studies of renal tubular reabsorption in-
dicate normal behavior in cases of Addison's dis-
ease (Reforzo-Membrives and Repetto, /. Clin.
Endocrinol, 1951, 11, 1454).

In cases with normal adrenal function, cortisone
increases extracellular fluid (Levitt and Bader,
Am. J. Med., 1951, 11, 715) and decreases intra-
cellular water with little change in total tissue
water (Eliel et al, 1951, loc. cit.). During the
first week or ten days of cortisone therapy there
is retention of sodium chloride but this does not
continue on further use of usual doses. Changes in
body fluid are usually correlated with renal glo-
merular filtration rate and there is no alteration
in sensitivity to the antidiuretic action of extracts
of the posterior lobe of the pituitary gland
(Rosenbaum et al, J. Clin. Inv., 1951. 30, 668).
A case of Cushing's syndrome was studied by
Thorn's group with the water-load test before and
after adrenalectomy and after cortisone therapy;
it was concluded that cortisone acts on the trans-
fer of water into cells regardless of any diuretic
action.

Action on Tissues. — Kidney. — In Addison's
disease, the severity of the azotemia, even though

extrarenal in origin, has long been recognized as
a criterion of the severity of the adrenal insuffi-
ciency. As already discussed, dehydration, hemo-
concentration, decreased plasma volume and de-
creased renal blood flow are responsible for inade-
quate renal function. A decrease in glomerular
filtration rate, a lesser decrease in renal plasma
flow and a decrease in filtration fraction occur
(Talbott et al, J. Clin. Inv., 1942, 21, 107;
Waterhouse and Keutmann, ibid., 1948, 27, 372).
These abnormalities are corrected by cortisone
therapy (Burston and Garrod. loc. cit.). The
action of cortisone or of desoxycorticosterone is
on the body fluids rather than directly on the
kidney (Pitts, Adrenal Cortex, Tr. Third Confer-
ence, New York. J. Macy Jr. Found.. 1952, p. 11)
although the ability to exchange hydrogen or am-
monium ion for sodium ion in the maintenance
of acid-base balance is impaired (Roemmelt et al,
Am. J. Physiol, 1949, 159, 124). Cortisone allevi-
ates this defect but to a much lesser extent than
does desoxycorticosterone (Roberts and Pitts.
Endocrinology, 1952, 50, 51). The loss of sodium
from the body in adrenal insufficiency, however,
is not due to failure of tubular reabsorption, since
the Addisonian patient is unable to excrete hyper-
tonic saline injected intravenously. This defect is
partially corrected by cortisone but not by desoxy-
corticosterone. Hence, it seems that cortisone is
able to modify towards normal either excessive
or insufficient renal tubular function. Perhaps it
acts in homeostasis.

In the patient with normal adrenal function,
cortisone causes an increased glomerular filtration
rate, a smaller increase in renal plasma flow, a
decrease in the venous blood hematocrit and an
increase in filtration fraction, but no change in
tubular function (when £-aminohippuric acid is
used for the test). Tubular reabsorption of sodium
is increased and when sodium is being retained
urinary excretion of potassium is increased. Gly-
cosuria may occur with or without a rise in the
blood sugar concentration as a result of increased
glomerular filtration or a decrease in tubular func-
tion (measured with glucose). An increased excre-
tion of uric acid and of phosphate in the urine
occurs independently of the changes in the con-
centrations in the blood as a result of increased
tubular secretion.

In humans, no benefit is observed with corti-
sone therapy in acute glomerular nephritis, acute
disseminated lupus erythematosus (Burnett et al,
New Eng. J. Med., 1950. 243, 1028) or peri-
arteritis nodosa (Thorn et al, Arch. Int. Med.,
1950, 86, 319) and it may aggravate the hyper-
tension or the azotemia in these patients.

Adrenal. — In doses of 50 to 75 mg. daily, corti-
sone suppresses adrenocortical secretion, as shown
by a decreased urinary excretion of 17-ketosteroids
and the Addisonian-collapse state which may fol-
low discontinuance of large doses of cortisone,
particularly by mouth, including weakness, fatigue,
hypotension, circulatory collapse, eosinophilia.
decreased excretion of both 17-ketosteroids and
formaldehvdogenic steroids in the urine and even
death (Fraser et al, I.A.M.A., 1952, 149, 1542).
After the use of cortisone, the administration of
corticotropin produces little or no decrease in the

Part I

Cortisone Acetate

379

blood eosinophil count or increase in the urinary
1 7-ketosteroid excretion which are commonly em-
ployed as tests of the response of the adrenal
cortex to stimulation by ACTH. Histologically,
cortisone therapy causes atrophy of the fascicular
and reticular layers of the adrenal cortex in ani-
mals and man (O'Donnell et al, Arch. Int. Med.,

1951, 88, 28) and there is less stainable lipid.
Pituitary. — Cortisone suppresses secretion of

corticotropin by the anterior lobe of the pituitary.
The atrophy of the adrenal cortex caused by cor-
tisone is prevented by simultaneous use of cor-
ticotropin (Sayers, Physiol. Rev., 1950, 30, 241).
The blood of patients with Cushing's syndrome
contains less corticotropic activity than normal.
Cortisone will prevent the usual response of the
adrenal cortex to stress, i.e., hypertrophy and de-
pletion of ascorbic acid and cholesterol. Larger
doses of cortisone are required to prevent deple-
tion of the adrenal cortex in response to more
severe forms of stress than to mild forms. The
poor response of patients with hypopituitarism to
corticotropin is similar to that of individuals after
a prolonged course of cortisone therapy. The
thyrotropic hormone of the pituitary gland seems
also to be depressed since there is less uptake of
iodine-131 by thyroid following cortisone therapy
(Frederickson et al., J. Clin. Endocrinol., 1952,
12, 541). However, hyperplasia of the beta cells
of the anterior hypophysis is found following cor-
tisone therapy, similar to that observed following
thyroidectomy (Halmi and Barker, Endocrinology,

1952, 51, 127), which has been interpreted to
indicate an increase in thyrotropic hormone for-
mation. The pituitary gonadotropin activity of the
urine is increased during use of cortisone (Sohval
and Softer, /. Clin. Endocrinol., 1951, 11, 677).
No effect has been recognized on the antidiuretic,
growth or diabetogenic hormones of the pituitary.
The bronze pigmentation of the skin common in
cases of Addison's disease has been ascribed to
activity of the intermediary lobe of the pituitary
gland (Johnsson and Hogberg, Nature, 1952, 169,
286) ; since the color fades during cortisone ther-
apy, inhibition of this lobe is suggested (Hall
et al,. J. Clin. Endocrinol., 1953, 13, 243).

Thyroid. — In cases of Addison's disease or in
individuals with normal adrenal function, use of
cortisone decreases the rate of uptake of radio-
active iodine by thyroid (Frederickson et al., loc.
cit.; Wolfson et al., J. Lab. Clin. Med., 1950, 36,
1005; Hill et al, J. Clin. Endocrinol, 1950, 10,
1375). The concentration of protein-bound iodine
in the blood is decreased also (Hardy et al, Am.
J. Med. Sc, 1950, 220, 290) but, as noted above,
the effect on the thyroid-stimulating hormone of
the pituitary requires further elucidation. In the
hypophysectomized rat, the action of thyroid-
stimulating hormone is inhibited by cortisone but
administration of cortisone alone in such animals
did not inhibit thyroid uptake of iodine-131
(Woodbury et al, J. Clin. Endocrinol, 1951, 11,
761). It seems clear that cortisone affects the
function of the thyroid gland but its effect on the
production of thyroid hormone requires further
evaluation (Albert et al, Endocrinology, 1952,
50, 324; Perry, ibid., 1951, 49, 284). In patients
with myxedema, cortisone seems to increase the

action of a given dose of thyroid (Hill et al, loc.
cit.; Lerman et al, J. Clin. Endocrinol, 1952, 12,
1306; Beierwaltes et al, 1950, 36, 799). However,
functioning adrenal cortex seems essential for full
metabolic action of thyroid (Wolfson et al, loc.
cit.).

Gonads. — No striking changes have been ob-
served with cortisone in humans. Irregular and
scanty menstruation, amenorrhea and loss of
libido occur in Cushing's syndrome and in some
patients receiving large doses of cortisone.

Pancreas. — Despite the definite effect of corti-
sone on the metabolism of carbohydrate, glyco-
suria and hyperglycemia rarely occur during
cortisone therapy except in persons with pre-
existent, if not recognized, mild cases of diabetes
mellitus. Patients with a family history of dia-
betes should be watched for this side effect
(Bookman et al, J. Clin. Endocrinol, 1952, 12,
945). On discontinuing cortisone, the defective
handling of carbohydrate in these cases disap-
pears. In Cushing's syndrome overt diabetes is
not common; of the 33 cases reviewed by Plotz
et al (Am. J. Path., 1950, 26, 709) 31 showed
an abnormal glucose tolerance and 9 had glyco-
suria but only 5 had clinical diabetes mellitus.
Pancreatitis and other pathological lesions are
frequently found in cases with Cushing's syn-
drome. Becker (Ann. Int. Med., 1952, 37, 273)
pointed out that the diabetes observed during cor-
tisone therapy resembles that found in the Kim-
melstiel-Wilson syndrome, with retinal capillary
aneurysms and failure to develop acidosis in the
absence of insulin. The capillary lesions were pro-
duced in rabbits by administration of cortisone
(see under discussion of Kidney above). An ex-
cessive secretion of the hyperglycemic-glyco-
genolytic factor from the alpha cells of the islets
of Langerhans (see under Insulin) has been postu-
lated (Dana et al, Bull. Johns Hopkins Hosp.,
1952, 90, 323). In Addison's disease complicated
by diabetes mellitus, cortisone therapy increases
the dose of insulin required but it also improves
the food intake, the body weight, and the exer-
cise tolerance, and minimizes the tendency to
hypoglycemic seizures. In other words, cortisone
aggravates the defect in carbohydrate metabolism
but the general improvement in the patient may
actually alleviate the diabetic disability.

Skin. — In Addison's disease, cortisone restores
hydration, as manifested by warmer, moister,
softer skin and increased growth of hair on the
extremities and the pubic region. With the re-
flectance spectrophotometer, a decrease in melanin
and melanoid pigment, and an increase in oxy-
hemoglobin, are seen after cortisone therapy (Hall
et al, J. Clin. Endocrinol, 1953, 13, 243). In
normal subjects, large doses of cortisone induce
the changes characteristic of Cushing's syndrome:
thinning of the skin with or without violaceous
striae, rounding of the face due to a peculiar and
characteristic deposit of fat, acne without sebor-
rhea (Brunsting et al, Arch. Dermat. Syph., 1951,
63, 29), keratosis pilaris and hirsutism. Albright
theorized that the skin changes were due to the
antianabolic action of cortisone on protein. In
patients with dermatoses, cortisone therapy causes
warmer, moister skin, increased blood flow, less

380

Cortisone Acetate

Part I

secretion of sebum and fat-soluble materials and
the more rapid absorption of intracutaneously
injected physiological saline solution (Sauer et al.,
Proc. Second ACTH Conference, Vol. 2, Mote,
1952, p. 529 J. Pigmentation of healed acute in-
flammatory lesions is marked in patients re-
ceiving cortisone and sites of cortisone pellet
implantation become brown but generalized pig-
mentation is rare. Lovell et al. {Brit. J. Exp.
Path., 1953, 34, 535) ascribed the slow resolu-
tion of bruises to impaired dispersion through
ground substance to lymphatics.

Detailed studies of the result of prolonged
topical application of cortisone to the skin of rats
have been reported by Baker and his associates
(Atiat. Rec, 1948, 102, 333; Endocrinology, 1950,
47, 234). The epidermis becomes thinner due to
fewer epithelial cells. There is inhibition of the
growth of hair and atrophy of the sebaceous
glands, with little if any systemic cortisone effect.
The dermis also becomes thinner due to a "melt-
ing" of collagen into a compact mass with fewer
fibroblasts, most of which contain pyknotic nuclei.
The fatty deposits disappear and there is less
ground substance which shows altered staining
characteristics. Elastic fibers seem unaffected.

Muscle. — The muscle weakness following ad-
renalectomy has provided a useful bioassay
method for the activity of steroid compounds
(Ingle and Kuizenga, Endocrinology, 1945, 36,
218). In Addison's disease the muscular weakness
is a striking symptom. In the exhaustion there is
also an element of circulatory failure. In correct-
ing the muscular deficiency, cortisone is much
more effective than desoxycorticosterone, corti-
costerone or dehydrocorticosterone. However, no
steroid or adrenal cortical extract fully restores
muscular strength or increases strength in persons
with normal adrenal function. In normal indi-
viduals cortisone may cause an increased excretion
of creatine but there is no change in the excre-
tion of preformed creatinine. The myotonic re-
sponse in cases of myotonia is often decreased
(Shy et al., J.A.M.A., 1950, 144, 1353). In
myasthenia gravis, improvement in muscle stamina
is reported (Torda and Wolff, /. Clin. Inv., 1949.
28, 1228) but some cases are aggravated by cor-
tisone therapy. In Cushing's syndrome and in pa-
tients receiving large doses of cortisone muscular
weakness is also a common finding. This may be
due to loss of potassium or to interference with
protein synthesis (Sprague et al., Arch. Int. Med.,
1950, 85, 199). Either an increase or a decrease
in the sodium-potassium ratio in the blood scrum
results in muscle weakness.

Bone. — As mentioned above, cortisone increases
excretion of calcium and phosphorus. The amount
of phosphate excreted is effected by alterations
in renal tubular function and the rate of storage
of glycogen in the liver but the calcium excreted
represents change in bone. Osteoporosis may de-
velop (Curtiss et al., J. A.M. A., 1954, 156, 467).
In Cushing's syndrome, Albright suggested that
the antianabolic action on bone is responsible for
the osteoporosis. Prolonged administration in ani-
mals results in decrease in cartilage cells, fewer
osteoblasts and hence less bone formation, in-
vasion of bone by connective tissue from the

marrow cavity and narrowed epiphyses (Winter
et al., Endocrinology, 1950, 47, 60). Pathologic
fractures have occurred in patients (Demartini et
al.,J.A.M.A., 1952, 149, 750; Teicher and Nelson.
J. Invest. Dermat., 1952, 19, 205). Cortisone
aggravates hypoparathyroid tetany (Moehlig and
Steinbach, J.A.M.A., 1954, 154, 42). However,
as an example of the importance of the net effect
of cortisone therapy on all tissues rather than the
single action on a specific tissue, Thorn et al.
{New Eng. J. Med., 1953, 248, 32 7) reported a
case of nontropical sprue with pathologic frac-
tures which failed to heal in spite of open reduc-
tion and immobilization of fragments with pins
until cortisone was given; the steatorrhea was
controlled, appetite improved, weight increased
and the fractures healed.

Joints. — In rheumatoid arthritis, the joint tem-
perature is decreased within 24 hours after intra-
articular injection of cortisone (Hollander et al.,
J.A.M.A., 1951, 147, 1629) and the chemistry of
the joint fluid returns toward normal. The in-
creased polymerization of hyaluronic acid and the
resulting increase in viscosity was mentioned
under Mucopolysaccharides above. However, hy-
drocortisone is more consistent in its favorable
effect on intraarticular injection.

Connective Tissue. — As discussed above under
Skin, cortisone acts on the connective tissue cells
and secondarily affects the fibers and the ground
substance (Baker, Pituitary-Adrenal Function,
A. A. A. S., 1950. p. 88). It inhibits fibril forma-
tion in tissue cultures (Sacerdote et al., Compt.
rend. soc. biol., 1951, 145, 1724) and delays fibro-
plasia in vivo regardless of the type of stimulus.
In large doses cortisone delays wound healing
(Ragan et al., Am. J. Med., 1949, 7, 741); this
has always been a problem in the management of
cases of Cushing's syndrome. Topical application
inhibits granulation tissue formation, fibroplasia,
vascularization and deposition of ground substance
(Baker and Whitaker, Endocrinology, 1950, 46,
544). Epithelial growth is not inhibited. After
injury, cortisone delays and minimizes traumatic
edema; the surface layer of fibrin and red blood
cells is thinner; leukocytes are fewer; fibroplasia
is delayed and the fiber bundles are abnormal;
there is an excessive degree of capillary dilatation
but vascularization of the injured area is delayed.
Adjacent tissues are thinned. Protein deficiency
aggravates these undesirable effects of cortisone
and should be corrected to avoid the formation
of decubitus ulcers (bed sores). Cortisone inhibits
adhesion formation due to the irritation of talc
on serous surfaces such as the pleura and peri-
toneum and increases the mobility of Dupuytren's
contracture of the hand (Baxter et al., Can. Med.
Assoc. J., 1950, 63, 540). This action has been
utilized to prevent adhesions and osteophyte for-
mation following arthroplastic operations. Keloids
were not dissipated (Ronchese and Kern, New
Eng. J. Med., 1954, 250, 238). In debilitating
diseases, the general improvement in appetite and
well-being may result in such improved nutrition
as to counteract the untoward effects on wound
healing and protein synthesis.

Elastic fibers are little affected by cortisone.
However, the reticular connective tissue cell.

Part I

Cortisone Acetate

381

which retains some of the multipotent embryonic
abilities in the adult tissues, is affected. Cortisone
causes disintegration of the reticular framework
of lymph nodes (Baker, Recent Progress in Hor-
mone Research, 1951, 7, 331). The reticular cells
become shrunken, with pyknotic nuclei. Lympho-
cyte and thymocyte formation is impaired (Baker
et al, Am. J. Anat., 1951, 88, 313). Splenic
phagocytosis is accelerated, according to Gordon
and Katsh (Ann. N. Y. Acad. Sc, 1949, 52, 1),
but depressed according to Spain et al. (Science,

1950, 112, 335).

Blood. — In Addison's disease, the hemoconcen-
tration has already been mentioned. Desoxycor-
ticosterone will correct this but cortisone is
needed to alter the normocytic anemia and the
leukopenia with relative lymphocytosis and eosin-
ophilia. In Cushing's syndrome there is usually a
decrease in the eosinophils and often a lympho-
penia; in some cases there is a polycythemia. The
characteristic decrease in eosinophils following
administration of cortisone seems to depend on
the concentration of the steroid in the blood
stream (Thorn et al., New Eng. J. Med., 1951,
245, 549; Kellgren and Janus, Brit. M. J., 1951,
2, 1183). Hence, eosinopenia is more readily pro-
duced by intravenous or oral administration than
by the more slowly absorbed intramuscular in-
jection (Sprague et al., Arch. Int. Med., 1950, 85,
199). The mechanism of this action is in contro-
versy. Following cortisone, degenerative changes
have been observed in eosinophils in blood and
in peritoneal exudates in rats (Padawer and
Gordon, /. Clin. Endocrinol., 1952, 12, 922).
Similar changes were observed in vitro (Muehrcke
et al., Science, 1952, 115, 377). Heparin neu-
tralizes this degenerative action in vitro and also
in vivo (Godlowski, Brit. M. J., 1951, 1, 854).
Increased segregation in the lungs and spleen was
suggested as the mechanism by Lanman et al.
(Blood, 1950, 5, 1099) but splenectomy does not
alter the eosinopenic response to cortisone (Hills
et al, ibid., 1948, 3, 755). Rosenthal et al. (Proc.
S. Exp. Biol. Med., 1950, 75, 740) observed an
increase in eosinophil count in human bone mar-
row as the blood eosinophil count decreased but
Gordon et al. (Endocrinology, 1951, 49, 497) did
not confirm this observation in mice nor did Root
and Andrews (Am. J. Med. Sc, 1953, 226, 304)
in man.

The lymphopenia after cortisone does not per-
sist on repeated use (Hills et al., loc. cit.) ; heparin
inhibits the lymphopenia (Godlowski, loc. cit.).
As in the case of the eosinophils, it is reported
that lymphocytes are destroyed in lymph nodes
(Dougherty and White, Endocrinology, 1944, 35,
1) and in tissue cultures (Feldman, ibid., 1950,
46, 552; Heilman, Proc. Mayo, 1945, 20, 318).
Baldridge et al. (Arch. Path., 1951, 51, 593),
however, did not confirm this observation and
reported that lymphocytes accumulated in the
bone marrow (see also Yoffey et al., Brit. M. J.,

1951, 1, 660). Lymphosarcoma and leukemia cells
are temporarily destroyed (Pearson and Eliel,
Recent Progress in Hormone Research, 1951, 6,
373). Neutrophils often increase in blood (Sprague
et al, loc. cit.; Finch et al, Blood, 1951, 6, 1034).
Large doses cause stimulation of neutrophil for-

mation in the bone marrow of the mouse (Quittner
et al, Blood, 1951, 6, 513).

Erythrocytes are increased in number following
cortisone and reticulocytes increase in a variety
of debilitating diseases such as rheumatoid arthri-
tis (Finch et al, loc. cit.) in those cases showing
clinical improvement. This suggests that the action
is on the disease process rather than directly on
the blood-forming tissues. Even in patients with
primary pernicious anemia reticulocytes increase
following cortisone therapy similar to but in lesser
degree than the response to active liver extracts;
polycythemia does not develop.

On the platelets in the blood and the mega-
karyocytes in the marrow cortisone has no effect
in normal subjects (Finch et al, loc. cit.). In
thrombopenic purpura there is no effect if the
marrow is hypoplastic or if the disease is due to
chemical poisoning or to roentgen irradiation. In
idiopathic thrombopenic purpura, the platelet
count may rise to normal (J.A.M.A., 1952, 149,
485) but the bleeding time returns to normal
prior to the rise in platelets. Cortisone may cause
cessation of abnormal bleeding without any change
in the thrombopenia in cases of aplastic anemia,
acute disseminated lupus erythematosus or leu-
kemia. Meyers et al. (Ann. Int. Med., 1952, 37,
352) found it useful in both idiopathic thrombo-
penic purpura and acquired hemolytic anemia.

Concerning coagulation of blood the reports are
contradictory. An increased incidence of thrombo-
embolic accidents has been reported in patients
receiving cortisone (Cosgriff, et al, Am. J. Med.,
1950, 9, 752) ; the coagulation time of five normal
subjects was shortened but the prothrombin time
and the heparin-like activity of the blood was
unaffected. However, Fahey (Proc. S. Exp. Biol.
Med., 1951, 77, 491) found no effect on blood
coagulation while Monto et al. (J. Lab. Clin. Med.,
1950, 36, 1008) described an initial prolongation
of coagulation time with an increase in heparin-
like activity, followed by a shortening of coagula-
tion after 24 hours in about half of the cases.

Cardiovascular . — The hypotension in Addison's
disease and the hypertension in Cushing's syn-
drome are of interest in relation to the unknown
etiology of essential hypertension (Perera, Bull
N. Y. Acad. Med., 1952, 28, 43). In cases of
essential hypertension the blood pressure decreases
if Addison's disease develops. Since the availa-
bility of cortisone and desoxycorticosterone made
it possible to maintain life and health in the
absence of adrenal glands, total (Thorn et al,
Ann. Int. Med., 1952, 37, 972) or subtotal
(Wolferth et al, ibid., 1951, 35, 8) adrenalectomy
has been performed in the management of severe
cases of essential hypertension. According to
Jeffers et al. (ibid., 1953, 39, 254) the indications
for adrenalectomy combined with sympathectomy
are : an average disastolic blood pressure in excess
of 120 mm. of mercury, failure to respond to
medical treatment, and evidences of progressive
vascular damage. The contraindications are: de-
ficient renal function as indicated by a blood urea
nitrogen of over 20 mg. per 100 ml., a cerebro-
vascular accident or a coronary occlusion during
the previous 6 months, age older than 55 years,
and inability to adhere to the postoperative

382

Cortisone Acetate

Part I

regimen. Among 82 patients treated in this man-
ner and followed for 1 to 33 months, 23 per cent
showed excellent improvement of their hyper-
tensive disease, 14 per cent had a fair response,
32 per cent a poor response, and 21 per cent died
from complications of their vascular disease. Im-
mediately following the operation the following
substitution therapy was used: 37.5 to 50 mg.
cortisone in divided dosage daily by mouth, 2 mg.
of desoxycorticosterone bucally, and 3 to 6 Gm.
of sodium chloride as enteric-coated tablets daily.
All of these doses were decreased according to
the response of the patient in subsequent weeks.
Although some excellent results have been ob-
tained for several months after this radical sur-
gery, sufficient time has not elapsed to evaluate
the long-term therapeutic results. Many studies in
experimental hypertension have been conducted
(Goldblatt, Ann. Int. Med., 1937, 11, 69; Turner
and Grollmann, Am. J. Physiol., 1951, 167, 462;
Perera et al, J. A.M. A., 1944, 125, 1030; Selye,
/. Clin. Endocrinol., 1946, 6, 117). The blood
pressure of the unilateral nephrectomized rat on
a high sodium and protein intake is increased by
cortisone. In experimental renal hypertension,
adrenalectomy is followed by a decrease in blood
pressure and use of cortisone substitution therapy
is followed by a rise in pressure (Gaudino, Rev.
Soc. argent, biol., 1944, 20, 470). In the nephritis
produced by cytotoxic serum in rats, cortisone
results in a rise of blood pressure either before
or after adrenalectomy (Knowlton et al., Proc. S.
Exp. Biol. Med., 1949, 72, 722). The arteritis
produced in animals by desoxycorticosterone is
inhibited by cortisone but the nephrosclerosis is
not prevented and the hypertension is aggravated
(Masson et al., Am. J. Med. Sc, 1952, 224, 175).
Studies of the effect of cortisone on the hyper-
tensinogen activity of the blood of humans showed
no changes and in dogs there was no change in
blood pressure even though the plasma hyper-
tensinogen level increased (Haynes et al., Am. J.
Physiol., 1953, 172, 265). The production of the
pathological lesions characteristic of the Kimmel-
stiel-Wilson syndrome with cortisone in animals
has been mentioned (see under Kidney).

In the vascular collapse of Addison's disease,
cortisone will correct the acute hypotension but
desoxycorticosterone is usually required for ade-
quate maintenance. In normal individuals, how-
ever, 50 to 150 mg. of cortisone daily does not
affect the blood pressure and even 500 mg. daily
causes hypertension in very few persons (Sprague
et al, Arch. Int. Med., 1950, 85, 199). In patients
with impaired renal function cortisone causes a
rise in blood pressure (Perera, Proc. S. Exp. Biol.
Med., 1951, 76, 583) just as it does in animals
(Perera et al, J. Clin. Inv., 1950, 29, 739). In
cases of congenital adrenal hyperplasia, the hyper-
tension is decreased by cortisone therapy (Wilkins
et al, I. Clin. Endocrinol, 1952, 12, 1015). In less
well characterized cases of human hypertension, a
hypotensive action of cortisone has been reported
(Perera et al, loc. cit.; Dunstan et al, Arch. Int.
Med., 1951, 87, 627).

On the peripheral circulation, increased capil-
lary resistance is reported after cortisone (Robson
and Duthie, Brit. M. J., 1950, 2, 971; Swingle

and Parkins, Am. J. Physiol, 1935, 134, 426).
The diffusion of intravenously injected dye into
a wound is inhibited by cortisone (Findlay and
Howes, New Eng. J. Med., 1952, 246, 597). How-
ever, vascular fragility is a characteristic of Cush-
ing's syndrome and the prolonged use of large
doses of cortisone has a similar action (Albright,
Harvey Lectures, 1942-3, p. 122). In hypertensive
human beings, the hypotensive response to ad-
ministration of tetraethylammonium chloride is
lessened by cortisone therapy but not by desoxy-
corticosterone (Brust et al, J. Clin. Inv., 1951,
30, 630). This action is not related to sodium
retention and is present even before the decrease
in blood eosinophil count indicates a full cortisone
effect. The increase in cutaneous blood flow
(Myers and Taylor, ibid., 1952, 31, 651) and the
changes in renal blood flow have been described.
Increase in hepatic blood flow and splanchnic
oxygen consumption has been reported.

With reference to lipids and atheromatosis, an
increase in plasma cholesterol occurs during use
of cortisone. A greater degree of atheromatosis
has been observed in chickens eating a high fat
and cholesterol diet if cortisone was also adminis-
tered (Stamler et al, Circulation, 1951, 4, 461).
Considerable lipoidosis of the intima and media
of the arteries of children who had received large
doses of cortisone for prolonged periods in the
treatment of such fatal conditions as leukemia has
been reported (Etheridge and Hoch-Ligeti, Am.
J. Path., 1952, 28, 315). But no change in the
lipoprotein macromolecules of the Sf 10-20 class
in the blood was found after months of therapy
with cortisone in humans (Bloom and Pierce,
Metabolism, 1952, 1, 155), although in rabbits
eating a high-fat and cholesterol diet the adminis-
tration of cortisone was followed by a decrease in
the Sf 40-80 class with accumulation of larger
molecules (Pierce and Bloom, ibid., 163).

On cardiac output, a slight decrease in normo-
tensive and rheumatoid arthritis cases (Horwitz
et al, Am. J. Med. Sc, 1951, 221, 669) and in a
hypertensive patient (Perera, Proc. S. Exp. Biol.
Med., 1951, 76, 583) has been reported; this
could be accounted for by a slower cardiac rate.
In Addison's disease, the electrocardiographic
changes — flat or inverted T waves, prolonged QT,
PR or QS intervals, low-voltage and depressed
S-T segments — are corrected by cortisone therapy
(Somerville et al, Medicine, 1951, 30, 43). In
Cushing's syndrome the PR interval tends to be
short. Perhaps the electrolyte changes — the so-
dium/potassium ratio in blood serum — are related
to these findings.

Gastrointestinal. — Both cortisone and desoxy-
corticosterone decrease the sodium and increase
the potassium concentration in saliva (Frawley
and Thorn, Proc. Second Clinical ACTH Conf.,
Vol. 1, Mote, 1951, p. 115). Following adrenalec-
tomy there is less acidity and increased mucin in
the fasting gastric secretion and the response to
vagal stimulation in terms of volume, acidity,
pepsin and rennin content is decreased. These
changes are corrected by adrenal cortical extract
(Tuerkischer and Wertheimer, /. Endocrinol,
1945, 4, 143). In the human with normal adrenal
function or in the patient with Addison's disease,

Part I

Cortisone Acetate

383

cortisone increases the fasting content and the
nocturnal secretion of acid and pepsin in the
gastric juice (Spiro et al., J. Lab. Clin. Med.,

1950, 35, 899; Gray et al, J.A.M.A., 1951, 147,
1529 and Gastroenterology, 1953, 25, 156). The
urinary excretion of uropepsin is increased to a
level comparable to that found in patients with
peptic ulcer. In patients with primary pernicious
anemia (atrophic gastritis) or following gastrec-
tomy, cortisone causes no increase in uropepsin.
However, the animal with a denervated gastric
pouch or the vagotomized human patient shows
a normal response to cortisone. Cortisone aggra-
vates cases of peptic ulcer (Gray et al., loc. cit.;
Kirsner et al., ibid., 1952, 20, 27). Hemorrhage,
perforation and reactivation of quiescent cases
have been observed. Perhaps cortisone is the
mechanism of the well-recognized deleterious
effect of psychic and other stresses in these pa-
tients. Uropepsin excretion seems to be a sensitive
index of adrenocortical function; it parallels ex-
cretion of the 17-hydroxycorticoids in the urine.
In patients with diseases of the liver, a slight
decrease in blood serum bilirubin is observed after
cortisone therapy (Havens et al., Metabolism,
1952, 1, 172), also the amount of bile aspirated
from a duodenal tube is increased. Except in non-
tropical sprue, where cortisone increases the gas-
trointestinal absorption of fat, protein and vita-
min A (Adlersberg et al., Gastroenterology, 1951,
19, 674), such studies in the normal or the patient
with adrenal insufficiency do not seem to have
been reported.

Nervous System. — In Cushing's syndrome de-
generative changes in the cells of several nuclei
of the hypothalamus are probably not the cause of
the syndrome, as was suspected at one time, since
such changes are produced by hyperadrenocor-
ticism (Castor et al., Proc. S. Exp. Biol. Med.,

1951, 76, 353). In Addison's disease, the charac-
teristic slow rhythm in the electroencephalogram
is corrected by 25 mg. of cortisone daily but not
by desoxycorticosterone or a high salt intake
(Lewis et al., Bull. Johns Hopkins Hosp., 1942,
70, 335). In Cushing's syndrome, or after large
doses of cortisone (Hoefer et al., J.A.M.A., 1950,
143, 620), abnormalities appear in the electro-
encephalogram which are not related to changes
in carbohydrate metabolism or to changes in mood
or behavior (Lidz et al., Psychosom. Med., 1952,
14, 363). In patients with disease of the central
nervous system under treatment with cortisone,
convulsions have been reported (Baehr and Soffer,
Bull. N. Y. Acad. Med., 1950, 26, 229). Cortisone
therapy lowers the threshold for seizures in elec-
troshock therapy (Woodbury, /. Clin. Endocrinol.,

1952, 12, 924). Studies of the possible analgesic
action of cortisone showed no differences in the
threshold for discomfort from radiant heat on the
skin, electrical current on the tooth or balloon
distention in the duodenum (Grokoest et al.,
J. Clin. Inv., 1951, 30, 644). In those cases of
Addison's disease with impaired mental concen-
tration, drowsiness or restlessness and insomnia,
cortisone produces greater improvement than
desoxycorticosterone. Some cases of Cushing's
syndrome show mental aberrations ranging from
irritability and depression to minor or major

psychoses (Plotz et al., Am. J. Med., 1952, 13,
597).

In some patients with rheumatoid arthritis and
other disorders alleviated by cortisone therapy,
mental and emotional disturbances have appeared
which in rare cases have been of serious magni-
tude. A sensation of fullness, heaviness or fuzzi-
ness in the frontal area of the head has been
common (Palmer, Am. J. Med., 1951, 10, 275).
Increased appetite, increase or loss of libido, and
euphoria are frequent. Although infrequent, nearly
all varieties of psychotic reactions have been re-
ported; often these seem to be exaggerations of
pre-existing behavior patterns (Brody, Psychosom.
Med., 1952, 14, 94). It has been suggested that
relief of symptoms in chronic illness may threaten
the existing neurotic adjustment of the individual
to the environment. Clark et al. (New Eng. J.
Med., 1952, 246, 205) described symptoms of
schizophrenia or of the affective psychoses (viz.,
manic-depressive), but in atypical patterns com-
pared to the naturally-occurring psychoses. Psy-
chiatric evaluation of patients prior to cortisone
therapy has failed to indicate those persons who
will respond with untoward psychotic symptoms.
Likewise no correlation with dose or duration of
treatment or degree of metabolic change induced
by the treatment has been found. Although symp-
toms have persisted for as long as two months
after discontinuing cortisone treatment, no perma-
nent effects nor any mental deterioration have
been reported (Lidz et al., loc. cit.). Psychiatric
observation of all cases treated in one medical
center during a period of four years (Fox et al.,
quoted by Thorn et al., New Eng. J. Med., 1953,
248, 334), concluded that the psychic effect of
cortisone represents the sum of three components:

(1) stimulation of biologic energy regardless of
relief of symptoms of the disease being treated;

(2) transference of instinctual energy from the
disease symptoms to the general interests of the
person; (3) unconscious phantasies regarding the
action of cortisone. In other words, the expres-
sion of the pre-existing personality was increased
and this was manifested by pleasant (euphoria)
or unpleasant (anxiety) stimulation or aggrava-
tion of a neurosis.

Growth of Certain Tissues and of the Whole
Organism. — Growth in children with Cushing's
syndrome is poor (Sprague, Vitamins and Hor-
mones, 1951, 9, 265). Cortisone suppresses growth
in young rats (Ingle et al., Endocrinology, 1946,
39, 52) and in mature normal (Winter et al., ibid.,
1950, 47, 60) or adrenalectomized rats (Wells
and Kendall, Proc. Mayo, 1940, 15, 324) even
though the intake of food is increased. Cortisone
will not sustain growth in immature, adrenal-
ectomized rats. It antagonizes the action of
somatotrophs hormone (growth) of the anterior
hypophysis (Becks et al., Endocrinology, 1944,
34, 305). Its depressant action on skin, connective
tissue and hematopoietic tissue has been described
(v.s.). Inhibition of certain types of growth in
plants has been reported (deRopp, Science, 1950,
112, 500). Transient inhibition of the growth of
tumors in animals of both epithelial (carcinoma)
and connective tissue (sarcoma) origin has been
produced in animals (Sugiura et al., Cancer Re-

3S4

Cortisone Acetate

Part I

search, 1950, 10, 244, and others). In humans,
good therapeutic results with lymphosarcoma,
leukemia, Hodgkins disease and plasma cell
myeloma have been numerous but the tumors
recur when cortisone is discontinued and the re-
sponse to a second course of treatment is usually
poor. Xathanson et al. (Symposium on Steroids in
Experimental and Cli?iical Practice, A. White.
1951, p. 379) conclude that the action is probably
on the environment rather than directly on the
neoplastic cell itself.

Anti-inflammatory Action. — With reference
to therapeutic use of cortisone in inflammatory
and allergic disorders a review of certain experi-
mental observations is pertinent. The patient with
Addison's disease is very vulnerable to any exoge-
nous stress. Cortisone therapy improves resistance
to the common mild stresses but the individual
is still not as adaptable as the person with normal
adrenal function. The pituitary-adrenal mecha-
nism is involved in the nonspecific resistance to
injury of any type. In fact, mobilization of cor-
tical steroids is the basis of the adaptation theory
of Selye (/. Clin. Endocrinol., 1946. 6, 117).
Cortisone therapy suppresses inflammation. In
rheumatoid arthritis, histological examination of
the synovial membrane after treatment with cor-
tisone shows fewer plasma cells and lymphocytes
and less edema, fibrin, necrosis and papillary
tufting (Hench et al., Proc. Mayo, 1949. 24, 181).
The inflammatory response to a variety of injuries
is suppressed: chemicals (Michael and Whorton.
Proc. S. Exp. Biol. Med., 1951. 76, 754; Woods
and Wood. Proc. Second Clinical ACTH Confer-
ence, Vol. 1. J. R. Mote. 1951, p. 455), foreign
protein (Long and Miles. Lancet, 1950. 1, 492;
Berthrong et al., Bull. Johns Hopkins Hosp., 1950,
86, 131) and bacteria (Kass and Finland. New
Eng. J. Med., 1951. 244, 464; Abernathy and
Spink. /. Clin. Inv., 1952. 31, 947). Microscopic
studies of the response to tuberculin in the rabbit-
ear-window, by Ebert and Barclay (Ann. Int.
Med., 1952. 37, 506). revealed that the systemic
action of cortisone inhibited the sticking of leuko-
cytes to the vascular endothelium, the alternating
vasoconstriction and vasodilatation, the hemocon-
centration. stasis, thrombosis, exudation and the
liquefaction of caseous material. Menkin (Fed.
Proc, 1951, 10, 91) reported that cortisone cor-
rected the increased capillary permeability found
in inflammation, as shown by diffusion of intra-
venously injected dye into the lesion. With ex-
perimental pneumococcal infections in rabbits,
Germuth et al. (Bull. Johns Hopkins Hosp., 1952,
91, 22) found fewer neutrophilic leukocytes in
the lesion despite the presence of neutrophilic
leukocytosis in the blood stream, less thrombosis
and necrosis of the blood vessels, more viable bac-
teria in a larger lesion and more bacteria in the
blood stream generally. Fewer mast cells were
found in the rabbits and also in humans (Asboe-
Hansen. Proc. S. Exp. Biol. Med., 1952. 80, 677).
In other words, cortisone inhibits inflammation
regardless of etiology, results in a greater spread-
ing of bacteria and interferes with the cellular
mechanisms of repair. It also diminishes fever,
toxemia and other systemic manifestations of in-
flammation. Unfortunatelv, cortisone has no bene-

ficial effect on the cause of inflammation. The
patient with rheumatoid arthritis relapses when
cortisone is discontinued. Perforation of a peptic
ulcer does not produce the usual signs of peri-
tonitis until death supervenes. Local infection
disseminates and becomes septicemia without the
usual diagnostic features. Tuberculosis spreads in
both animals and man (New Eng. J. Med., 1951,
245, 662). The local improvement in inflamma-
tion is often gratifying but the total result is
often tragic.

The clinical efficacy of cortisone in the control
of disorders of hypersensitivity is most valuable.
But the mechanism of the inhibition of allergic
phenomena is most confused. Conflicting reports
on the effect of cortisone on circulating antibody
have appeared (see Massell et al., Proc. Second
Clinical ACTH Conference, Vol. 1, J. R. Mote.
1951, 486; also Mirick. Bull. Johns Hopkins
Hosp., 1951, 88, 332). With very careful technic.
inhibition of the usual rise in antibody titer has
been demonstrated following administration of a
foreign protein (Bj0rneboe et al., J. Exp. Med.,

1951, 93, 37; Germuth et al., ibid., 1951, 94,
139 ) but cortisone seemed to have no influence on
the disappearance rate of administered antibody.
This suggests that cortisone inhibits synthesis of
antibody. The suppression of the active Arthus
phenomenon reported by Germuth et al. (loc. cit. )
and the failure to suppress the local, passive
Arthus reaction (Fischel, Bull. N. Y. Acad. Med.,
1950, 26, 255) is compatible with such a conclu-
sion. However, redistribution or increased rate of
degradation must be invoked to explain some ob-
servations on antibody titers in the blood (Fischel
et al., J. Immunol., 1949, 61, 89). In general,
cortisone does not prevent anaphylaxis, that is. it
does not prevent union of antigen and antibody.
However, reports of protection with large doses
have appeared (Nelson et al., Proc. S. Exp. Biol.
Med., 1950. 75, 181; Hoene et al, J. Allergy,

1952, 23, 343). Germuth (Am. J. Path., 1952. 28,
565) suggests that large doses suppress tissue
reactivity. Cortisone prevents actively induced
nephrotoxic nephritis from bovine gamma globulin
(Wedgwood et al., Proc. Second Clinical ACTH
Conference, Vol. 1, J. R. Mote, 1951, p. 108) and
from horse serum (Rich et al., Bull. Johns Hop-
kins Hosp., 1950. 87, 549) but it does not prevent
that induced passively with kidney antiserum
(Knowlton et al., Proc. S. Exp. Biol.' Med., 1949,
72, 722). The striking similarity of the pharma-
cological actions of histamine to the manifesta-
tions of anaphylaxis stimulated study of the effect
of cortisone (Rose. Recent Progress in Hormone
Research, 1952, 7, 375). Grob et al. (Bull. Joints
Hopkins Hosp., 1952. 90, 301) found no evidence
that corticotropin affected the response of the
body to histamine or the release of histamine in
the body despite the gratifying control of the
clinical symptoms of hypersensitivity. Large doses
of cortisone inhibit local allergic responses such
as the tuberculin reaction (Long and Favour.
ibid., 1950. 87, 186), allergic encephalomyelitis
in monkeys (Kabat et al., J. Immunol., 1952. 68,
265) and the Schwartzman reaction (Schwartz-
man et al., Proc. S. Exp. Biol. Med., 1950. 75,
175). In an excellent review of this complicated

Part I

Cortisone Acetate

385

situation, Fischel (Tr. Third Conf. Connective
Tissue, C. Ragan, New York, Josiah Macy, Jr.
Found., 1952, p. 117) concluded that the clinical
effect of cortisone in disorders of hypersensitivity
is probably due to alteration in tissue reactivity
produced by cortisone, comparable to its action
towards inflammation. It is pointed out that skin
hypersensitivity to a specific allergen persists
even though the allergic symptoms are controlled
in the patient. Hence, any inhibition of antibody
synthesis produced by cortisone represents a
trivial fraction of the total antibody in the body.

The clinical efficacy of cortisone is well estab-
lished in hay fever (Koelsche et al., Ann. Allergy,
1951, 9, 573), bronchial asthma (Evans and
Rackemann, Arch. Int. Med., 1952, 90, 96) and
allergic dermatoses (Lever, New Eng. J. Med.,
1951, 245, 359). In plastic surgery, cortisone
minimizes the postoperative edema and ecchymosis
and perhaps the degree of fibrosis (Goldman et al.,
Eye, Ear, Nose & Throat Monthly, Oct. 1952).
Cornbleet (/. Invest. Dermat., 1953, 21, 273)
observed that 2.5 mg. of cortisone acetate added
to solutions for subcutaneous or intramuscular
injection, which are usually quite painful, relieves
the discomfort by virtue of its anti-inflammatory
action rather than any local anesthetic-like action.

Diagnosis of Abnormal Adrenal Function.
— Because of the predominance of the disturbance
of electrolyte balance in Addison's disease (ad-
renal cortical insufficiency) the clinical and labo-
ratory criteria of this disease are presented under
desoxycorticosterone acetate (q.v.), which is the
most active available mineralocorticoid. As already
mentioned, cortisone is valuable in replacement
therapy of this endocrine insufficiency condition.
Measurement of the response of the adrenal cortex
to stimulation is discussed under corticotropin;
this provides the most specific test of the func-
tional ability of the adrenal cortex.

The characteristics of hyperadrenocorticism
(Cushing's syndrome) are more predominantly
those of excessive action of cortisone and will be
discussed here. Cushing's syndrome includes: "a
distinctive habitus characterized by obesity or
an abnormal distribution of fat and wasting of
muscles so that the face, neck and trunk appear
obese and the extremities thin; muscular weak-
ness; hypertension; osteoporosis; amenorrhea or
impotence; hirsutism and acne of some degree in
the absence of other evidences of virilization;
thin skin with distinctive purplish striations and
a tendency to ecchymosis; and a cervicodorsal
fat pad" (Sprague et al., J.A.M.A., 1953, 151,
629). The syndrome does not refer to obese
women with hirsutism and menstrual abnormali-
ties in the absence of definite evidence of hyper-
function of the adrenal cortex. A variety of endo-
crine lesions has been found in cases with
Cushing's syndrome, including the basophilic ade-
noma of the anterior portion of the pituitary
gland in the cases initially reported by Cushing,
degenerative changes in these basophilic cells of
the pituitary, tumors of the thymus gland, tumor
or hyperplasia of the adrenal cortex and an ad-
renal-cortical-like tumor of the ovary; it is clear,
however, that excessive action of the hormones
of the adrenal cortex is common to all of these

anatomical lesions. The metabolic and tissue ab-
normalities have been described (v.s.). The prac-
tical clinical differentiation between tumor and
hyperplasia of the adrenal cortex is often suffi-
ciently difficult that Sprague et al. (loc. cit.)
recommend surgical exploration of the adrenal
glands in all suspected cases. An increase in the
urinary excretion of 17-ketosteroids is present in
these cases; Engstrom (Am. Pract. Dig. Treat.,
1952, 3, 626) lists the following approximate
amounts excreted in mg. per 24 hours: for normal
men, 7 to 25 (average 15); normal women, 5 to
17 (average 10); Addisonian men, 1 to 5 ; Addi-
sonian women, less than 2 ; Cushing's syndrome
with adrenal tumor, 30 to 1000; Cushing's syn-
drome without adrenal tumor, 8 to 40; adreno-
genital syndrome with adrenal tumor, 30 to 1000;
adrenogenital syndrome without adrenal tumor,
up to 120. Unfortunately diagnostic usefulness is
limited because many serious, chronic diseases
which may simulate Addison's disease clinically
often show a subnormal excretion and in the cases
of Cushing's syndrome studied by Sprague et al.
there was considerable overlapping in the findings
in those cases with tumor as compared with those
without tumor. Jailer {Med. Clin. North America,
1952, 36, 757) discussed the difficulties in inter-
preting the significance of the 17-ketosteroid ex-
cretion in urine since these steroids are derived
not only from the adrenals but also from the
testes or ovaries. It is suggested that these pa-
tients fail to convert 17-hydroxyprogesterone to
hydrocortisone, with resultant excess androgenic
and deficient mineralocorticoid and glucocorticoid
action. In the case of urinary formaldehydogenic
steroids, Sprague et al. were likewise unable to
find sufficient differences between cases with ad-
renal tumor or simple hyperplasia to have diag-
nostic value. However, Thorn et al. (New Eng. J .
Med., 1953, 248, 634) confirmed the report that
daily intramuscular injection of 50 to 100 mg. of
cortisone for 7 to 14 days produces a significant
decrease in the increased urinary excretion of
17-ketosteroids in cases of adrenal hyperplasia but
fails to result in any depression in cases with
tumor. At any rate the availability of cortisone
has made it possible to carry these patients
through the heretofore fatal period of postopera-
tive adrenal insufficiency following removal of an
hyperfunctioning tumor or after subtotal adren-
alectomy in cases of hyperplasia. Since the cause
in cases of hyperplasia must exist elsewhere in
the body, the possibility of relapse after subtotal
adrenalectomy remains and search for more spe-
cific therapy continues. The results with roentgen
therapy directed at the pituitary gland are difficult
to evaluate and hypophysectomy causes more
disability than it cures.

The adrenogenital syndrome due to hyperplasia
of the adrenal cortex, although infrequent, calls
for brief discussion because of the successful use
of cortisone in its management by Wilkins et al.
(J. Clin. Endocrinol., 1952, 12, 257). Among
the causes of female pseudohermaphroditism is
congenital adrenal hyperplasia, which may be
recognized by increased excretion of urinary 17-
ketosteroids, accelerated growth and osseous de-
velopment, and precocious development of sexual

386

Cortisone Acetate

Part I

hair. This results from excessive formation of
adrenal androgen in the condition. Females de-
veloping the syndrome postnatally show viriliza-
tion at an early age; the increase in 17-ketosteroids
in the urine distinguishes these cases from those
of simple constitutional hirsutism. In postpuberal
females a differential diagnosis between hyper-
plasia and tumor must be made, as in the instance
of Cushing's syndrome. In the male child, adrenal
hyperplasia results in precocious puberty, which
must be differentiated from other causes, such as
pituitary or testicular tumor; there is also an
abnormally large urinary 17-ketosteroid excretion.
Cortisone is used successfully in treatment of this
syndrome. Following daily intramuscular adminis-
tration of 25 mg. (for children under 2 years of
age) or of 50 mg. (for children over 2 years of
age) of cortisone for 5 to 10 days to produce
rapid suppression of adrenal cortical function, an
oral maintenance dose is selected on the basis of
a determination of urinary 17-ketosteroid excre-
tion; for patients over 8 years of age the desired
excretory level is' 4 to 6 mg. of 17-ketosteroids
daily; for infants under 2 years 0.5 mg. daily is
satisfactory. The immediate results with cortisone
have been good; hirsutism, abnormal menstrua-
tion and breast development, hypertension, and
pigmentation have been corrected. In many of
these cases a salt intake of 3 to 5 Gm. daily, and
administration of desoxycorticosterone acetate, are
required, particularly during the initial phase of
cortisone therapy (Crigler et al., Pediatrics, 1952,
10, 397).

Therapeutic Uses. — Cortisone has been tried
in the treatment of practically every disorder
known to mankind. Considering its many meta-
bolic, physiologic and pharmacologic actions,

many therapeutic actions exist. Except as replace-
ment therapy in instances of adrenal or pituitary
insufficiency, cortisone does not provide a biologic
cure for any known disease. However, cortisone
(and corticotropin and hydrocortisone) provide
nonspecific and at least temporary control of
many inflammatory, allergic or metabolic dis-
orders. These drugs must be used cautiously
and with understanding. In using cortisone (or
hydrocortisone or corticotropin) to correct an
abnormality, the physician must not forget the
other effects which are induced in the patient or
the modification in the usual response to adreno-
corticoid therapy which may be caused by the
particular disease under treatment. These com-
pounds are very useful in therapeutics, but they
are also dangerous drugs and often the benefit to
be expected must be weighed against the liability
of damage from their use. The accompanying
table lists most of the more common uses of cor-
tisone, with a reference to at least one report for
the reader desirous of obtaining detailed informa-
tion. Philosophically, the therapeutic uses of
adrenocorticoid therapy may be classified into:
(a) life-saving indications — as in acutely fatal
conditions such as pemphigus vulgaris or thrombo-
cytopenic purpura; (b) organ-saving — as in cer-
tain destructive inflammatory diseases of the eye;
(c) symptom-saving — as in the relief of tempo-
rary, potentially dangerous, acute discomfort due
to self-limited inflammatory or allergic disorders
such as intractable bronchial asthma, contact
dermatitis, early toxemic response to the use
of appropriate antibiotics in typhoid fever or
brucellosis, etc.; (d) disability-postponing — as in
the mitigation of destructive and fibrotic changes
in the articular tissues in rheumatoid arthritis.

Therapeutic Uses (In Pharmacologic Doses) of
CORTISONE (E), HYDROCORTISONE (F) AND CORTICOTROPIN (ACTH)

Condition

Number of Cases
Treated Responded

Treatment

Anemia, Aplastic or Hypoplastic (1, la)
Hemolytic (la, 2)
Refractory (lb)
Arthritis, Hypertrophic (Osteo-) (3, 4, 5)
1280 joints injected
Rheumatoid (3, 4, 5, 9)

2419 joints injected
Rheumatoid (6, 7, 8)
Rheumatoid (10)
Rheumatoid (11)
Asthma (12-19)
(14-21)
(lc, 22)
(23)
(ld-lf)

Bell's Palsy (24)
Beryllium Granuloma, Skin (80)
Brucellosis, Acute (72)
Burns (lg, lh, 77a)

Bursitis (3, 4, 25, 26)

E or ACTH

289

—

F intraarticular

—

1106

296

—

F intraarticular

—

2271

E or ACTH intramuscular

F oral

ACTH intravenous

135

117

129

115

ACTH

ACTH Gel

E aerosol

138

E or ACTH

E ointment

E and antibiotic

ACTH (not generally ac-
cepted)

F intrabursal, E, F or
ACTH

Cystitis, Interstitial (li)

ACTH or E

Part I

Cortisone Acetate

387

Condition

Number of Cases
Treated Responded

Treatment

Dermatitis, Atopic (le, lj, 27)
Exfoliative (lj, 11)
Herpetiformis (lj)
Lichenoid (lj, 27)
Venenata (rhus) (43)

Dermatomyositis (28)

Drug Reactions (lc, le, 79) (penicillin, etc.)

gold (79, 84)

hydralazine (86), iodide (75)

Eczema (lj, 66)

Erythema Multiforme Bullosum (Ik)

Exudativum (87)

Gout (4, 11, lm)

Guillain-Barre Syndrome (77)

Hay Fever (lc, 22)
Hepatitis (In, 29-31, 78)
Herpes Zoster (lj)
Hodgkin's Disease (la, lj, lo)
Hyperemesis Gravidarum (32, 64)
Hypoglycemia, Spontaneous (lp)

Leukemia (la, lo, lq, 73)

Leukemia Cutis (lj)

Lichen Planus (lj)

Lupus Erythematosus Disseminatus (1, lc, lj,

Ik, lr, 4, 28, 33-36, 74)
Lymphosarcoma (la, lo, 37)

Mononucleosis, Infectious (la, 38)

Multiple Sclerosis (Is)

Myasthenia Gravis (It, 39)

Mycosis Fungoides (lj)

Myeloma, Multiple (Plasma Cell) (lo, lu, 37)

Myotonic Dystrophy (33)

Nephrotic Syndrome (lv, 11, 40, 41, 65, 69)

Ophthalmic Disorders :

Burns, Corneal (42)

Choroiditis, Chorioretinitis (lw, lx, 42)

Conjunctivitis, Blepharitis, Allergic (lw)

Bacterial (42)

Episcleritis, Scleritis (42)

Herpes Zoster (42)

Iridocyclitis (lw, lx, 42)

Iritis (42, 44)

Keratitis & Corneal Ulcer (lw, lx, 42)

Macular Disease (lw, lx)

Neuritis, Optic (lw, lx, 42)

Neuritis, Retrobulbar (lx)

Retinitis Pigmentosa (lx)

Retrolental Fibroplasia (lx, 42)

Sympathetic Ophthalmia (88)

Uveitis (lx, 42, 44)

Uveitis, Granulomatous (44)
Osteitis, Pubis (ly)

Paget's Disease of Bone (76)
Panniculitis (45)
Periarteritis Nodosa (lc, 4, 46)
Pemphigus Foliaceus or Vegetans (lj)
Pemphigus Vulgaris (lj, Ik, 27, 28, 47)
Pruritus Ani and Vulvae (68)

E or ACTH

E ointment

E or F ointment (not con

firmed) (85)
E or ACTH

E or ACTH

ACTH i. m., i. v., F intra
articular

ACTH

ACTH Gel

E or ACTH

ACTH

E or ACTH

ACTH

282

171

E or ACTH

ACTH

118

106

E, F or ACTH

E or ACTH

ACTH

E or ACTH

135

E or ACTH

4
27

4
21

E topical
E or ACTH

E or ACTH

0
6
3

E topical
E topical
E

E or ACTH

42
7

37
4

E topical
E or ACTH

E or ACTH

ACTH

E or ACTH

3
3

0
3

E subconjunctival
ACTH

ACTH

E or ACTH

E ointment

388

Cortisone Acetate

Part I

Condition

Number of Cases
Treated Responded

Treatment

Psoriasis (lj, Ik. 11. i

Pulmonary Fibrosis, Beryllium or Silica ( 1L t

Purpura. Thrombocytopenic (1. la. 48-50, 81)

Reiter's Syndrome (51-53)
Rheumatic Carditis (lz. laa. 54)
Rheumatic Fever (lab, 5

Sarcoidosis. Boecks (lj. 11. 89)
Sarcoma, reticulum-cell (lj)
Serum Sickness (79)
Sclerema Neonatorum (82)
Scleroderma (lj, Ik)
Shoulder-Hand Syndrome (lac. 4)
Spondylitis. Rheumatoid (90)
Sprue (56. 57)

Tetanus (71)
Thyroiditis (58-60)
Trichinosis (61 >
Tuberculous Meningitis (70)
Typhoid or Paratyphoid (lad)

Ulcerative Colitis (lae. 11. 62. 67 >
Urticaria (Id, le)

Venomous Poison Bites (snakes, etc.) (laf, 83)

Bibliography for reference numbers in table

1. Proc. Second Clinical ACTH Conference,
Vol. 2. J. R. Mote. Philadelphia. Blakiston. 1951:
Bethell et al., pp. 173. 179, 180; la. Rosenthal
et al., p. 259; lb. Hill et al, p. 181: lc. Howard,
p. 20; Id. Rose et al., p. 414; le. Cooke, p. 417;
If. Shulman et al., p. 401; lg. Whitelaw et al.,
p. 310; lh. Adams et al., pp. 322 and 532;
li. Weaver et al., pp. 507 and 515 (see also Dees.
/. Urol., 1953. 69, 496); lj. Sauer et al.. p. 529;
Ik. Lever et al., pp. 541 and 544; 1L. Kennedy
et al., pp. 449 and 456: lm. Hollander et al.,
p. 122; In. Proc. First Clinical ACTH Confer-
ence, J. R. Mote. Philadelphia. Blakiston. 1950.
pp. 505 and 509; lo. Proc. Second Clinical ACTH
Conference (v.s.), Farber et al., pp. 226. 230 and
231; lp. McQuarrie et al., p. 69; lq. Schulman.
p. 281; lr. Softer et al.. p. 6S0; Is. Glaser et al.,
p. 141; It. Torda et al., p. 126; lu. Engle et al.,
p. 209; lv. Famsworth et al., p. 149; lw. Thorpse.
p. 467; lx. Gordon et al., p. 457; ly. Whitmore
et al., p. 516: lz. McEwen. p. 675; laa. Wilson
et al.,p. 677: lab. Fleet, p. 671; lac. Steinbrocker
et al., p. 706 (see also J.A.M.A.. 1953. 153, VSS I :
lad. Roche, p. 373; lae. Halsted et al., pp. 489
and 500; laf. Cluxton. p. 445.

2. Rosenthal et al.. Lancet, 1952. 1, 1135.

3. Ramsev et al., Missouri Med., 1953, 50,
604.

4. Brown et al.. Am. J. Med., 1953. 15, 656.

5. Boland, Calif. & West. Med., 1952. 77, 1.

6. Hench et al., Arch. Int. Med., 1950. 85,
545.

7. Thorn et al, New Eng. J. Med., 1949. 241,
529.

8. Boland et al., J. A.M. A., 1949. 141, 301.

9. Kersley et al., Lancet, 1952, 2, 269.

5
31

13
49
18

38
2
6
2
3
9

27
5
3

107
10

6 E or ACTH

5 E or ACTH
28 E or ACTH

11 E or ACTH

49 E or ACTH

10 E or ACTH

24 E or ACTH

1 ACTH

6 ACTH. E or F

2 ACTH

1 E or ACTH

4 E. F or ACTH

— see Arthritis. Rheumatoid
9 E or ACTH

11 E orallv and Antitoxin

5 E or ACTH

3 E or ACTH

— ACTH and chemotherapy

2 E or ACTH and chemo-

therapy

76 E or ACTH

4 E or ACTH

5 ACTH or E and Antivenin

10. Boland et al., J. A.M. A., 1952, 148, 981.

11. Revnold et al., New Eng. J. Med., 1951,
244, 796.

12. Schwartz et al, J.A.M.A., 1951. 147, 1734.

13. Lowell et al., J. Allergy, 1953. 24, 112.

14. Friedlaender et al., Ann. Allergy, 1951. 9,
588.

15. Carey et al., Bull. Johns Hopkins Hosp.,
1950. 87, 387.

16. Feinberg «-: a/., /. Allergy, 1951. 22, 195.

17. Baldwin et al, ibid., 1952. 23, 15.

18. Franklin et al. ibid., 21.

19. Cooke et al, ibid., 1951. 22, 211.

20. Segal et al, Ann. Allergy, 1950. 8, 786.

21. McCombs et al, Bull New Eng. M. Center,
1950. 12, 187.

22. Rov et al, J. Allergy, 1953. 24, 506.

23. Gelfand. New Eng. J. Med., 1951. 245, 293.

24. Rothendler. Am. J. Med. Sc, 1953, 225,
358.

25. Stein et al. Am. J. Surg., 1953. 85, 215.

26. Stein et al., ibid., 86, 123.

27. Sulzberger et al, J. Invest. Dermat., 1952,
19. 101.

28. Lever. New Eng. J. Med., 1951. 245, 359.

29. Havens et al, Metabolism, 1952. 1, 172.

30. Butt et al, J. Lab. Clin. Med.. 1951, 37,
870.

31. Evans et al, Ann. Int. Med., 1953.38, 1115.

32. Wells. Am. J. Obst. Gyn., 1953. 66, 598.

33. Shy etal., J.A.M.A., 1950. 144, 1353.

34. Newman et al, J. Invest. Dermat., 1951,
17, 3.

35. Baehr et al, Btdl. N. Y. Acad. Med., 1950,
26, 229.

36. Cohen et al, Lancet, 1953, 2, 305.

37. Pearson et al, Recent Progress in Hormone
Research, 1951, 6, 373.

Part I

Cortisone Acetate

389

38. Doran et al, Ann. Int. Med., 1953, 38,
1058.

39. Torda et al, J. Clin. Inv., 1949, 28, 1228.

40. Thorn et al, Arch. Int. Med., 1950, 86, 319.

41. Burnett et al, New Eng. J. Med., 1950,
243, 1028.

42. Agatson, Am. J. Ophth., 1951, 34, 1655.

43. Fuhrman, Missouri Med., 1954, 51, 113.

44. Koff etal,J.A.M.A., 1950, 144, 1259.

45. Harrison et al, Missouri Med., 1953, 50,
427.

46. Tucker et al, Proc. Second Clin. ACTH
Conf. (v.s.), p. 696.

47. Teicher et al, J. Invest. Dermat., 1952,
19, 205.

48. Robson et al, Brit. M. J., 1950, 2, 971.

49. Evans et al, Arch. Int. Med., 1951, 88, 503.

50. Jacobson et al, New Eng. J. Med., 1952,
246, 247.

51. Ogryzlo etal, J. A.M. A., 1950, 144, 1238.

52. Larson et al, Am. J. Med., 1953, 14, 307.

53. Hall et al, Ann. Int. Med., 1953, 38, 533.

54. Wilson et al, Am. J. Dis. Child., 1953, 86,
131.

55. Shetlar et al, J. Lab. Clin. Med., 1952, 39,
372.

56. Colcher et al, Ann. Int. Med., 1953, 38,
554.

57. Meyer et al, Stanford M. Bull, 1953, 11,91.

58. Kahn et al, Ann. Int. Med., 1953, 39, 1129.

59. Teitelman et al, ibid., 38, 1062.

60. Kinsell, Ann. Int. Med., 1951, 35, 615.

61. Luongo et al, New Eng. J. Med., 1951,
245, 757.

62. Wirts et al, J.A.M.A., 1954, 154, 36.

63. Robison, ibid., 142.

64. Carreras, Obst. Gyn., 1954, 3, 50.

65. Lange et al, Proc. S. Exp. Biol. Med., 1953,
82, 315.

66. Hill, New Eng. J. Med., 1953, 248, 1051.

67. Kiefer et al, Gastroenterology, 1954, 26, 29.

68. Baumeister, J. -Lancet, 1954, 74, 89.

69. Luetscher et al, J. A.M. A., 1953, 153, 1236.

70. Bulkeley, Brit. M. J., 1953, 2, 112 7;
Houghton, Lancet, 1954, 1, 595.

71. Lewis et al, J. A.M. A., 1954, 156, 479;
Indian J. Med. Sc, 1954, 8, 1.

72. Magill et al, Am. J. Med., 1954, 16, 810.

73. Fessas et al, Arch. Int. Med., 1954, 94, 384.

74. Soffer et al, ibid., 93, 503.

75. Waugh, ibid., 299.

76. Neugebauer, Wien. med. Wchnschr., 1953,
103, 827.

77. Essellier and Kopp, Schweiz. med. Wchn-
schr., 1954, 84, 485.

77a. Trusler et al, Plastic & Reconstruct.
Surg., 1952, 9, 478.

78. Ducci and Katz, Gastroenterology, 1952,
21, 357.

79. Shulman et al, Bull Johns Hopkins Hosp.,
1953, 92, 196.

80. Fisher, Arch. Dermat. Syph., 1953, 68, 214.

81. Zarafonetis et al, Am. J. Med. Sc, 1954,
228, 1.

82. Eisenoff et al, J. A.M. A., 1954, 155, 905.

83. Hoback and Green, ibid., 1953, 152, 236.

84. den Oudsten and van Schouwen, Nederland.
Tijdschr. Geneesk., 1953, 79, 1583.

85. Hoagland, U. S. Armed Forces Med. J.,
1953, 4, 581.

86. Dustan et al, J.A.M.A., 1954, 154, 23.

87. Weeks and Lehmann, /. Pediatr., 1954,
44, 508.

88. Haik et al, Arch. Ophth., 1952, 47, 437.

89. Israel et al, J. A.M. A., 1954, 156, 461.

90. Hart, Brit. M. J., 1952, 1, 188; Queries,
J.A.M.A., 1954, 155, 1545.

In general, the therapeutic effects of cortisone,
hydrocortisone or corticotropin are the same.
For prompt action after parenteral administration
in patients with functioning suprarenal glands,
corticotropin may be preferred (perhaps traces
of other pituitary hormones have played an un-
recognized role in the therapeutic action). For
most patients, however, oral administration of
cortisone acetate or hydrocortisone is equally
effective and more convenient. For topical appli-
cation, hydrocortisone acetate is often preferred.
In the following paragraphs a brief statement of
the current practice in the more important indi-
cations for these substances will be presented.

Rheumatoid Arthritis. — Cortisone is indi-
cated in patients with active disease (not in cases
with non-progressing deformities) who have not
responded adequately to general measures includ-
ing analgesics, physical therapy, extra rest, cor-
rection of postural mechanical trauma to joints,
adequate nutrition and other supportive measures.
Contraindications (v.i.) must be absent and the
patient should be psychologically capable of sus-
tained cooperation since this therapy is suppres-
sive rather than curative and the future course of
therapy must often be adjusted just short of toxic
manifestations. Careful clinical evaluation of the
patient in general and of each joint in particular
at regular visits to the physician is essential,
together with measurement of body weight,
urinalysis, blood pressure, erythrocyte sedimen-
tation rate, blood hemoglobin and leukocyte
count, and roentgenogram of the chest at appro-
priate intervals. The dosage must be tailored to
fit the individual and changes are often necessary.
Initially, 75 mg. of cortisone acetate for a large
man or 15 mg. for a small child is recommended
in 3 or 4 divided portions daily (Hench and Ward,
in Medical Uses of Cortisone, Including Hydro-
cortisone and Corticotropin, ed. by F. D. W.
Lukens, 1954, p. 534). As soon as some improve-
ment appears, the dose is reduced by 2.5 to 12.5
mg. daily, according to the size of the initial dose,
at intervals of 3 to 7 days until a dose capable
of producing comfort, if not complete relief, on
most days of the week is reached. This dose be-
comes the maintenance dose. If the initial dosage
does not bring relief in a few days, increments of
5 to 10 mg. daily may be added at intervals of
several days. Hench prefers this milder and more
gradual schedule to the larger doses commonly
employed when cortisone was first available. As
maintenance dosage the following maximum daily
doses should seldom be exceeded unless for a few
days: 65 mg. for men, 45 mg. for women, 25 mg.

390

Cortisone Acetate

Part I

for children and 35 mg. for postmenopausal
women. For mild exacerbations of the disease,
acetylsalicylic acid, rather than extra cortisone,
should be prescribed. Ordinarily, the steroid may
be given three times daily at meal time and at
bedtime. More than one-quarter of the daily dose
may be indicated on arising, with a smaller portion
at noon and at bedtime in sedentary individuals.
Physically active patients may benefit from a
larger portion at noon and at supper time to con-
trol the discomfort of the mechanical trauma and
fatigue of the day's labors. The relief of all symp-
toms on all days often requires a dose which leads
eventually to untoward side-effects. In the ex-
perience of the Mayo Clinic (Ward et al.,
J.A.M.A., 1953, 152, 119), about 50 per cent of
cases can be controlled with small and well-
tolerated doses. About 35 per cent have required
larger and potentially toxic doses at times but can
be handled successfully with close attention. About
15 per cent have not been responsive to tolerable
doses. Bunim (Bull. Rheum. Dis., 1954, 5, 73)
reported on the results in a group of 71 patients
observed over a period of 4 years: 23 per cent
were in remission, 28 per cent had major im-
provement, 42 per cent showed minor improve-
ment, and 7 per cent experienced no benefit. The
best response was in cases of less than a year's
duration and the least benefit was observed in
cases of more than 10 years' duration. However,
Duthie (Proc. Roy. Soc. Med., 1954, 47, 323)
concludes that continuous treatment with corti-
sone or corticotropin in rheumatoid arthritis is
never indicated, on the grounds that such treat-
ment does not change the natural course of the
disease, untoward side-effects are frequent and
the contraindications to adrenocorticoid therapy
are frequently present (but often unrecognized)
in the age group most susceptible to arthritis.
Duthie recommends cortisone therapy only for
patients with but one joint involved, or for short
periods to slow the deterioration of an acute,
rapidly progressive case of rheumatoid arthritis.

Precaution. — It must be remembered that pa-
tients receiving cortisone continuously are unable
to respond normally to injury, operation or other
forms of stress. Under such circumstances they
require large doses of cortisone similar to those
required by the patient with a crisis of Addison's
disease. Such individuals should carry cards, such
as those used by those with diabetes mellitus,
indicating their regular use of cortisone.

Other Rheumatic Disorders. — Cortisone is
useful in the arthropathy of serum sickness,
bursitis, epicondylitis, periarthritis, shoulder-hand
syndrome, tenonitis, tenosynovitis, fibrositis,
psoriatic arthritis, and Reiter's syndrome. In these
conditions, observance of the principles outlined
under rheumatoid arthritis is important. Although
cortisone will relieve the acute attack of gout,
acute gouty symptoms recur on withdrawal of
adrenocorticoid therapy; colchicine is preferred
in the treatment of most acute attacks of gout.
Although systemic cortisone therapy is often
effective in osteoarthritis and acute traumatic
arthritis, intraarticular injection of sterile hydro-
cortisone acetate suspension is usually preferred
because it is more effective and topical application

avoids the undesirable features of systemic corti-
sone action.

Rheumatic Fever. — Cortisone is indicated in
patients with active rheumatic carditis. A dose
of 300 mg. the first day, followed by 200 mg. daily
for 5 to 10 days, and 100 mg. daily for 2 to 4
weeks, is recommended. If the patient has re-
sponded completely, the steroid may be discon-
tinued gradually by decreasing the daily dose by
25 mg. at weekly intervals. During use of corti-
sone, sodium intake in the diet should be de-
creased to less than 1 Gm. daily and, if edema is
present or develops, sodium intake should not
exceed 50 mg. daily. As long as the dose of cor-
tisone is 100 mg. or more daily, 1 Gm. of potas-
sium chloride in enteric-coated tablets should be
prescribed daily. Cortisone is not a cure for rheu-
matic fever. It is hoped that early adrenocorticoid
therapy will decrease the extent of residual cardiac
damage (Heffer et al, J. Pediatr., 1954, 44, 630)
but sufficient experience has not accumulated to
evaluate this hope. Indeed, the comparative re-
sults with corticotropin, cortisone or salicylate
therapy show no significant differences between
the responses (Houser et al., Am. J. Med., 1954,
16, 168). However, cortisone controls the acute
symptoms — fever, tachycardia, increased erythro-
cyte sedimentation rate, poor appetite and malaise.
Measures to protect such patients from current
and future infections with beta-hemolytic strep-
tococci by penicillin or sulfadiazine prophylaxis
are most important to prevent recurrent attacks
of rheumatic fever and the resulting further
cardiac damage (see under Benzathine Penicillin
G). In mild cases of acute rheumatic fever,
salicylate therapy is probably preferred. In a
study of adrenocortical steroid excretion in the
urine during salicylate therapy, Smith et al.
(J. Endocrinol., 1954, 10, xvii) found no evidence
that salicylates increase the production of adreno-
corticoids by the patient.

In patients with chorea minor, Schwartzman
et al. (J. Pediatr., 1953, 43, 278) recommend
combined therapy with corticotropin and cortisone
but the value of adrenocorticoid therapy in this
condition is not fully established.

Rebound Phenomena. — Within 3 to 14 days
after cortisone is discontinued in patients with
acute rheumatic fever, relapse appears in most
cases — fever, tachycardia, arthritis, increased
erythrocyte sedimentation rate, etc. Symptoms
are usually mild and may persist for as long as
1 to 2 weeks ; retreatment with cortisone is seldom
indicated.

"Collagen Diseases." — In acute disseminated
lupus erythematosus, cortisone controls the arthri-
tis, the polyserositis (pleural, pericardial, etc.),
the hemolytic anemia, the thrombocytopenic pur-
pura, the convulsions and mental aberrations, and
the dermatitis. The cardiorenal manifestations,
however, respond poorly. The disease is suppressed
but not cured.

In periarteritis nodosa, cortisone controls many
of the manifestations — fever, asthma, eosinophilia,
arthritis, dermatitis — but does not mitigate the
extensive vascular involvement of the heart and
the kidneys which usually progresses and causes
the patient's demise despite the suppression of the

Part I

Cortisone Acetate

391

other manifestations. However, since this is not
an invariably fatal disease, suppressive therapy
is indicated.

In diffuse scleroderma, cortisone causes im-
provement in the skin lesions and the Raynaud's
phenomenon in early cases but treatment must
usually be prolonged as in the case of patients
with rheumatoid arthritis.

In dermatomyositis, symptomatic control has
been attained in early cases.

Asthma and Rhinitis. — For rapid control of
allergic bronchial asthma or seasonal or perennial
rhinitis, cortisone is most effective but it is not
curative and it should be reserved only for in-
tractable cases or for dangerously ill patients
(linger and linger, Ann. Int. Med., 1954, 40,
721). The dosage in these severely ill patients is
300 mg. the first day, 200 mg. the second day,
and 100 to 200 mg. thereafter daily, in divided
portions every 6 hours. All other usual therapeutic
measures should be continued — bronchodilators,
expectorants, sedatives, oxygen inhalation, etc.
Determination of the etiologic agent must be
made, if at all possible. The cause should be elimi-
nated, if possible, or hyposensitization procedures
performed since these patients relapse when corti-
sone is discontinued, within 1 day in acute cases
and 1 to 3 weeks in more chronic and less specifi-
cally allergic cases. If cortisone fails, corticotro-
pin injection should be tried. Failure to respond
to corticosteroid therapy is usually due to pres-
ence of infection which must be treated specifi-
cally. Among 50 cases of refractory asthma,
linger and Unger reported 16 relieved, 26 im-
proved and 8 not benefited. When steroid therapy
was discontinued, 16 relapsed. Fatal anaphylactic
reactions to corticotropin have occurred. Bicker-
man and Barach (/. Allergy, 1954, 25, 312) re-
ported complete or partial remission in 82.3 per
cent of patients with corticotropin, 86.2 per cent
with cortisone, and 96 per cent with hydrocorti-
sone (in a dose 50 to 60 per cent of that of corti-
sone) among 163 patients with intractable asthma
and pulmonary emphysema. During corticosteroid
therapy, immediate (urticarial) skin test responses
are not inhibited and testing for specific sensitivi-
ties may be carried out; the delayed type of skin
response (bacterial sensitivity type) is usually
suppressed during corticosteroid therapy.

Drug Allergy. — In sensitivity reactions to
drugs, as in the case of asthma, serum sickness,
etc., cortisone is a useful therapeutic agent. Al-
lergy, it may be recalled, refers to altered reac-
tivity. These reactions refer to acquired sensitivity
rather than to the effect of toxic doses of chemi-
cals or the unusual hypersensitivity of some per-
sons to doses of drugs which have no untoward
effect on most persons. Aside from drugs of pro-
tein nature, such as the antisera prepared in
horses against diphtheria or tetanus toxins, non-
protein drugs, by combining with body proteins,
may produce foreign antigens and cause hyper-
sensitivity. The manifestations vary from fever,
urticaria, angioneurotic edema, arthralgia, lympha-
denopathy — i.e., serum sickness — to hemorrhagic,
bullous or exfoliative dermatitis, asthma, agranu-
locytosis, thrombocytopenic purpura, and ana-
phylactic shock. In serum sickness due to tetanus

antitoxin, cortisone should be started early, in
doses of 100 mg. by mouth, repeated in 4 hours
and then 50 mg. given every 4 hours for 6 doses.
In penicillin urticarial reactions, atropine derma-
titis and insulin resistance, to mention only a
few (see accompanying table), cortisone is effec-
tive. Cortisone may be life-saving in cases of
exfoliative dermatitis.

Dermatologic Conditions. — Cortisone is indi-
cated in many cases, particularly the severe ones,
including acute urticaria and angioneurotic edema,
dermatitis medicamentosa, atopic dermatitis and
infantile eczema, exfoliative dermatitis, pemphi-
gus, nummular dermatitis, erythema multiforme
and nodosum, and id eruptions. Hydrocortisone
ointment, rather than systemic adrenocorticoid
therapy, is preferred for most cases of contact
dermatitis, seborrheic dermatitis, pruritus ani or
vulvae and chronic lichen simplex. The frequently
fatal collagen diseases with dermatologic manifes-
tations have already been discussed (v.s.). Except
for these potentially fatal cases, it must be em-
phasized that systemic therapy is indicated only
in severe dermatologic cases; mild and moderate
cases should be treated by other conventional and
supportive methods and correction of causative
factors must not be neglected even when cortisone
is used. Usually cortisone is not indicated in
chronic discoid lupus erythematosus, psoriasis,
sarcoidosis, mycosis fungoides, lichen planus, alo-
pecia areata, acne vulgaris or rosacea, postherpetic
neuralgia, lepra reaction, dermatitis herpetifor-
mis, keloids or chronic urticaria. The physician
will not prescribe systemic corticosteroid therapy
until this question can be answered: Does this
patient have pulmonary or other tuberculosis,
peptic ulcer, cardiovascular-renal disease or psy-
chiatric disorders which may be aggravated by
such therapy of a dermatosis (King and Livin-
good, Texas State J. Med., 1953, 49, 682)?

Granulomas. — In several pulmonary granu-
lomatous diseases, cortisone has therapeutic value,
albeit of a suppressive nature. In Boeck's sarcoid,
cortisone improves constitutional symptoms and
the local manifestations in the lungs, lymph nodes,
liver, spleen, etc. Relapses usually follow discon-
tinuation of the steroid therapy. In beryllium
granulomatosis of the lungs, cortisone increases
oxygen saturation of the blood and decreases hy-
perpnea. In other nonspecific pulmonary granu-
lomatoses, cortisone may cause hyalin and fibrous
changes in the granuloma. In silicosis, cortisone
has little value in the advanced fibrotic stage
with inelastic lungs and dyspnea on exertion. If
obstructive emphysema and asthmatic bronchitis
are prominent, cortisone is helpful. If tuberculosis
or other pulmonary infection is present, cortisone
therapy may spread the infection and aggravate
the disability of the patient. In Loeffler's syn-
drome, cortisone produces prompt improvement.
In Hodgkin's disease, cortisone causes temporary
relief of symptoms and a decrease in the size of
the tumor masses; it often makes the terminal
stage of this disease more tolerable.

Infections. — Except for replacement therapy
for acute adrenal insufficiency secondary to the
infection, such as the Waterhouse-Friderichsen
syndrome, cortisone is usually contraindicated

392

Cortisone Acetate

Part I

because while its anti-inflammatory action may
relieve the symptoms it may permit spreading of
the infection through inhibition of the defense
mechanisms ( Jawetz. Arch. Int. Med., 1954. 93,
However, in severe and often fatal infec-
tions for which effective chemotherapy is avail-
able, cortisone, in combination with specific chem-
otherapy, may prove life-saving (Jahn et al.. J.
Pediatr., 1954. 44, 640 >. For example, cortisone
along with chloramphenicol is indicated in the
treatment of typhoid fever and Rocky Mountain
spotted fever. In combination with chemotherapy,
it is valuable in the treatment of peritonitis and
of keratodermia blennorrhagica (systemic gono-
coccal infection*. Cortisone controls the symp-
toms of trichinosis. It is not used in malaria or
leprosy and only rarely in tuberculosis i see the
table; also Morgan et al., J. Bact., 1954. 67, 2 5 "
In experimental infections cortisone enhances
M. tuberculosis, meningococcus, hemolytic strep-
tococcus, staphylococcus, pneumococcus. influ-
enza or poliomyehtis virus, brucella, treponema.
malaria, trichophyton, etc.

Ophthalmologic Conditions. — In many dis-
eases of the eye cortisone is sight-saving. It does
not cure the disease or correct the cause but it
prevents the inflammation and exudation which
may destroy vision. Adrenocorticoid therap;
most valuable in allergic disorders of the external
eye and nongranulomatous inflammations of the
uveal tract. Cortisone should always be accom-
panied by specific therapy to eliminate the cause.
In tuberculous and other granulomatous lesions,
cortisone has only temporary value and must be
used with caution to avoid spreading the inflam-
mation into a larger necrotic lesion. For the con-
junctiva and the anterior ocular segment — iris,
ciliary body. etc. — topical application of cortisone
or preferably hydrocortisone is the treatment of
choice. For lesions of the posterior segment of
the eye — optic neuritis, chorioretinitis, etc. — sys-
temic therapy is required with patience and
perseverance (Quinn and Wolfson. Univ. Mich.
M. Bull., 1952. 18, 1 ). For topical use. a special
sterile ophthalmic suspension containing 0.5 or
2.5 per cent cortisone in a phosphate buffer solu-
tion is available for instillation into the conjunc-
tival sac even" 1 or 2 hours. A 1.5 per cent corti-
sone ointment using an Aquaphor or lanolin base
provides more prolonged action and is effective
when applied every 5 or 4 hours. Results with
subconjunctival injection do not seem to be gen-
erally superior to topical application.

Gastrointestinal Conditions. — In this 5
tem of the body, cortisone has shown less value.
Recurrence, perforation or hemorrhage from pep-
tic ulcer is an untoward, a typically manifested
and at times unexpected complication of adreno-
corticoid therapy of other disorders. For perito-
nitis, cortisone with appropriate chemotherapy is
often useful. In sprue and celiac disease, corti-
sone controls symptoms, increases appetite and
improves nutrition; this may lead to recovery.
In regional enteritis and chronic ulcerative colitis,
results are unpredictable. In chronic hepatitis,
cortisone improves the appetite and well-being
and decreases fatty infiltration of the liver, but

it may increase ascites and even precipitate coma.
In acute hepatitis reports are conflicting (see
tabk

Blood Dyscrasias. — Cortisone therapy will
control the hemorrhagic phenomena in thrombo-
cytopenic purpura. Although many cases relapse
when cortisone is discontinued, retreatment will
stop bleeding again and splenectomy can be per-
formed with relative safety. Control of bleeding
5eems to be related to an effect on capillary in-
tegrity rather than on platelet count. If the
platelet count has not reached normal in the
blood in 10 days of therapy, it is not likely to
rise with more prolonged therapy and splenectomy
is indicated without further delay. Sustained re-
missions may be expected in cases of less than
3 months' duration but are rare if the hemorrhagic
state has been present for 6 months. The usual

■-;• of cortisone in purpura is 75 mg. every 6
hours: the equivalent dose of corticotropin in-
jection is 25 units every 6 hours. Cortisone is
effective in allergic (non-thrombopenic. Schonlein-
Henoch) purpura and in thrombotic thrombopenic
purpura.

In idiopathic acquired hemolytic anemia, com-
plete clinical and hematologic remission in 7 of
12 cases has been reported but 6 of these 7 re-
lapsed when cortisone or corticotropin treatment
was discontinued (Bethell. in Lukens' Medical
L's-ss of Cortisone, 1954 >. Four cases showed par-
tial remission; 1 failed to show any response. Of
the 6 who responded and relapsed. 5 were re-
lieved by splenectomy. Of the 4 with a partial
response, only 1 was relieved by surgical removal
of the spleen. Adrenocorticoid therapy often
;::..r.ce5 the C : : :\m ~ test from positive :: nega-
tive (see discussion of Rh factor under Citrated
Whole Human Blood) but Davidsohn and Spur-
rier (J.A.M.A.. 1954. 154, S18) noted that a
considerable titer of antibody persisted in the
blood serum; it was suggested that cortisone
therapy inhibits the combination of antibody with
the antigen (the erythrocyte ) . Wiener (ibid., 1954.
155, 63) denied the value of cortisone the:
during pregnancy in the prophylaxis of erythro-
blastosis fetalis as was reported to be the case
by Hunter (ibid., 154, 905).

In agranulocytosis, cortisone or corticotropin
will either hasten recovery or at least control the
progressively fatal manifestations. In this condi-
tion, infection is not a contraindication to corti-
sone therapy; antibiotics are also indicated. In
splenic neutropenia or periodic neutropenia, corti-
sone has not proven effective. In pancytopenia
and in refractory or hypoplastic anemia, the re-
sults have been poor. It may have value in termi-
nating the crises in sickle cell anemia.

In leukemia decided clinical and hematologic
improvement occurs in 40 to SO per cent of cases,
with virtually complete remission in about 20 per
cent, particularly among children with acute
lymphatic leukemia. Adult cases and patients
with granulocytic leukemia do not respond as
well. Monocytic leukemia is unresponsive. On
discontinuing cortisone, relapse follows in 2 to 10
weeks and about half of the cases will respond
to a second course of cortisone. A third response

Part I

Cortisone Acetate

393

is rarely observed. Combination therapy with cor-
tisone and Aminopterin is used (Marie et al.,
Bull. sec. med., 1951, 67, 621).

Use of cortisone in Hodgkin's disease has been
mentioned {v.s.). Multiple myeloma shows tem-
porary symptomatic and laboratory response. In
neoplasms in general, cortisone has some sympto-
matic but no curative action.

Renal Disease. — In nephritis, cortisone or
corticotropin has little use. The increased renal
function, which occurs in normal humans receiv-
ing adrenocorticoids. often fails to occur in the
nephritic patient. Cortisone may aggravate albu-
minuria, edema, oliguria and hypertension. The
catabolic action of cortisone increases the urea
and potassium to be excreted. Some patients with
the nephrotic syndrome are benefited. When 2
to 3 weeks of cortisone therapy is abruptly dis-
continued, a diuresis may occur with a remission
in the disease until a respiratory infection or other
stress precipitates the svndrome again (Luetscher
et al., J.A.M.A., 1953. 153, 1236). Merrill et al.
(Arch. Int. Med., 1954, 94, 925) reported suc-
cessful therapy with repository corticotropin in-
jection used continuously for many months in 24
of 25 patients who had failed to respond to the
short course of adrencorticoid therapy or had
relapsed following improvement. Lauson et al.
(J. Clin. Inv., 1954, 33, 657) reported a decrease
in the abnormal permeability of the glomerulus
to protein in such cases. *

Untoward Effects. — Since poisoning in the
ordinary meaning of the term does not occur, the
usual caption of Toxicology is not employed.
However, the untoward effects associated with
the use of large doses of a substance which pos-
sesses the action of a normally-occurring and
potent hormone are many and serious and even
fatal (see review by Thayer, Stanford Med. Bull.,
1952, 10, 1). Perhaps the greatest hazard in the
use of cortisone arises from the masking of the
common manifestations of a spreading infection
as a result of the anti-inflammatory action of this
steroid and its antipyretic, analgesic and euphoric
effects. In the therapeutic use of cortisone for a
particular purpose, the other actions of the drug
on other tissues and physiological functions must
always be kept in mind. The therapeutic use of
cortisone involves a pharmacological dose rather
than the physiological action of a normal endo-
crine substance. The replacement dose of corti-
sone in patients with the adrenal insufficiency of
Addison's disease is seldom greater than 25 mg.
daily.

Two general types of untoward effects are to
be considered: (1) overdosage and (2) withdrawal
manifestations. Most therapeutic doses produce
mild hyperadrenocorticism (Cushing's syndrome I :
round, "moon" face, and characteristic deposits
of fat on the torso, acne, hirsutism, striae in the
skin, amenorrhea, loss of libido, etc. In the pres-
ence of definite therapeutic indications for corti-
sone, these untoward effects are a nuisance but
not a contraindication to its continuation. During
the first few days of use, homeostasis effectively
prevents marked abnormality but these compen-
satory mechanisms are soon exceeded and meta-

bolic and eventually structural changes appear;
these are all reversible when the steroid is dis-
continued. Where the probable therapeutic bene-
fit justifies the use of a short course of cortisone,
the common untoward effects may be accepted
and the use of certain precautions will minimize
their severity. The blood pressure and body weight
should be recorded and urinalysis and blood
count performed weekly during the use of large
doses and less frequently, perhaps monthly, dur-
ing the prolonged administration of small doses.
Certain predispositions require special precau-
tions, such as active or quiescent peptic ulcer or
active or latent diabetes mellitus. In immobilized
patients, osteoporosis is a particular threat and
individuals with hypertension or impaired renal
function also require individual evaluation of the
risk. In general, caution against overexertion re-
sulting from the euphoria produced by the steroid
is important.

Precautions in the clinical use of cortisone in-
clude: A roentgenogram of the chest is essential
before commencing a prolonged course of corti-
sone therapy. The presence of active tuberculosis
is an absolute contraindication unless the thera-
peutic indication is replacement therapy of Addi-
son's disease due to tuberculosis of the adrenals.
If the film shows a healed lesion, cortisone may
be used but frequent roentgenograms are essential.

Roentgen examination of the gastrointestinal
tract is demanded by symptoms or a history of
peptic ulcer. If an active ulcer is found, cortisone
is contraindicated. If deformity suggesting a
healed ulcer is found, cortisone may be used if
the therapeutic indication is grave enough to jus-
tify the risk and the patient can be kept on a
strict therapeutic regimen for peptic ulcer.

Urinalysis for sugar and. if there is a family
history of diabetes mellitus. fasting and post-
prandial blood sugar determinations are essential.
The presence of glycosuria or hyperglycemia is
not a contraindication to the use of cortisone but
careful observation and treatment of any diabetic
manifestations are mandatory. In the case of
known diabetics, cortisone may be used with
careful observation and appropriate increases in
the dose of insulin.

Determination of basal (resting) blood pressure
as well as search in the urinalysis for evidences of
renal disease is essential since hypertension or
impaired renal function demands close observa-
tion during the use of the steroid. A significant
rise in blood pressure calls for discontinuance of
the drug or the institution of diet and other
measures (v.i.) to minimize the untoward effect.

Heart disease is not an absolute contraindica-
tion to the use of cortisone even in severe ana-
tomical but compensated lesions or in cases previ-
ously in congestive heart failure which has been
controlled by digitalis and other appropriate ther-
apy. Cortisone therapy in such patients must be
approached with caution, care, and prophylactic
measures to counteract the undesirable actions. In
decompensated cases of heart disease, cortisone
is contraindicated unless the cause may be cor-
rected by cortisone, as in the case of acute rheu-
matic myocarditis (Greenman et al., J. Clin. Inv.,

394

Cortisone Acetate

Part I

195 1, 30, 644). In cases of compensated heart
disease, measures to minimize the retention of
sodium chloride and water and the loss of potas-
sium are essential. A low sodium diet — less than
1 Gm. daily — is helpful; such a low intake of
sodium also minimizes the loss of potassium
(Seldin et al., ibid., 673; Greenman et al., loc.
cit.). From 1 to 3 Gm. of potassium chloride is
indicated by mouth daily to minimize potassium
loss and counteract sodium retention (Liddle et
al, J. Clin. Inv., 1953, 32, 1197). If daily body
weight is increasing, mercurial diuretics are indi-
cated. The appearance of general muscular weak-
ness calls for an electrocardiogram in search of
the characteristic changes associated with hypopo-
tassemia (v.s.) because the syndrome of hypo-
chloremic alkalosis, though rare, may develop
very rapidly (Grawley, Arch. Indust. Hyg., 1951,
3, 587). Cardiac arrhythmia and hypotension
may ensue. Electrocardiographic changes call for
the administration of 1 Gm. of potassium chlo-
ride by mouth immediately and its repetition as
many as 4 to 6 times that day. For any patient
receiving more than 100 mg. of cortisone daily
a prophylactic dose of 1 Gm. of potassium chlo-
ride daily is indicated and testosterone therapy
may be useful prophylactic therapy in the main-
tenance of both electrolyte equilibrium and pro-
tein anabolism. Caution, however, is required
since patients with cardiovascular-renal disease
may rapidly develop hyperpotassemia which is
equally deleterious on cardiac and renal function.
Frequent examination for glycosuria, and if
found for hyperglycemia, is important in order to
employ insulin before a serious disturbance of
carbohydrate metabolism develops. In other
words, careful watch for all the common untoward
effects is essential for the safe use of cortisone
in patients with heart disease.

Discontinuance of cortisone therapy is indi-
cated by the appearance of: Symptoms or signs
of peptic ulcer or of diverticulitis ; infection with
an organism which is not sensitive and quickly
responsive to treatment with an available anti-
biotic or chemotherapeutic agent; delayed wound
healing in an individual whose protein deficiency
cannot be corrected quickly by a high protein
diet and the aid of an anabolic steroid such as
testosterone (this is more important during heal-
ing of surgical incisions in viscera than in wounds
of the skin) ; marked mental confusion, frontal
headaches, insomnia and rapid swings in emo-
tional mood (in this instance gradual rather than
sudden discontinuance is particularly advised).

Continuation of a reduced dose of cortisone, if
the therapeutic indication is sufficiently grave, is
indicated with caution by the following: Edema,
which also calls for a low sodium and high potas-
sium and protein diet and if necessary at first
the use of mercurial diuretics; osteoporosis, which
in the immobilized or postmenopausal patient also
calls for a high protein diet and testosterone ther-
apy; convulsions, which also call for the use of
anticonvulsant drugs; ecchymoses. In patients with
liver disease receiving cortisone, possible thrombo-
embolic complications should be anticipated with
prophylactic physical and anticoagulant therapy,
particularly during the period of discontinuing

the use of cortisone (Thorn et al., New Eng. J.
Med., 1953, 248, 369).

Withdrawal symptoms of adrenal insufficiency
constitute the other serious aspect of the thera-
peutic use of cortisone. Prolonged use of even
moderate doses of this steroid depresses the func-
tion of the adrenal cortex. Insufficiency is usually
brief and mild — asthenia and anorexia — but in
rare cases it may be serious or may persist for
several months. As a result of severe stresses at
the time of discontinuing cortisone therapy a
disastrous syndrome resembling the crisis of
Addison's disease may develop. Such stresses
are frequent in the form of a relapse of the dis-
ease being treated with cortisone or an unrelated
but coincident stress from infection or physical
or psychic injury. Hence, cortisone therapy
should always be discontinued gradually — 12.5 to
25 mg. daily for 2 to 7 days — to allow recovery
of the patient's own adrenal cortical function;
often a daily intramuscular injection of a reposi-
tory dosage form of corticotropin is valuable to
stimulate the atrophic adrenal gland. Even during
treatment with cortisone, a relative adrenal in-
sufficiency may arise if an intercurrent stress
appears, since the depressed adrenal gland is
unable to respond to the normal stimulation of
endogenous corticotrophin. An increase in the
dose of cortisone is demanded under such circum-
stances. It is obviously of great importance to
folfow the patient as closely during the discontinu-
ance of cortisone therapy as during its use.

Contraindications. — Being relative as well as
absolute, these are discussed under Untoward
Effects (v.s.). Among the more important condi-
tions which preclude or modify the therapeutic
use of cortisone are: tuberculosis and other acute
or chronic infections, peptic ulcer or ulcerative
disease of the intestine, diabetes mellitus, hyper-
tensive cardiovascular-renal disease, heart disease,
recent visceral wounds, psychoses, edema, osteo-
porosis, convulsions, and thromboembolic disease.
Prevention of adrenal insufficiency when cortisone
is discontinued is of equal importance. During
pregnancy, cortisone may be given with care,
although large doses in rabbits cause degenera-
tion of the fetus and abortion (DeCosta and
Abelman, Am. J. Obst. Gyn., 1952, 64, 746).
During the postpartum period discontinuation of
cortisone must be done very slowly to avoid
severe adrenal insufficiency (Margulis and Hodg-
kinson, Obst. & Gyn., 1953, 1, 276).

Routes of Administration. — Intramuscu-
lar Injection. — Initially cortisone was available
only as a microcrystalline suspension of cortisone
acetate containing 25 mg. per ml. with suspending
agents (polysorbate 80 and sodium carboxymeth-
ylcellulose) and a preservative (1.5 per cent
benzyl alcohol) . With this preparation the amount
of cortisone in the blood never reaches high con-
centrations (Nelson et al., J. Clin. Inv., 1952, 13,
843). The peak concentration occurs between 8
and 12 hours after injection, the steroid persisting
in the blood for 24 hours or longer. A clinical
effect is detectable within 3 to 4 hours. Hence,
for a maximal effect the intramuscular dose
should be repeated every 8 to 12 hours but for
maintenance therapy a single daily dose is ade-

Part I

Cortisone Acetate Suspension, Sterile 395

quate. When the injections have been given for
many days, some action persists for several days
after the last dose as a result of the repository
nature of this dosage form.

Oral Ingestion. — The use of cortisone acetate
by mouth is effective, as demonstrated by clinical
(Freyberg et al, Science, 1950, 112, 429) and
metabolic effects (Thorn et al., New Eng. J. Med.,
1951, 245, 549). Equivalent action is obtained
with a dose 1 to \Yz times the intramuscular dose.
Actually, from an oral dose the response is much
more rapid than from an intramuscular injection.
The peak, concentration in the blood is reached in
4 to 8 hours, as measured by the decrease in the
blood eosinophil count, with a rapid decline in
the level. Urinary electrolyte changes occur dur-
ing the first day of oral use but are not definite
until the third day after intramuscular adminis-
tration. Oral administration every 6 hours pro-
duces an effect resembling the continuous action
of a single daily intramuscular injection. For
continuous inhibition of pituitary function, intra-
muscular injection is preferable (Wilkins et al.,
J. Clin. Endocrinol., 1952, 12, 27), but for prompt
therapeutic action in acute situations oral (or
intravenous) administration is more effective.
When treatment is discontinued after prolonged
use, the rapid decrease in cortisone effect from
oral administration is more likely to lead to acute
adrenal insufficiency than is the slower disappear-
ance from intramuscular doses. Since gastroin-
testinal absorption of cholesterol, labeled with
carbon-14, has been demonstrated as occurring
through the lymphatics and the thoracic duct
(Chaikoff et al., J. Biol. Chem., 1952, 194, 407),
it seems probable that cortisone follows a similar
pathway, rather than passing through the portal
vein to the liver.

Subcutaneous Implantation. — Because of
the efficacy and simplicity of oral administration
implantation is seldom employed. An implant of
1 to 1.5 Gm. of pellets of cortisone acetate pro-
duces an effect similar to that obtained from
release of 10 mg. of cortisone from an intramuscu-
lar injection daily; this effect persists for 4 to 5
months (Thorn et al, Tr. A. Am. Phys., 1949, 62,
233).

Intravenous Injection. — The alcohol form of
cortisone was used experimentally by Thorn et al.
(New Eng. J. Med., 1953, 248, 414) by dissolving
sterile cortisone in a concentration of 10 mg. per
ml. of 80 per cent alcohol and dispersing this by
means of a syringe or pipet into an appropriate
volume of sterile isotonic solution of sodium
chloride for injection or in 5 per cent dextrose in
water for injection. The slow injection of 100 mg.
of cortisone in 500 ml. of such a solution intra-
venously, over a period of 8 hours, produces
maximum effect (Thorn et al., Tr. A. Am. Phys.,
1952, 65, 281).

Topical Application. — In an effort to produce
a desired local therapeutic action without the
other systemic effects of adequate doses, various
topical applications have been employed. Perhaps
the most successful of these procedures is the use
of a 2.5 per cent microcrystalline ophthalmic sus-
pension of cortisone acetate in a phosphate buffer
vehicle with 0.5 per cent of benzyl alcohol and

0.02 per cent of benzalkonium chloride as preser-
vatives. For disorders of the anterior segment of
the eye, the topical application of 1 or 2 drops
every 1 or 2 hours of this ophthalmic suspension
has been most effective (Steffanson, J.A.M.A.,
1952, 150, 1660). To avoid administration during
the night, a 1.5 per cent ophthalmic ointment in
a petrolatum base has been employed at bedtime.
Leopold et al. (Am. J. Ophth., 1951, 34, 361)
demonstrated penetration into the ocular fluids
following topical application. Subconjunctival in-
jection of 0.05 to 0.4 ml. of a saline suspension,
in combination with a local anesthetic, has been
employed successfully (Koff et al., J. A.M. A., 1950,
144, 1259) ; the therapeutic effect in disorders of
the anterior segment of the eye (iritis, keratitis,
etc.) persists for several days. For disorders of
the posterior segment of the eye amenable to cor-
tisone therapy, systemic action is required.

On the skin, topical application of cortisone
ointments in discoid lupus erythematosus and
other dermatoses has produced less striking re-
sults than those following systemic use of the
steroid (Newman and Feldman, /. Invest. Der-
mal., 1951, 17, 3). Hydrocortisone is more effec-
tive than cortisone on the skin.

For instillation into synovial cavities, such as
joints, hydrocortisone is much more effective
(Hollander et al., J.A.M.A., 1951, 147, 1629).

Aerosol administration has been tried in the
treatment of bronchial asthma but oral or paren-
teral administration is far more effective (Gel-
fand, New Eng. J. Med., 1951, 245, 293). @

Dose. — The usual dose of cortisone acetate is
25 mg. four times daily by mouth or 100 mg.
daily intramuscularly. The range of dose by
mouth is 2.5 to 75 mg. ; intramuscularly it is
from 5 to 300 mg. The maximum safe dose by
mouth is generally 75 mg. ; intramuscularly it is
300 mg. For details of dosage in specific afflictions
or diseases see above. For topical application the
usual dose is that amount of a preparation con-
taining 0.5 to 2.5 per cent of cortisone required
to cover the area; the amount of cortisone thus
applied should not exceed the limits prescribed
for oral or intramuscular use.

Storage. — Preserve "in tight, light-resistant
containers, preferably of Type I glass." U.S.P.

STERILE CORTISONE ACETATE
SUSPENSION. U.S.P.

"Sterile Cortisone Acetate Suspension is a
sterile suspension of cortisone acetate in a suit-
able aqueous medium. It contains not less than
90 per cent and not more than 110 per cent of
the labeled amount of C2.3H30O6." U.S.P.

This dosage form of cortisone acetate is va-
riously prepared by the several producers of it;
representative of the suspending and dispersing
agents employed are sodium carboxymethylcellu-
lose and polysorbate 80, while 1:10,000 of thi-
merosal or 0.9 or 1.5 per cent of benzyl alcohol
is used as an antibacterial agent. The U.S.P. re-
quires the injection to have a pH between 5 and 7.

Assay. — A dehydrated alcohol solution of a
measured volume of the suspension is alkalinized
with tetramethylammonium hydroxide T.S.,

396 Cortisone Acetate Suspension, Sterile

Part I

treated with an alcohol solution of triphenyltetra-
zolium chloride, and the intensity of the resulting
red color measured at 485 mji. Quantitative eval-
uation of the color is achieved through measure-
ment of the color, similarly produced, of a stand-
ard preparation made with U.S. P. Cortisone Ace-
tate Reference Standard. U.S.P.

Uses. — For uses and dose of this injection see
under Cortisone Acetate, particularly the sections
on Routes of Administration and Dose.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferablv of Type I glass."
U.S.P.

Usual Sizes. — 10- and 20-ml. vials containing
25 mg. per ml.; 10-ml. vials containing 50 mg.
per ml.

CORTISONE ACETATE OPHTHAL-
MIC SUSPENSION. U.S.P.

"Cortisone Acetate Ophthalmic Suspension is
a sterile suspension of cortisone acetate in an
aqueous medium' with a suitable bacteriostatic
agent. It contains not less than 90 per cent and
not more than 110 per cent of the labeled amount
of C23H30O6." U.S.P.

The uses of this preparation are discussed under
Cortisone Acetate (see especially under Routes of
Administration). Suspensions containing 0.5 or 2.5
per cent of cortisone acetate are commercially
available.

Storage. — Preserve "in tight containers."
U.S.P.

CORTISONE ACETATE TABLETS.
U.S.P.

"Cortisone Acetate Tablets contain not less
than 90 per cent and not more than 110 per cent
of the labeled amount of C23H30O6." U.S.P.

Usual Sizes.— 5 and 25 mg.

PURIFIED COTTON. U.S.P.

Absorbent Cotton, [Gossypium Purificatum]

"Purified Cotton is the hair of the seed of cul-
tivated varieties of Gossypium hirsutum Linne,
or of other species of Gossypium (Fam. Mal-
vacece), freed from adhering impurities, deprived
of fatty matter, bleached, and sterilized." U.S.P.

Gossypium Depuratum; Gossypium Asepticum. Fr. Coton
hydrophile; Coton sterile. Ger. Gereinigte Baumwolle;
Hydrophile Baumwolle. It. Cotone idrofilo; Cotone as-
sorbente. Sp. Algodon hidrofilo ; Algodon absorbente;
Algodon Purificado.

For description of the cotton-plant, see under
Cotton Root Bark, in Part II. There is consider-
able difference in the capsules or so-called bolls,
the seeds, as well as the lint of the several species
of Gossypium. The bolls of Sea Island (G. bar-
badense) cotton are uniformly smaller, more
sharply pointed, contain fewer and smaller seeds
and longer lint than the Upland bolls. The Sea
Island cotton has small black seeds from which
the lint separates readily. The Upland cottons
have large seeds which are greenish in color, and
surrounded by a short dense hair beneath the
longer and more valuable lint. The lint of the Sea
Island cotton is from 3.5 to 6.5 cm. in length,

while the Upland cotton seldom exceeds 3.5 cm.
in length, usually being much shorter. There are
numerous hybrids between G. herbaceum and
G. barbadense and between G. hirsutum and
G. herbaceum. The long and extra long fibers pro-
duced in the United States are all obtained from
varieties of G. barbadense and their hybrids, the
shorter fibers being usually Upland cottons of the
G. hirsutum and G. herbaceum types. The com-
mercial grading of cotton by the New York Cotton
Exchange is as follows: Samples the average fiber
of which is under 25 mm. in length are called
"short staple"; those between 25 to 30 mm. are
called "medium" and from 30 to 40 mm. are
called "long staple."

The chemical "purification" of cotton, previ-
ously separated from its seeds, consists in remov-
ing the fatty substances. This is accomplished by
boiling it in a dilute solution of sodium hydrox-
ide, then thoroughly washing it to remove the
saponified fats and the excess of alkali. Following
this it may be immeresd in a chlorine solution,
then rinsed with water, acidulated with hydro-
chloric acid and again thoroughly washed with
pure water. Afterwards, the water is pressed out
and the cotton dried quickly. It is then subjected
to mechanical processes of sorting the fibers, and
finally forming the rolls or balls which represent
the finished product; the packaged cotton is
sterilized.

Description. — "Purified cotton occurs as
white, soft, fine filament-like hairs appearing
under the microscope as hollow, flattened, and
twisted bands, striate and slightly thickened at
the edges. It is nearly odorless and almost taste-
less. Purified cotton is insoluble in ordinary
solvents, but is soluble in ammoniated cupric
oxide T.S." U.S.P.

Standards and Tests. — Residue on ignition.
— Not over 0.2 per cent. Alkalinity or acidity. —
A 10-Gm. portion of cotton is saturated with
100 ml. of recently boiled and cooled water and
then pressed with a glass rod to separate two
25-ml. portions of liquid into white porcelain
dishes; no pink color develops in either portion
on adding 3 drops of phenolphthalein T.S. and 1
drop of methyl orange T.S., respectively. Water-
insoluble substances. — Not over 0.25 per cent.
Fatty matter. — Not over 0.7 per cent. Dyes. —
10 Gm. of cotton is extracted, in a narrow perco-
lator, with sufficient alcohol to yield 50 ml. of
percolate. When the latter is observed downward
through a column 20 cm. deep it may have a yel-
lowish color, but neither a blue nor a green tint.
Fiber length. — Not less than 60 per cent, by
weight, of conditioned fibers shall be 12.5 mm. or
greater in length, and not more than 10 per cent.
by weight, shall be 6.25 mm. or less in length.
Absorbency. — Purified cotton retains not less than
24 times its weight of water. Sterility. — Purified
cotton meets the requirements of the Sterility
Test for Solids. U.S.P.

Purified cotton is soluble in strong alkaline so-
lutions, and decomposed by concentrated mineral
acids. Chemically, it is a form of cellulose,
(Ct;Hio05)n. Cotton will take fire spontaneously
if impregnated with linseed oil, or some other fixed
oils, and allowed to stand; the heat produced by

Part I

Cottonseed Oil

397

the oxidation of the oil suffices to ignite the
matted fibers of the cotton.

Uses. — The uses of cotton are so well known
that little need be recorded there. Purified cotton
is much used in surgery as a dressing for burns
and wounds, in order to prevent the access of
pathogenic germs and to absorb discharges. Cot-
ton batting is often employed to maintain a uni-
form temperature in inflamed parts but is better
made from raw cotton than from absorbent cot-
ton. Purified cotton is useful as a filtering medium
for liquids, and also for air; the latter, when
passed through a sufficient thickness of cotton,
becomes sterile.

Storage. — "Package Purified Cotton in rolls
of not more than 454 Gm. (1 pound) of a con-
tinuous lap, with a light-weight paper running
under the entire lap, the paper being of such
width that it may be folded over the edges of the
lap to a distance of at least 25 mm. (1 inch), the
two together being tightly and evenly rolled, and
enclosed and sealed in a second well-closed con-
tainer. Purified Cotton may be packaged also in
other types of containers if these are so con-
structed that the sterility of the product is main-
tained. Sterilize Purified Cotton in the sealed
container." U.S. P.

Labeling. — "The label of Purified Cotton
bears a statement to the effect that the sterility
of the Cotton cannot be guaranteed if the package
bears evidence of damage or if the package has
been opened previously." U.S. P.

COTTONSEED OIL. U.S.P., B.P.

Oleum Gossypii Seminis

"Cottonseed Oil is the refined fixed oil obtained
from the seed of cultivated plants of various
varieties of Gossypium hirsutum Linne or of other
species of Gossypium (Fam. Malvacece)." U.S. P.
The B.P. gives its origin as the seeds of cultivated
species of Gossypium.

Cotton Oil. Fr. Huile de cotonnier. Ger. Baumwoll-
samenol. Sp. Accite de Semilla dc Algodon.

_ From the seed of the cotton plant (for descrip-
tion of the plant see under Cotton Root Bark, in
Part II), once regarded as a nuisance, there is
now expressed in the vicinity of 200,000,000 gal-
lons annually of a highly useful oil. In seeds con-
taining 6 to 12 per cent moisture, the content of
oil is between 14 and 25 per cent; also present are
16 to 26 per cent of proteins, 24 to 31 per cent
of carbohydrates (but little or no starch), 14
to 2 1 per cent of crude fiber, and 3 to 4 per cent
of ash.

Several methods of expressing cottonseed oil
are employed; some mills crush and press seed
which has been delinted only, others press decorti-
cated seed or "meats" previously ground to a
coarse meal. Many types of mills are in use,
and many variants in their operation. An excel-
lent summary of the several commercial processes
is given by Jamieson in Vegetable Oils and Fats,
Second Edition, 1943.

The crude oil resulting after the liquid obtained
by expression is clarified by subsidence or filtra-
tion may be red, amber, or nearly black, depend-

ing on the method of manufacture and the quality
of seed employed. The color, sometimes erro-
neously attributed to gossypol, is due chiefly to
resins and plant pigments. Refining of the oil
consists first in agitating it with a solution of
enough caustic soda to neutralize the free acids,
then heating it to expel moisture and bleaching it
by agitation with 2 to 6 per cent of fuller's earth,
sometimes with the addition of 0.5 to 1 per cent
of activated carbon, then deodorizing it with
steam under diminished pressure. For many uses
this refined oil needs to be chilled to separate
the higher melting glycerides; this stearin frac-
tion is employed in the manufacture of lard sub-
stitutes. Such "wintered oil," when properly pre-
pared, will remain clear and bright even after
being cooled to 0° for 5 hours (compare with the
U.S. P. description).

A number of grades of crude and of refined
cottonseed oil are recognized on the American
market; the crude oil is graded on its acidity,
refining loss and flavor, the refined on its color,
odor, and flavor. Specifications for all grades have
been drawn up by the National Cottonseed Prod-
ucts Association.

The oil-cake remaining after extraction of the
oil amounts to about 50 per cent of the weight of
the whole seed and is largely used as food for
cattle; the toxic gossypol (see under Constitu-
ents) occurring in it is, fortunately, combined
with protein to form an indigestible compound.
The hulls, comprising about 25 per cent of the
seed, are used for bedding and feed for stock;
also as a fuel and, after removal of hull fiber, to
make a hull bran with which to reduce the protein
content of meal to the desired percentage. The
linters obtained from the seed, amounting to 5 to
10 per cent, are sold to manufacturers of gun-
cotton, films, artificial silk, mattresses, paper and
other articles.

Description. — "Cottonseed Oil is a pale yel-
low, oily liquid. It is odorless or nearly so, and
has a bland taste. At temperatures below 10°
particles of solid fat separate from the Oil, and at
about 0° to —5° the Oil becomes solid or nearly
so. Cottonseed Oil is slightly soluble in alcohol.
It is miscible with ether, with chloroform, with
petroleum benzin, and with carbon disulfide."
U.S.P.

Standards and Tests. — Specific gravity. —
Not less than 0.915 and not more than 0.921.
Identification. — A mixture of 2 ml. of cottonseed
oil with 2 ml. of a mixture of equal volumes of
amyl alcohol and a 1 in 100 solution of sulfur in
carbon disulfide is warmed carefully until the car-
bon disulfide is expelled and then the test tube
containing the liquid immersed to one-third of
its length in a boiling, saturated solution of sodium
chloride: a red color develops in the mixture
within 5 to 15 minutes (this is the well-known
Halphen test for cottonseed oil). Iodine value. —
Not less than 109 and not more than 116. Saponi-
fication value. — Not less than 190 and not more
than 198. Solidification range of the fatty acids. —
The dry, mixed acids solidify between 31° and
35°. U.S.P.

The B.P. description and standards are similar
to those of the U.S. P.; the former gives the re-

398

Cottonseed Oil

Part I

fractive index as from 1.4645 to 1.465S at 40°.
and specifies the acid value as not more than 0.5.

Constituents. — Analysis of a typical refined
cottonseed oil shows it to contain 39.35 per cent
linoleic acid, 33.15 per cent oleic acid, 19.1 per
cent palmitic acid, 1.9 per cent stearic acid, 0.6
per cent arachidic acid, and 0.3 per cent myristic
acid — combined as glycerides. Also present are
small quantities of phospholipids (lecithin, etc.),
phytosterols, and pigments.

The toxic polyphenols pigment gossypol is
present in raw cottonseed and in oil-cake, but is
not found in the oil. Clark et al. (Oil and Fat Ind.,
1929, 6, 15) reported that though it is very toxic
as it occurs in raw cottonseed, gossypol is not
poisonous in cottonseed cake or meal since it is
combined with protein as to render it harmless.
Any free gossypol which may be present occurs
in such a small amount that harmful effects will
not follow if animals are fed normally. Ill effects
which have been reported are the result of over-
feeding with cottonseed cake or meal alone, the
proteins in these substances not being adequate
to maintain normal growth; other articles must
be used in the diet. Gossypol has the formula
C30H30O8; its structure has been the subject of
extensive researches by Adams and his colleagues
(J.A.C.S., 1937, 59, 1938, 60).

Uses. — Cottonseed oil possesses the nutritive
and emollient properties of the fixed vegetable
oils. Occasionally it is used, in large doses (30
ml.), as a lubricant cathartic. It is used by some
manufacturers as the solvent or vehicle for pre-
paring certain injections, as of estrogenic sub-
stances. The N.F. uses it as the vehicle of camphor
liniment. The oil has the disadvantage of becom-
ing gummy on exposure to air.

Nearly three-fourths of the cottonseed oil pro-
duced in the United States is used in the manu-
facture of lard substitutes of various kinds; for
such use some or all of the oil is hardened by
hydrogenation so that the product may have the
desired degree of hardness. Most of the remainder
of the oil is used in making cooking and salad oils,
and margarine, and the oil which is unsuitable for
refining is made into soap, [v]

Dose, 8 to 30 ml. (approximately 2 to 8 flui-
drachms).

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Camphor Liniment, N.F.

COUMARIN. N.F.

[Coumarinum]

aCH=CH
0-C=0

"Coumarin, C6H4(CH)2OCO, is the lactone of
ortho-hydroxycinnamic acid." N.F. VII.

Cumarin; Tonka Bean Camphor. 1,2-Benzopyrone.

Coumarin is found widely distributed through
the vegetable kingdom, notably in the tonka bean,
in several species of clover, in several sweet-
scented grasses, in the composite Trilisa odoratis-
sima Cass (Liatris odoratisshna Willd) (com-

monly known as vanilla leaf or hound's tongue),
in Asperula odorata L. (or sweet woodruff) and in
some species of orchids. It may be extracted from
the plants by boiling with 80 per cent alcohol.

Coumarin was first synthesized by Perkin by
heating the sodium derivative of salicylaldehyde
with acetic anhydride. Instead of using the so-
dium compound, a mixture of the aldehyde itself,
acetic anhydride and sodium acetate is now com-
monly employed in synthesis. The salicylaldehyde
may be prepared from phenol by the Reimer-
Tiemann process employing chloroform and con-
centrated sodium hydroxide.

Description. — "Coumarin occurs as colorless,
prismatic crystals, with a characteristic, fragrant
odor, and a bitter, aromatic, burning taste. Cou-
marin is slightly soluble in water. It is freely sol-
uble in alcohol, in ether, in chloroform, and in
fixed or volatile oils. Coumarin melts between 68°
and 70°." N.F.

Standards and Tests. — Identification. — A
brown, flocculent precipitate is formed on adding
iodine T.S. to a saturated aqueous solution of
coumarin; on shaking the precipitate coalesces
to form a dark green, curdy mass, leaving a clear
supernatant liquid (distinction from vanillin).
Distinction from vanillin. — Coumarin is not ex-
tracted from an ether solution by ammonia T.S.
Acetanilid. — The disagreeable odor of phenyliso-
cyanide is not evolved on heating 100 mg. of
coumarin with 1 ml. of a 1 in 4 solution of so-
dium hydroxide in alcohol and a few drops of
chloroform. N.F.

Uses. — Coumarin has no recognized medicinal
usage, having been employed only for its odorous
qualities. Tests by the Federal Food and Drug
Administration, made some years ago before
coumarin was considered to be a toxic substance,
indicate that 1 part of coumarin is approximately
equivalent, in flavor, to 3 parts of vanillin. It
was much used as a flavoring agent for medicinal
substances, to mask unpleasant odors (as of iodo-
form), as an ingredient of imitation vanilla ex-
tracts, and as a fixative for perfumes.

In 1953 the report of a private pharmacologic
testing laboratory that coumarin is toxic to ani-
mals resulted in the voluntary withdrawal of cou-
marin from the market, and also a federal prohi-
bition of its use, as a food flavor, notably of
chocolate products. While no publication of the
toxicological data in question has come to our
attention, it appears that there is basis for con-
cern that coumarin, which is related to bishydroxy-
coumarin, may induce a hemorrhagic tendency on
prolonged ingestion. In his review of the pharma-
cology and toxicology of coumarin, Jacobs (Am.
Perfumer, 1953, 62, 53) states that while not a
single instance of serious physiological effects in
humans from use of coumarin in food products
has been reported, there have been three cases of
pathological effects, including hemorrhage, attrib-
utable to therapy with coumarin (Dominici, Rass.
din. sci., 1st biochim. ital., 1948, 24, 233); it is
not indicated for what therapeutic purpose the
coumarin was used.

Coumarin is recognized officially only because
it is an ingredient of aromatic castor oil; the
small proportion of it present in the oil, and the

Part I

Creosote

399

relatively infrequent use of the preparation by
any one person, makes it extremely unlikely that
such use may in any wise be dangerous.
Off. Prep.— Aromatic Castor Oil, N.F.

CREOSOTE. N.F., B.P.

Creasote, Wood Creosote, [Creosotum]

"Creosote is a mixture of phenols obtained
from wood tar." N.F. The B.P. defines it as a
mixture of cresol, guaiacol and other phenols ob-
tained from the distillation of wood tar.

Kreosotum. Fr. Creosote officinale. Ger. Kreosot ;
Buchenholzteerkreosot. It. Creosote Sp. Creosota.

When wood tar (see Pine Tar) is subjected to
fractional distillation the first portion of the dis-
tillate is an oily liquid analogous to the crude
carbolic acid obtained from coal tar. This phenolic
solution constitutes the substance known as creo-
sote, in crude form. Its composition varies ac-
cording to the source of tar from which it has
been distilled; the tar from the hard woods, such
as beech, oak, and maple, as a rule yields a larger
proportion of phenolic substances than that from
pines and other coniferous trees.

Creosote is contained only in those fractions of
the distillate heavier than water. After agitation
of the distillate with sodium hydroxide, insoluble
oils are separated, and the mixture is heated to
hasten oxidation of certain impurities. The alka-
line solution is treated with dilute sulfuric acid,
and the crude creosote which separates is again
submitted to further treatment with alkali and
acid until the creosote no longer becomes brown
on exposure to air, but only slightly reddish. It is
then dissolved in a strong solution of sodium hy-
droxide and distilled; the fraction distilling in the
range of 200° to 220° is creosote.

Creosote may also be extracted from pyrolig-
neous acid. The name creosote refers to its anti-
septic properties, being derived from xoe«5, flesh,
and ocb^co, / preserve.

Composition. — Creosote is a mixture, in in-
definite proportions, of a large number of phenolic
bodies, of which at least ten have been identified.
The most abundant single ingredient is usually
creosol (methyl guaiacol), and the next is guaia-
col. Sickman and Fischelis (/. A. Ph. A., 1929,
18, 1145), from a study of 16 samples of creosote,
found that these two together constituted, on the
average, approximately 50 per cent, although
there was considerable variation between indi-
vidual samples. The experiments, however, of
Gershenfeld, Pressman, and Wood (/. A. Ph. A.,
1933, 22, 198) indicate that these are not the
most important ingredients from the therapeutic
standpoint. They found that many of the other
ingredients, especially the xylenols of which there
are present at least two isomers, were three or
four times as powerful germicidally as either of
the pyrocatechol derivatives. If any considerable
portion of the creosote distils below 203° it is
likely to contain cresol. In the experiments of
Gershenfeld et al., it was found that all of the
various fractions distilling from 187° to 210° were
more toxic than the higher distilling fractions.

Description. — "Creosote is an almost color-
less or yellowish, highly refractive, oily liquid,

having a pentrating, smoky odor, and a burning,
caustic taste. It does not readily become brown
on exposure to light. Creosote is combustible,
burning with a luminous, smoky flame. Creosote
is slightly soluble in water, but is miscible with
alcohol, with ether, and with fixed or volatile
oils. The specific gravity of Creosote is not less
than 1.076°. Creosote begins to distil at about
203°, and not less than 90 per cent of it, by
volume, distils between 203° and 220°." N.F.

Mixed with water, creosote forms two layers,
the upper consisting of one part of creosote and
about 80 of water, the lower of one part of water
and 10 of creosote. Creosote dissolves a large
proportion of iodine, of phosphorus, and of sul-
fur, especially when warmed. It also dissolves a
number of metallic salts and reduces some of
them to the metallic state, as, for example, silver
nitrate and acetate.

Standards and Tests. — Identification. — A
transient violet-blue color forms on adding 1 drop
of ferric chloride T.S. to 10 ml. of a saturated
aqueous solution of creosote; the liquid becomes
cloudy almost instantly, its color changing rapidly
from grayish green to muddy brown, finally pro-
ducing a brown precipitate. So-called coal-tar
creosote. — The volume of the creosote layer
which separates after shaking a mixture of 4 ml.
of creosote, 4 ml. of glycerin and 1 ml. of dis-
tilled water equals or exceeds the volume of
creosote taken. Hydrocarbons and bases. — Not
less than 10 ml. and not more than 18 ml. of 1 N
sodium hydroxide is required to dissolve 2 ml.
of creosote; the liquid remains clear on dilution
with 50 ml. of distilled water. Phenol and so-
called coal-tar creosote. — No permanent coagu-
lum results on mixing equal volumes of creosote
and collodion in a dry test tube. Other impurities.
— An agitated mixture of 1 ml. of creosote, 2 ml.
of petroleum benzin and 2 ml. of freshly pre-
pared barium hydroxide T.S. separates into three
distinct layers on standing; the upper layer is
neither blue nor brown. N.F.

Incompatibilities. — Creosote produces with
ferric salts a bluish color and usually a brown
precipitate. With lead subacetate it forms a
white precipitate. When triturated with strong
oxidizing agents creosote may cause an explo-
sion. Gums may be precipitated by it. The
tendency of creosote to permeate the wall of a
gelatin capsule may be lessened by mixing it
with twice its volume of olive or expressed
almond oil.

Uses. — Creosote has been used as an anti-
septic externally and an expectorant internally.
The early hope of its serving as a systemic anti-
bacterial agent has been abandoned.

Action. — The physiological effects of creosote
resemble those of phenol. It is absorbed from
the gastrointestinal tract and excreted, in part,
in the urine as conjugation products with sul-
furic and glucuronic acids. Following oral ad-
ministration of therapeutic doses it does not
appear to be excreted by the lungs (J.A.M.A.,
1938, 110, 209), although it has been claimed
that after intravenous administration of guaiacol
there is evidence of excretion of that substance
in the sputum.

400

Creosote

Part I

Topically creosote, like phenol, is a paralyzant
to sensory nerves; it possesses irritant, anesthetic,
and germicidal actions. It is less caustic, and
probably less anesthetic, than phenol, but it is
considerably more germicidal. Gershenfeld. Press-
man, and Wood (/. A. Ph. A., 1933, 22, 198)
found that against Bacillus typhosus and Staphy-
lococcus aureus the phenol coefficient of various
samples of creosote ranged between 2.4 and 3.9.

Although the composition of even genuine
beechwood creosote varies considerably in the
proportion of guaiacol and creosol present the
physiological and therapeutic actions of these
constituents are so similar that variation in their
proportion is of little consequence.

Expectorant. — Creosote was introduced in
the treatment of pulmonary tuberculosis with
the idea that it would exercise an antiseptic
action in the lungs. In tubercular states it was
given in large doses, well diluted. There is no
evidence, however, that the drug can reach
pulmonic tissue, in sufficient concentration to
have any direct antibacterial action (Fellows,
Am. J. Med. Sc, 1939, 197, 683). Kraus et al.
(Ztschr. ges. exp. Med., 1932, 83, 567) showed
that it is excreted through the bronchial mucosa;
by virtue of this action creosote has been em-
ployed in treating chronic bronchitis. Brown
(J.A.M.A., 1937, 109, 268) reported that creo-
sote improved the odor and taste of foul sputum.
Because of its irritant action it should not be
used in acute bronchitis. Creosote has been
added to steam inhalations but it is rather irri-
tating for this purpose and its chief value is
probably the characteristic odor imparted to
the atmosphere of the room.

Creosote has been recommended as a gastro-
intestinal antiseptic in the treatment of fermenta-
tive gastritis and enteritis and for its local
anesthetic action upon the gastric mucosa in
nausea and vomiting. It is, however, irritating
to the gastrointestinal tract.

Antiseptic. — Externally it has been used as
a surgical disinfectant. It is more actively anti-
septic and less poisonous than phenol but because
of its stronger odor and greater cost it is not
popular as a general surgical disinfectant. When
there is foul discharge, as in fetid leukorrhea,
otorrhea, empyema or gangrene, its use was
preferred by some practitioners. Creosote is also
useful in various skin diseases, both for its local
anesthetic and antibacterial properties. In capil-
lary hemorrhages it has some power as a hemo-
static, but is not capable of arresting bleeding
from large vessels. As a local application it may
be employed in strengths of from 1 to 10 per
cent, according to the purpose for which it is
used. By virtue of its local anesthetic and anti-
septic actions, it is employed by dentists for
obtunding sensitive dentine and as an ingredient
of pastes for destruction of nerves. One or two
drops of the pure substance are carefully intro-
duced into the hollow of the tooth on a little
cotton, avoiding contact with the tongue or
cheek; the hollow of the tooth must be well
cleansed before it is applied. lY]

Toxicology. — In overdose creosote acts as a
poison, producing giddiness, dim vision, circula-

tory collapse, convulsions, and coma. It is less
poisonous than phenol and doses as high as
2 to 4 ml. have been administered three times
a day without harmful results. Freudenthal {Med.
Rec, April, 1892) reported a case of a woman
who took six hundred drops of creosote in a
very short time, the ingestion being followed
almost immediately by unconsciousness with in-
tense trismus, contracted immobile pupils, and
general cyanosis, but recovery followed practi-
cally without administration of remedies; subse-
quently this same patient by graduating the dose
was able to take five hundred drops daily without
ill effect. Thorling (Upsala lakarej. fdrh., Sept.
1, 1921) reported a case of fatal poisoning in
an infant of two months from what was esti-
mated to be 0.6 ml. of creosote. Icterus and evi-
dence of destruction of the blood cells were
prominent symptoms. Treatment consists in
evacuation of the poison and administration of
stimulants (see Phenol).

The dermatitis caused by the handling of creo-
sote-dipped wood in industry- is minimized by a
coating of soft paraffin on the hands (/. Indust.
Hyg. Toxicol., 1943, 25, 418).

Dose. — The usual dose of creosote is 0.25 ml.
(approximately 4 minims) 3 or 4 times a day,
which may be gradually increased. When being
used freely it should never be given in the form of
capsules, but rather dissolved or dispersed in
either water or milk; the patient should take at
least one-half an ounce of fluid for every drop
of creosote.

Storage. — Preserve "in tight containers, pro-
tected from light, and avoid excessive heat." N.F.

CRESOL. U.S.P., B.P., IP.

[Cresol]
CH3.CeH4.OH

"Cresol is a mixture of isomeric cresols ob-
tained from coal tar. It contains not more than
5 per cent of phenol (CeHeO)." U.S.P. The B.P.
defines it as a mixture of cresols and other phenols
obtained from coal tar. The LP. definition is
identical with that of the U.S.P. but not less than
50.0 per cent of w-cresol is required.

IP- Cresolum. Tricresol; Oxytoluene: Methylphenol;
Cresylic Acid. Cresolum; Cresolum Crudum; Cresylolum.
Fr. Cresylol officinal; Phenols cresyliques; Cresols. Ger.
Rohes Kresol; Rohkresol. It. Cresolo grezzo. Sp. Cresol.

There are three isomeric cresols: ortho-cresol,
melting at 30° and boiling at 191° to 192°;
meta-cresol, a liquid boiling at 202° and melting
at 11° to 12°; and para-cresol, forming colorless
prims, melting at 35.5° and boiling at 201.8°.
These cresols are all obtainable by fractional
distillation from that portion of coal tar boiling
between 190° and 210°. The official drug is a
mixture of all three, with meta-citsol being the
predominant constituent.

Description. — "Cresol is a colorless, or yel-
lowish to brownish yellow, or pinkish, highly re-
fractive liquid, becoming darker with age and on
exposure to light. It has a phenol-like, some-
times empyreumatic odor. A saturated solution
of Cresol is neutral or only slightly acid to litmus.
One ml. of Cresol dissolves in about 50 ml. of

Part I

Cresol Solution, Saponated 401

water, usually forming a cloudy solution. It is
miscible with alcohol, with ether, and with
glycerin, and is dissolved by solutions of the
fixed alkali hydroxides. The specific gravity of
Cresol is not less than 1.030 and not more than
1.038. Not less than 90 per cent by volume of
Cresol distils between 195° and 205°." U.S.P.

The B.P. specifies that not more than 2 per
cent v/v distils below 188°, and not less than
80 per cent v/v between 195° and 205°; the LP.
requires that not more than 6.0 per cent v/v boils
below 185°, not less than 50.0 per cent distils
below 195°, and not less than 90 per cent distils
below 205°.

Standards and Tests. — Identification. — Fer-
ric chloride T.S. produces a bluish violet color
when added to a saturated solution of cresol.
Hydrocarbons. — A solution of 1 ml. of cresol in
60 ml. of water is no more turbid than a mixture
of 1.5 ml. of 0.02 N sulfuric acid, 1 ml. of barium
chloride T.S. and 58 ml. of water which has
been allowed to stand 5 minutes. Phenol. — The
quantitative colorimetric method employed is that
of Chapin (Ind. Eng. Chem., 1920, 12, 771),
based on the fact that under certain conditions
Millon's reagent (containing mercurous nitrate)
yields a red color with phenol but not with cer-
tain other phenols. In the test formaldehyde is
used to bleach the red color in order that the
yellow color produced by cresols may be com-
pensated for. U.S.P.

Uses. — Cresol is used in medicine solely for
its disinfectant properties. It far surpasses
phenol in power, both as a germicide and anti-
septic. Ditthorn (/. Soc. Chem. Ind., 1920, 39,
799A) found that, of the three isomers, meta-
cresol is the most actively germicidal and that
the or/Ao-cresol is slightly weaker than para-
cresol. Klarmann (7. Bad., 1929, 17, 423) re-
ported the phenol coefficient of meto-cresol as
2.5. Because of the sparing solubility of cresol
in water it is generally employed in the form
of a 50 per cent soapy solution or emulsion
(see Saponated Cresol Solution).

Cresol is used chiefly as a surgical disinfectant,
both for the purpose of sterilizing instruments
and as a wound dressing. For the former purpose
3 to 5 per cent of the saponated solution should
be employed, while for application to wounds one
per cent of the saponated solution (representing
one-half per cent of cresol) is generally recom-
mended. A 1 in 500 dilution of the 50 per cent
soapy emulsion is used as a vaginal douche. A
2 per cent solution of cresol is suitable for a
hand wash. Cresol is used to disinfect the excreta
of patients with contagious diseases in 5 per cent
concentration. Cresol has been employed to a
limited extent as a gastrointestinal antiseptic in
various types of enteritis and gastritis. For this
purpose 0.06 to 0.12 ml. (approximately 1 to 2
minims) of the cresol, well diluted, may be given.

Cresol is sometimes employed, in concentra-
tions of 0.25 to 0.5 per cent, as a bacteriostatic
agent in parenteral solutions. Vanderkleed and
E'we reported, however, that cresol acts as an
alkaloidal precipitant under certain conditions
and advise against the use of cresol as a pre-
servative in alkaloidal solutions, [v]

Toxicology. — Cresol is perhaps somewhat
less toxic than phenol, but the difference is not
very great, and there have been a number of fatal
cases of cresol poisoning reported from its use
as a douche as well as from swallowing. Deich-
mann and Witherup (/. Pharmacol., 1944, 80,
233) compared the toxicity of the three cresols
and phenol. The total amount, rather than the
concentration, of the solution was found to be
the important factor in either oral or percutane-
ous poisoning. Phenol and ^-cresol were about
equally toxic; w-cresol was the least toxic. They
found that soap and much water removed these
substances from the skin effectively; 50 per cent
alcohol was also effective but it may be absorbed
in sufficient amount either through the skin or
by mouth to aggravate the collapse induced by
the cresol. On the skin, it causes erythema, a
burning sensation and then numbness. In the
eye, severe damage results. After ingestion,
there is a severe burning sensation in the mouth
and upper abdomen, dysphagia, vomiting and
later diarrhea. White burned spots are seen on
mucous membranes. Unconsciousness and circula-
tory collapse follow. If the patient survives a
few days, jaundice, oliguria and uremia develop
(von Oettingen, Nat. Inst. Health Bull., 1949,
190, 68). Friedlander (Therap. Monatsh., 1907)
recommended as antidotes large quantities of oil
or white of egg, which he believed act by pre-
venting absorption; milk and watery fluids are
to be avoided (see also under Phenol).

As a disinfectant, a 1 to 5 per cent solution is
used on utensils. A 0.5 per cent solution has been
used on wounds, and a 0.1 per cent as a vaginal
douche. It is not prescribed by mouth; the B.P.
1932 listed an oral dose of 0.06 to 0.2 ml. (ap-
proximately 1 to 3 minims).

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

SAPONATED CRESOL SOLUTION.

N.F. (B.P.)

Compound Cresol Solution, [Liquor Cresolis Saponatus]

"Saponated Cresol Solution contains, in each
100 ml., not less than 46 ml. and not more than
52 ml. of cresol. It is prepared by the saponi-
fication of a mixture of cresol with vegetable
oils, or the mixed fatty acids derived therefrom,
excluding coconut and palm kernel oils. The
vegetable oil may be corn, cottonseed, linseed,
or soya bean, or similar oils which have a saponi-
fication value not greater than 205, and an
iodine value not less than 100." N.F.

B.P. Solution of Cresol with Soap. Liquor Cresolis Corn-
positus; Cresolum Saponatum. Fr. Cresol savonneux. Ger.
Kresolseifenlosung. It. Cresolo saponato. Sp. Cresol
jabonoso; Solution de Cresol Saponificada.

Saponated cresol solution may be prepared
extemporaneously by mixing 350 ml. of the vege-
table oil with 55 ml. of alcohol, and adding to
this a hot solution of 73 Gm. of potassium
hydroxide in 100 ml. of purified water while
stirring the mixture vigorously with a mechanical
stirrer; the stirring is continued until a small
portion of the soap dissolves to form a clear
solution in hot purified water. To the soap is

402 Cresol Solution, Saponated

Part I

added 500 ml. of cresol, the mixture stirred
until a clear solution is obtained, and finally
enough purified water to make 1000 ml. of solu-
tion. If desired, 37 Gm. of sodium hydroxide
may be used in place of 58 Gm. of the potassium
hydroxide; also, the alcohol may be replaced
with 20 ml. of oleic acid, in which case the
oil is warmed to 85° before adding the solution
of alkali and the mixture heated, if necessary, to
complete saponification. The quantities of alkali
directed to be used have been calculated on the
assumption they contain 85 per cent of KOH
and 95 per cent of NaOH, respectively; if the
content of alkali is different, an equivalent
amount of the respective hydroxides shall be
used. N.F.

As indicated in the official definition, saponated
cresol solution may also be prepared from the
total fatty acids of vegetable oils. Martin and
Prout (/. A. Ph. A., 1940, 29, 327) found that
the solution may be rapidly prepared by replacing
the oil with sodium oleate or sodium stearate,
240 Gm. of either soap being employed with 500
ml. of cresol and enough water to make 1000
ml.; the mixture is heated to about 65° until
solution is effected. The reason for excluding
coconut and palm kernel oils from use in pre-
paring the solution, notwithstanding that their
soaps potentiate the germicidal properties of
cresol to a greater degree than do the soaps of
the other oils (as established by Enright, Harvey
and Beal, of the Mellon Institute, in 1930), is
that the former soaps are more irritating than
those officially permitted, and would therefore
be objectionable when the solution is to be applied
to the more sensitive tissues of the body.

The B.P. adds 180 Gm. of linseed oil to a
solution of 42 Gm. of potassium hydroxide in
250 ml. of distilled water and directs the mixture
to be heated on a water bath until a portion dis-
solves in water without separation of oily drops;
500 ml. of cresol is added and. after mixing,
enough distilled water to make 1000 ml.

The B.P. cautions that: "The use of the name
Lysol as a synonym for Solution of Cresol with
Soap, is limited to Great Britain and Northern
Ireland. In parts of the British Empire, in which
the word Lysol is a trademark, it may be used
only when applied to the product made by the
owners of the trademark."

Description. — The N.F. does not provide a
description. The B.P. describes the solution as
an amber to reddish-brown liquid having the
odor of cresol and being soapy to the touch; it
is miscible with water in all proportions up to
10 per cent v/v, also in all proportions with 95
per cent alcohol. Although a clear solution is
formed with distilled water, with tap water
saponated cresol solution produces some turbidity
as a result of the precipitation of calcium soaps.
This does not affect, apparently, the efficacy of
the preparation.

Standards and Tests. — Characteristics of the
liberated fatty acids. — After distilling the cresol
out of 50 ml. of the solution, to which water and
diluted sulfuric acid have been added, the liber-
ated fatty acids in the residual liquid are ex-
tracted with ether. The ether solution is dried

with anhydrous sodium sulfate, the solvent evapo-
rated frim the filtered solution, and the residue
of acids dried at 105° for 1 hour. The acid value
of the acids is required to be not more than
205, the iodine value not less than 95. U.S.P.

The B.P. provides the following tests, among
others: (1) A mixture of 5 ml. of the solution
with 95 ml. of water is clear and shows no
opalescence on standing for 3 hours. (2) Not
more than 0.6 ml. of 1 N hydrochloric acid is
required for neutralization of 5 ml. of the solu-
tion mixed with 50 ml. of neutralized alcohol
(95 per cent), using phenol red as the indicator.

Assay. — A 50-ml. portion of solution is mixed
with 150 ml. of purified kerosene and 3 Gm. of
sodium bicarbonate and the cresol, with kero-
sene, distilled out of the mixture. After washing
the kerosene solution of cresol with 50 per cent
sulfuric acid and then discarding the latter, the
cresol in the former is extracted with a 15 per
cent sodium hydroxide solution; the increase in
volume of the sodium hydroxide solution repre-
sents the volume of cresol in 50 ml. of saponated
cresol solution. The assay is based on the fact
that cresol, being phenolic, is dissolved in the
sodium hydroxide solution, increasing the volume
of the latter by an amount equal to the volume
of cresol present. In order that purification of
the cresol distillate may be effected, and the
proportion of the phenolic substance present de-
termined, it is essential to use a water-immis-
cible liquid, such as kerosene, in the assay. After
the amount of cresol present is determined the
alkaline solution is acidified, the liberated cresol
separated, washed with calcium chloride solution,
dried with anhydrous calcium chloride, filtered
and a definite volume of it distilled. At least 90
per cent of the cresol is required to distil between
195° and 205°. N.F.

The B.P. method of assay is quite different
from that of the N.F. The cresol is distilled out
of the saponated solution after adding a large
volume of kerosene ; from the kerosene and cresol
solution obtained in the distillate (from which
the aqueous phase has been separated and this
discarded) the cresol is extracted by shaking
with a solution of sodium hydroxide; finally,
the volume of cresol is calculated by difference,
from observation of the volume of sodium hy-
droxide solution required to make up the total
volume to 100 ml. (a small correction is intro-
duced because the total volume is slightly less
than the sum of the volumes of the two com-
ponents).

Alcohol Content. — Not more than 5 per
cent, by volume, of C2H5OH. N.F.

Although this solution forms a clear solution
with distilled water, with tap water it becomes
cloudy, owing to precipitation of lime soaps.
This change, however, does not appear to inter-
fere with its therapeutic properties.

Uses. — Because of the sparing solubility of
cresol in water it is generally employed in the
form of a soap solution or emulsion. This solu-
tion retains the germicidal properties of the
cresol; thus Fox (Report of the Commissioner
of Health of the State of Pennsylvania, 1907, p.
123) found that one per cent of the official sapo-

Part I

Cubeb

403

nated cresol solution kills non-sporulating bac-
teria after two minutes' exposure and is superior
to a one per cent solution of phenol. McClintock
(U. S. Hyg. Lab. Bull., No. 82, April, 1912)
reported the phenol coefficient of saponated cresol
solution as 3.0 when organic matter is absent
and 1.87 when it is present. There is some
difference in the germicidal powers of the various
cresols so that the mixture which is known offi-
cially as cresol varies more or less in activity.
Cresol is less caustic than phenol, but the state-
ment that it is much less poisonous has been
shown to be untrue. Many deaths are reported
annually from solutions of this type. The solution
is especially useful for sterilizing instruments and
the skin, its soapy nature making it particularly
valuable for the latter purpose. It may be diluted
with from 30 to 90 volumes of water. It has
been occasionally used internally as an antiseptic
in fermentative gastritis. For further information
see under Cresol. S

Storage. — Preserve "in tight containers."
N.F.

CUBEB. N.F.

Cubeb Berries, [Cubeba]

"Cubeb is the dried, nearly full-grown, un-
ripe fruit of Piper Cubeba Linne filius (Fam.
Piperacece). Cubeb yields not less than 13.0 ml.
of volatile cubeb oil from each 100 Gm. of
drug." N.F.

Cubebs; Cubeb Berries; Tailed Pepper. Cubebae Fruc-
tus; Piper Cubeba; Piper Caudatum. Fr. Cubebe; Poivre
a queue. Ger. Kubeben; Cubebenpfeffer. It. Pepe cubebe.
Sp. Fruto de cubeba.

Piper Cubeba is a climbing perennial plant,
with a smooth, flexuous, jointed stem, and entire,
petiolate, oblong or ovate-oblong, acuminate
leaves, rounded or obliquely cordate at the base,
strongly nerved, coriaceous, and very smooth.
The flowers are dioecious and in spikes. The fruit
is a globose drupe, with a stem-like portion at-
tached to its base which represents a develop-
ment of the pericarp called the thecaphore. This
species of Piper is a native of Java, Borneo and
Sumatra. It is extensively grown in the coffee
plantations, supported by the trees which are
used for shade, and has been introduced into
Ceylon and the West Indies. The fruits are
found in numbers of 50 or more on each spike.
They are collected while still green, though full
grown, and dried in the sun. In 1952, a total of
2,240 pounds of Cubeb was imported into the
U. S. A. from Indonesia.

In various parts of the world the fruits of
other species of Piper have been used by the
natives and sometimes enter commerce under the
name of false cubebs. Among the more impor-
tant of these are the following:

African cubebs (also known as Congo cubebs,
African black pepper, or Guinea pepper). These
are apparently derived from the P. Clusii or the
P. Guineense. According to Rosenthaler (Pharm.
J., 1927, 2, 29) they may be distinguished from
the genuine cubeb in that in both of the false
species the seed grows into, and is attached to,
the pericarp, whereas in the genuine cubeb it lies

in a cavity, and also by their color reaction with
sulfuric acid — the pericarp of the true cubeb
shows a bright red color when touched with
sulfuric acid, that of the P. Clusii a violet, and
the P. Guineense a brownish.

The chief false cubeb of English commerce is
apparently from the P. crassipes Korthals — which
some believe to be identical with the P. ribesioides
Wallich — and the Keboe cubeb (or Karbauw ber-
ries) from the P. mollis simum. For further in-
formation on these false cubebs see Goester and
Steenhauer (Phartn. Weekblad, 1927, 64, 870).
Hartwich classified the false cubebs into three
groups: (1) fruits of the Piperacece having slen-
der stalks (like the true cubebs), (2) fruits of
Piperacece without stalks, and (3) fruits from
other plants bearing some superficial resemblance
to cubeb ; this means of distinguishing these vari-
ous fruits was summarized in the U.S.D., 21st
edition, p. 394.

Description. — "Unground Cubeb occurs as a
fruit, the upper portion of which is nearly globu-
lar, from 3 to 6 mm. in diameter, the lower
portion being abruptly contracted into a slender
stem-like portion seldom exceeding 7 mm. in
length. The pericarp is dusky red to moderate
brown, rarely grayish in color, coarsely reticu-
late, and about 0.3 mm. in thickness. The fruit
is 1-locular, and 1-seeded, the seed being at-
tached at the base of the pericarp and usually
not completely filling the loculus. Cubeb has an
aromatic, characteristic odor, and a strongly aro-
matic and pungent taste." N.F. For histology see
N.F. X.

"Powdered Cubeb is moderate yellowish brown
to dusky brown. The starch grains are numerous,
single and compound, the individual grains being up
to \2\i in diameter. The stone cells are numerous
in palisade-like groups, with rather prominent
dark lumina and yellowish, much thickened,
lamellated, pitted walls. Fragments of wood bun-
dles are few, with spiral vessels, tracheids, and
fibers, the latter up to 1 mm. in length with
blunt, rounded, or very much attenuated ends,
the walls being strongly lignified and having
numerous oblique pits." N.F.

Standards and Tests. — Identification. — A
purplish color develops in 1 drop of sulfuric acid
placed on powdered or crushed cubeb and viewed
downward against a white background. Shriveled
and immature fruits. — Not over 10 per cent.
Stems. — Not over 5 per cent. Foreign organic
matter. — Not over 2 per cent, other than shriv-
eled and immature fruits and stems. Acid-insoluble
ash. — Not over 2 per cent. N.F.

Assay. — The volatile oil in 20 Gm. of cubeb,
preferably coarsely comminuted, is estimated as
directed in the official Volatile Oil Determination.
N.F.

Constituents. — The most obvious constituent
of cubeb is the volatile oil, the proportion of
which varies from 5 to 20 per cent. It is a mixture
of several terpenes and the sesquiterpene cadi-
nene.

The oil distilled from old cubeb deposits on
cooling large, transparent inodorous octahedra
of camphor of cubeb, C15H2GO.

Another constituent of cubeb is cubebin,

404

Cubeb

Part I

C20H20O6. This is an odorless substance, crystalliz-
ing in small needles or scales, melting at 132°, hav-
ing a bitter taste in alcoholic solution; it is soluble
in alcohol, chloroform, and ether. On oxidation it
yields cubcb-inolide, identical with hinokinin, a
naturally occurring phenolic resin. For chemical
structure of cubebin see Haworth {Chemistry
and Industry, 1936, p. 901). It is devoid of im-
portant physiological properties. Cubebic acid,
a white amorphous substance, is present in the
proportion of about 1 per cent; the therapeutic
value of the drug has been said to be largely
due to this constituent. There is also about 3
per cent of amorphous resin. Cubeb gradually de-
teriorates on standing in consequence of the
loss of its volatile oil.

Clevenger {J.A.O.A.C, 1937, 20, 140) reported
on the yield of resin and volatile oil from cubeb,
and gave data on physical and chemical prop-
erties. Adulteration is most readily detected by
the physical characteristics of the volatile oil.
These are given in Bull. X.F. Com., 1939. 7, 293.

Uses. — Cubeb. because of its local irritant
action, acts as a stimulant to the mucous mem-
branes. Its active principles appear to be capable
of absorption and elimination through the kid-
neys, exerting their characteristic effects upon the
mucous membrane of the genitourinary tract.
Formerly it was widely used in the treatment of
the latter stages of gonorrheal urethritis and occa-
sionally in chronic bronchitis and as a local
remedy in the form of lozenges for the relief of
relaxed conditions of the throat. The most com-
monly used dosage form was cubeb oleoresin,
which was official in X.F. IX. This was prepared
by extracting cubeb with alcohol, evaporating
the alcohol, and separating the liquid portion
from the waxy and crystalline portion; the liquid
portion was the one employed. Jordan (Bio-
chem. J., 1911, 5, 274) found that the volatile
oil, when taken by mouth, exerts a positive, if
not very strong, antiseptic effect on the urine.
At present, however, it is rarely employed.

Dose, of powdered cubeb, 0.6 to 4 Gm. (ap-
proximately 10 to 60 grains).

Storage. — Preserve "in tight containers." N.F.

CYANOCOBALAMIN. U.S.P., B.P., LP.

Vitamin B12 (U.S.P. XIV)

"Cyanocobalamin. assayed by the method de-
scribed below, has a purity of not less than 95
per cent, calculated on the dried basis." U.S.P.

The B.P. requires that Cyanocobalamin. pro-
duced in suitable media by the growth of suitable
micro-organisms or obtained from liver, contain
not less than 95.0 per cent of anhydrous cyano-
cobalamin, calculated with reference to the sub-
stance dried to constant weight at 105°. The LP.
rubric is not less than 95.0 per cent of cyanoco-
balamin, calculated with reference to the substance
dried in vacuo at 105°.

Crystalline Vitamin Bi^. Betalin-12 (Lilly): Bevidox
(Abbott); Cobione (Merck); Rametin (Bio-Ramo).

Historical. — Since 1926 chemists have been
seeking to isolate the anti-pernicious anemia fac-
tor of liver. The search was not easy, for until
recently the only method for testing the activity

of the many fractions which were prepared from
liver was to assay them clinically on untreated
pernicious anemia patients. In 1947, however, a
simplified method of testing was found in the
observation of Shorb (/. Bio. Chem., 1947. 160,
455) that the organism Lactobacillus lactis Dor-
ner required a growth factor, designated the LLD
factor, found in highest concentrations in certain
liver extracts which in other studies had been
demonstrated to contain a factor essential for the
growth of rats. This LLD factor was found to
be present in the liver extracts almost in linear
proportion to the anti-pernicious anemia potency
of the extracts; this suggested the possibility
that the LLD factor might be the anti-pernicious
anemia principle.

With this assay to guide them. Rickes et al. of
the Merck Research Laboratories further purified
clinically active liver fractions and. on April 16,
1948, announced the isolation of a red crystalline
compound possessing to a high degree the activity
of the LLD factor, and also being highly active
in producing positive hematological response in
patients afflicted with addisonian pernicious ane-
mia {Science, 1948. 107, 396; see also Shorb,
ibid., 1948, 107, 397, and West, ibid., 1948, 107,
398). Eight days after this announcement Smith,
of the British Glaxo Laboratories, reported isola-
tion of a red concentrate which yielded a crystal-
line material identical with that separated by the
Merck group (Nature, 194S. 161, 638; Biochem.
J., 1948, 43 (Xo. 1), viii).

Chemical Structure. — The new principle,
called vitamin B12. is an optically active, complex
polyacidic organic base having a minimum molecu-
lar weight of about 1300. It contains 4.5 per cent
of cobalt, also nitrogen and phosphorus; the em-
pirical formula is C61-64H-86-92X14O13PC0. The
cobalt atom is present in a coordination complex
which also contains a cyano group; this cyano
group may be replaced by a hydroxo group, a
nitrito group, or certain other groups, yielding
analogs of vitamin Bi2. Since all these substances
contain cobalt and all the rest of the vitamin B12
molecule except the cyano group the term cobala-
min has been proposed for that part which is
common to all the substances; a suitable prefix,
such as cyano-, hydroxo-, nitrito-. thiocyanato-,
etc., is combined with cobalamin to indicate the
specific form of vitamin B12. On this nomencla-
ture basis the substance commonly referred to as
vitamin B12 is now commonly known as cyano-
cobalamin. It is to be noted, however, that the
term cobalamin is very frequently employed ge-
nerically to refer to any substituted derivative,
including even cyanocobalamin. By reducing cy-
anocobalamin under certain conditions the cyano-
( CX) group is replaced by hydroxo- (OH) group,
yielding the vitamin B12 analog which has been
called vitamin B12* or hydroxo cobalamin. The
analog vitamin B12* is either absolutely identical
with vitamin Bi2« or is very closely related to it;
it has been suggested that vitamin Bi2>> is an
equilibrium mixture of hydroxocobalamin and
aguocobalamin, the latter having a molecule of
water in the coordination complex in place of
the hydroxo-group of hydroxocobalamin (Smith
et al.', Biochem. /., 1952.' 52, 395). Vitamin Bi2*,

Part I

Cyanocobalamin 405

isolated from Streptomyces griseus fermentation
liquors, has been shown to be nitritocobalamin;
it may be prepared from vitamin Bi2b by inter-
action with nitrous acid (Smith et al., ibid., 1952,
52, 389). Vitamin Bi2i, obtained by removing the
nitrite group of vitamin Bi2c, and once thought to
be a new vitamin B12 analog, has been shown to
be identical with vitamin Bi2b, which appears to
be the same as vitamin Bi2a (see above, also
Smith et al., ibid., 1952, 52, 389). It is of interest
that all of these analogs may be converted to
cyanocobalamin by treatment with cyanide solu-
tion.

A large portion of the cyanocobalamin molecule
and related molecules consists of 5,6-dimethyl-
benzimidazole glycosidally linked to a molecule of
ribose which is phosphorylated at the C2 or C3
position; the cobalt-containing moiety appears to
be attached to the phosphoric acid component.
The term ribazole has been applied to the ribose-
dimethylbenzimidazole fragment. Acid hydrolysis
of cyanocobalamin has also yielded two molecules
of Dg-l-amino-2-propanol, and five molecules of
ammonia, one of which is assumed to be derived
from the cyano group.

Commercial Source. — Because the amount
of cyanocobalamin obtainable from liver is very
small — 20 tons of liver containing about one gram
of the vitamin, of which the largest part is lost
during isolation and purification — another source
of the vitamin was sought. Shorb had found the
LLD factor in such materials as fish meal, whey
extracts, eggs, cow manure extracts, and other
natural products. The possibility of production of
the vitamin by a fermentation process suggested
itself, and in a short time Rickes et al. {Science,
1948, 108, 634) announced its isolation from cul-
tures of Streptomyces griseus, the mold which
produces streptomycin. The commercial product
is currently obtained from residue of streptomycin
manufacture (for data see Ind. Eng. Chem., 1954,
46, 843). It is stated that properly processed
sewage sludge, which contains sufficient vitamin
B12 to make recovery economically feasible, may
be used for production of a medicinal grade of
cyanocobalamin. Isolation of vitamin B12 from
fermentation liquors from which neomycin is ob-
tained has been reported (J.A.C.S., 1951, 73, 337).

Description. — "Cyanocobalamin occurs as
dark red crystals or as a crystalline powder. The
anhydrous compound is very hygroscopic and
when exposed to air it may absorb about 12 per
cent of water. One Gm. of Cyanocobalamin dis-
solves in about 80 ml. of water. It is soluble in
alcohol, but is insoluble in acetone, in chloro-
form, and in ether." U.S.P.

Stability. — Cyanocobalamin is very stable in
substantially neutral aqueous solution; such solu-
tions may be autoclaved for 20 minutes at 120° C.
The vitamin is slowly inactivated in alkaline solu-
tion and in strongly acid solution. Reducing
agents, oxidizing agents, and heavy metal ions
decompose it. While vitamin B12 is stable in solu-
tions containing thiamine or niacinamide the find-
ings of Blitz et al. (J.A.Ph.A., 1954, 43, 651)
indicate that when both thiamine and niacinamide
are present large losses of vitamin B12 occur at
elevated temperatures; at normal storage tem-

peratures vitamin B12 is stable in such combina-
tions for long periods (Macek and Feller, ibid.,
1954, 44, 254).

Standards and Tests. — Identification. — (1)
Cyanocobalamin exhibits ultraviolet absorption
maxima within ±1 mn at 278 mix and 361 m.u
and within ±2 mjx at 550 m\i. The ratio of absorb-
ances A3G1/A278 of the solution prepared for the
assay is between 1.62 and 1.88, while that repre-
sented by A361/A550 is between 2.83 and 3.45.
(2) When the vitamin is fused with potassium
bisulfate the cobalt in the residue produces a red
or orange-red color with nitroso R salt. (3) Hy-
drocyanic acid released from cyanocobalamin by
the action of hypophosphorus acid is distilled into
a solution of sodium hydroxide, where it is con-
verted to a blue or blue-green complex by inter-
action with ferrous and ferric (the latter produced
by oxidation of the former) ions. Loss on drying.
— Not over 12 per cent, when dried at 105° for 2
hours at a pressure of not more than 5 mm. of
mercury. Pseudo cyanocobalamin. — Absence of
certain cyano-cobalt pigments is established by
shaking an aqueous solution of cyanocobalamin
with a mixture of carbon tetrachloride and cresol,
which mixture is subsequently shaken with a
dilute sulfuric acid solution: the acid solution is
colorless or has no more color than a reference
solution containing a small amount of potassium
permanganate. U.S. P. The B.P. requires measure-
ments of absorbance to be made at five different
wavelengths, and specifies absorbance ratios for
four of these wavelengths as an identification test
for cyanocobalamin.

Assay. — The purity of cyanocobalamin is cal-
culated from the absorbance of a solution contain-
ing 4 mg. of cyanocobalamin in 100 ml., at 361 mn.
U.S.P., B.P., LP.

Uses. — Vitamin B12 (cyanocobalamin) is the
active antianemia substance in liver extract (West
and Reisner, Am. J. Med., 1949, 6, 643; Cuthbert-
son et al., J. Pharm. Pharmacol., 1949, 1, 705)
and the extrinsic factor of Castle (Berk et al.,
New Eng. J. Med., 1948, 239, 911) which, to-
gether with the intrinsic factor of Castle (see
under Vitamin B12 with Intrinsic Factor Concen-
trate, in Part I) present in normal human gastric
juice, is essential for normal hematopoiesis. Paren-
terally administered, crystalline vitamin B12 pro-
duces the same therapeutic result as does liver
injection in patients with primary (addisonian)
pernicious anemia (Spies et al., J.A.M.A., 1949,
139, 521; Ungley, Brit. M. J., 1949, 2, 1370:
Blackburn et al., ibid., 1952, 2, 245; Murphy and
Howard, New Eng. J. Med., 1952, 247, 818;
Heinle and Bethel, J. A.M. A., 1953, 151, 42). Like
liver extract, an oral dose 30 to 60 times greater
than the parenteral dose is required in primary
pernicious anemia unless intrinsic factor (Hall
et al, Proc. Mayo, 1949, 24, 99; 1950, 25, 105)
is ingested simultaneously. Furthermore, the re-
sponse to oral administration without intrinsic
factor may be incomplete, as it often is with oral
liver extract. In addition, vitamin B12 alleviates
the neurological abnormalities (posterolateral col-
umn sclerosis of the spinal cord and peripheral
neuropathy) and the glossitis often present in this
anemia. Vitamin B12 is effective regardless of its

406 Cyanocobalamin

Part I

source, whether from liver or from Streptomyces
griseus (Erf and Wimer, Blood, 1949, 4, 845).
Vitamin B12 is particularly useful in the patient
with an allergic sensitivity to liver injection
(Berger, AT. Y. State J. Med., 1950, 50, 331).
Cyanocobalamin is one of several "animal protein
factors" which facilitate utilization of vegetable
proteins of low nutritional value (Stokstad et al.,
J. Biol. Chem., 1949, 180, 647).

Action. — Dietary vitamin B12 occurs in liver,
kidney, meat and clams (Procter and Lang. Na-
ture, 1951, 168, 36) and to a lesser extent in
milk and eggs. Human milk contains about 0.41
microgram per liter and cow's milk has 2 or 3
times this concentration (Castle et al., J. A.M. A.,
1951, 146, 1028). Very little is present in plant
foods, including yeast. It is actively synthesized
by bacteria in the intestinal contents of most
mammalian species. In certain geographical areas
the virtual absence of cobalt from soil has been
associated with a macrocytic anemia in sheep re-
sulting from an insufficiency of cobalt for bacterial
synthesis of cyanocobalamin in the intestine
(Smith et al., J. Nutrition, 1951, 44, July). In
man intrinsic factor in the stomach seems to be
essential for normal absorption of cyanocobala-
min. The physiological function of vitamin B12 in
hematopoiesis is closely related to that of folic
acid, and its active form folinic acid, and also to
ascorbic acid; these vitamins are essential in
normal metabolism of protein, nucleoprotein, car-
bohydrate and fat. From studies of bacterial
metabolism it would appear that folic acid is
essential for formation of purines and thymine
from simpler precursors, while cyanocobalamin is
required for the formation, from purines and
pyrimidines, of nucleosides, such as thymidine,
from which nucleotides and hence nucleic acid
arise (Girdwood, Blood, 1952, 7, 77). In mam-
malian tissues cyanocobalamin is found at sites
of active nucleoprofein synthesis, i.e., liver, spleen,
kidney, muscle, skin, brain, gonads and pancreas.
As noted above it has "animal protein factor"
activity which improves protein utilization (Rawi
and Geiger. /. Nutrition, 1952, 47, 119) and
growth in children, animals and fowls. It is in-
volved in the transfer of preformed methyl
groups in metabolism, as in the conversion of
choline and homocystine to methionine (Oginsky.
Arch. Biochem., 1950, 26, April). It is concerned
with fat metabolism, and the normal blood sulf-
hydryl concentration is dependent on adequate
vitamin B12 nutrition (Ling and Chow, /. Biol.
Chem., 1954, 206, 797). The optimal daily dietary
requirement of man or animals is unknown but
the Food and Drug Administration, U.S.A. (Fed.
Reg., Feb. 10, 1954) has recognized its essential-
ity; 0.001 mg. daily parenterally is adequate for
most patients with pernicious anemia. Vitamin B12
activity is found in normal feces and, in fact, also
in those of patients with pernicious anemia. Defi-
ciency states therefore seem to be more related to
failure of absorption or perhaps to diseases caus-
ing an increased need for this factor.

Finch (Med. Clin. North America, 1952, 36,
1223) summarized current knowledge concerning
vitamin B12. Cyanocobalamin in food, or that
synthesized by bacteria in the presence of intrinsic

factor in the stomach, is absorbed across the
mucous membrane; a vitamin Bi2-protein com-
plex is found in blood plasma. Perhaps some in-
trinsic factor remains in the upper small intestine
and absorption may continue. In cases of total
gastrectomy, Swedenseid et al. (Proc. S. Exp-
Biol. Med., 1953, 21, 224) found that oral B12
was not absorbed unless intrinsic factor was given.
It is unknown whether vitamin B12 arising from
bacterial synthesis in the colon is absorbed nor-
mally or in diseased states. At any rate there is
often more vitamin B12 activity in the feces
(Callender and Spray, Lancet, 1951, 1, 1391)
than was ingested. Moreover, sewage contains
considerable vitamin B12 activity (Hoover et al.,
Science, 1951, 114, 213). As noted above, the
vitamin is found in many tissues, particularly in
liver, kidneys and muscle. Following enteral ab-
sorption little if any vitamin B12 activity is found
in urine but after parenteral administration, par-
ticularly of large doses, the vitamin circulates in
the blood in unbound form for about 8 hours,
during which time it is rapidly excreted in the
urine (Mollin and Ross, /. Clin. Path., 1952, 5,
129); after this the vitamin remaining in the
blood is present in bound form (unavailable to
bacteria in the assay method) and very little uri-
nary excretion occurs. Watkin et al. (Fed. Proc,
1954, 13, 161) found that renal clearance of
vitamin B12 paralleled that of inulin; glomerular
filtration occurs in proportion to plasma concen-
tration. After parenteral doses of 0.1 to 1 mg.,
Reisner and Weiner (Blood, 1953, 8, 81) found
51 to 98 per cent of the dose in the urine, but with
a dose of 0.042 mg. very little appeared in the
urine (Sokoloff et al, ibid., 1952, 7, 243). Protein
binding of the vitamin appears to occur at a
rather constant rate regardless of dose. As noted
above, cyanocobalamin appears to be involved in
the conversion of thymine to thymidine, which is
essential in hematopoiesis in the bone marrow and
also in the formation and maintenance of myelin
sheaths of nerve fibers (Peterman and Goodhart,
J. Clin. Nutrition, 1954, 2, 11). It may be in-
volved also in the conversion of conjugated folic
acid present in food into free folic acid and,
along with ascorbic acid, in the conversion of
folic acid to folinic acid which is in turn essen-
tial for conversion of uracil to thymine. In addi-
tion to hepatic lipotropic action, related to trans-
methylation and maintenance of sulfhydryl con-
centration, and formation of certain important
amino acids, other actions have been reported for
vitamin B12, including antihistaminic (Traina,
Nature, 1950. 166, 651. but not confirmed by
Sharpe et al., ibid., 166, 651), hormonal, and
diuretic actions. No clinical diuretic action has
been found (Bedford, Lancet, 1951. 1, 1232).

Megaloblastic Anemia. — In the treatment of
megaloblastic anemias three substances — folic
acid, citrovorum factor (folinic acid) and vitamin
B12 (cyanocobalamin) — have been available in
recent years in numerous dosage forms, including
the pure substances themselves, and also various
concentrates, liver extracts, antibiotic residues,
powdered stomach, etc. Sacks (Ann. Int. Med.,
1954, 40, 375) suggested that the success of
Minot and Murphy in pernicious anemia with

Part I

Cyanocobalamin 407

feeding of whole fresh liver was probably due to
the folic and folinic acid it contained while the
efficacy of subsequently highly purified liver ex-
tracts given parenterally was very likely depend-
ent on the vitamin B12 content since such extracts
contain very little folic acid. Almost all megalo-
blastic anemias respond favorably to folic acid
but in primary pernicious anemia the neurological
changes are not corrected and the hematologic
response is often only temporary (Vilter and
Spies, J. Lab. Clin. Med., 1947, 32, 262). On the
other hand, the megaloblastic anemias of preg-
nancy, infancy, and sprue, and the tropical macro-
cytic anemia fail to respond to vitamin B12 or
liver extract (Davidson et al, Brit. M. J., 1948,
1, 819; Furman et al, Am. Pract., 1950, 1, 146;
Zuelzer and Ogden, /. Lab. Clin. Med., 1947, 32,
1217); these latter seem to involve a deficiency
of folic acid. In pernicious anemia the rapid
though incomplete and temporary hematopoietic
response is thought to arise from a mass action
effect of folic acid on the formation of thymine,
with resulting increase in thymidine formation
but actually a further impoverishment of the tis-
sue supply of cyanocobalamin and resulting ag-
gravation of the neurological lesions. The thera-
peutic effect of vitamin B12 in primary pernicious
anemia is blocked by the simultaneous adminis-
tration of the folic acid antagonist Aminopterin
(Bethell et al, J. Lab. Clin. Med., 1948, 33, 1477).
Thymine, which is 5-methyluracil, in the large
doses of 12 to 15 Gm. daily by mouth corrects
the megaloblastic anemia in cases of primary per-
nicious anemia, nutritional macrocytic anemia and
sprue, according to Spies et al. {Lancet, 1948, 2,
519); this dose is about 1000 times the amount
of folic acid required, which in turn is about 1000
times the amount of vitamin B12 required. Like
folic acid, however, thymine does not benefit the
neurological manifestations of the disease. Vilter
et al. (Proc. Central Soc. Clin. Res., 1953, 26,
#147) found that the ratio of ribonucleic acid to
desoxyribonucleic acid and of uracil to thymine
were abnormally high in the buffy coat of megalo-
blastic marrow aspirates, that therapy with either
cyanocobalamin or folic acid decreased these
ratios toward normal before the increase in reticu-
locyte count appeared in the peripheral blood,
and that the total nucleic acids contained more
thymine and less uracil after therapy. Studies of
erythropoiesis in tissue cultures of bone marrow
have shown that the addition of folic acid or
folinic acid to megaloblastic marrow results in
conversion to normoblastic marrow, whereas the
addition of cyanocobalamin in vitro does not cause
this conversion in either normal blood serum or
serum from patients with pernicious anemia in
relapse (Lajtha, Clin. Sc, 1950, 9, 287). In vivo,
Horrigan et al. (J. Clin. Inv., 1951, 30, 31) in-
stilled 1 microgram of cyanocobalamin into the
marrow of the ilium and found erythroid matura-
tion 48 hours later at this site but not in the
marrow of other bones at a distance from this
injection site; 2 mg. of folic acid did not cause
such local maturation. In vitro, however, addition
of cyanocobalamin together with a thermolabile
substance from normal gastric juice resulted in
conversion to normoblasts. This Bi2-intrinsic fac-

tor complex was inactive as a source of vitamin
B12 in the bacterial assay; heating disrupted the
complex and the B12 became available to bacteria
but the mixture lost its megaloblast-ripening ac-
tion. It was concluded that only a bound form of
vitamin B12 was hematopoietically active (Cal-
ender and Lajtha, Blood, 1951, 6, 1234); Mollin
and Ross (Brit. M. J., 1953, 2, 640) reported a
correlation between the level of bound vitamin
B12 in the blood and the degree of maturation in
the marrow during the treatment of pernicious
anemia with cyanocobalamin. Extensive studies of
Bi2-binding capacity and intrinsic factor activity
of a variety of preparations from gastrointestinal
mucosa seemed to show a correlation until the
work of Spray (Biochem. J., 1952, 50, 587),
Prusoff et al. (Blood, 1953, 8, 491) and others
succeeded in separating these two activities in
gastric juice. Hence, the mechanism seems not
quite so simple as binding of the cyanocobalamin.
Lajtha had observed that tissue culture of normal
normoblastic marrow in the serum of untreated
patients with pernicious anemia showed conver-
sion from normoblasts to megaloblasts. This in-
hibitor of normal maturation could be eliminated
by diluting the pernicious anemia serum with nor-
mal serum or by adding folic acid or the B12-
intrinsic factor combination. The inhibitor was
thermostabile and was also present in the cerebro-
spinal fluid of the anemic patient. Feinmann et al.
(Brit. M. J., 1952, 2, 14), however, found no
inhibitor. Furthermore, an increased rate of de-
struction of erythrocytes, both of the patient and
of normal red blood cells transfused into the
patient, with an increase in bilirubin formation
has long been recognized as a toxic, hemolytic
element in pernicious anemia (Singer et al, J.
Lab. Clin. Med., 1948, 33, 1068; DeGorvin et al,.
ibid., 1952, 40, 790). In conclusion, then, it seems
that both cyanocobalamin and folic acid are
necessary for normal maturation of erythrocytes,
which fails in the total absence of either one, that
cyanocobalamin is required for normal functioning
of the nervous system, that folic acid is absorbed
by mouth in most patients but that the specific
defect in primary pernicious anemia is the failure
to absorb vitamin B12 from the gastrointestinal
tract (Wallerstein et al, J. Lab. Clin. Med., 1953,
41, 363).

The availability of cyanocobalamin labeled
with the radioactive isotope cobalt-60 has further
confirmed this defect in pernicious anemia. Inges-
tion of 0.0005 mg. of labeled cyanocobalamin by
untreated patients with pernicious anemia results
in fecal excretion of 70 to 95 per cent of the dose
(Heinle et al, Tr. A. Am. Physicians, 1952, 65,
214). If a source of intrinsic factor is ingested
simultaneously, only 5 to 30 per cent appears in
the feces. This observation provides both a diag-
nostic criterion for primary pernicious anemia and
an assay method in the human for the intrinsic
factor activity of various substances, which may
be used, it seems, in both untreated (anemic)
patients, which are very scarce, and the more
numerous treated (non-anemic) patients. Schill-
ing (/. Lab. Clin. Med., 1953, 42, 860) modified
this procedure to measure the radioactivity in the
urine during 24 hours following a subcutaneous

408 Cyanocobalamin

Part I

flushing-out dose of 1 mg. of nonradioactive cyan-
ocobalamin given 6 hours after the ingestion of 2
micrograms of radioisotope-tagged vitamin B12.
Glass determined the radioactivity over the area
of the liver with a scintillation counter 5 days
after the ingestion of the labeled vitamin (Glass,
Clin. Res. Proc, 1954, 2, 32). Only small doses
of cyanocobalamin can be used for this purpose
since, as noted above, large doses of vitamin are
absorbed after ingestion by the untreated patient
with pernicious anemia; Ungley (Brit. M. J.,
1950, 2, 905) found that oral doses of 3 mg. of
vitamin B12 without intrinsic factor would pro-
duce an hematopoietic effect comparable to the
parenteral injection of 0.02 to 0.04 mg. of the
vitamin.

Pernicious Anemia. — In the treatment of
primary pernicious anemia cyanocobalamin ad-
ministered parenterally and in combination with
an intrinsic factor concentrate orally is replacing
liver extract. Since 1 microgram (0.001 mg.) of
cyanocobalamin is approximately equivalent to
1 U.S. P. antiariemia unit of liver extract in
hematopoietic action following parenteral admin-
istration, the doses in pernicious anemia are iden-
tical in terms of micrograms with the number of
units of liver extract formerly employed. As an
example, 15 to 30 micrograms of cyanocobalamin
is injected intramuscularly in the pernicious
anemia case in relapse weekly for 6 to 8 weeks,
after which an average dose of about 1 microgram
daily is injected every 2 to 4 weeks (15 or 30
micrograms respectively) for the rest of the indi-
vidual's life as a maintenance dose. In the case
with manifestations of posterolateral sclerosis of
the spinal cord and peripheral neuropathy, larger
doses are indicated, as is the practice with liver
extracts. For example, a dose of 15 to 30 micro-
grams is injected every other day for 3 to 4 weeks,
then weekly for the remainder of a year at least,
and continued according to the neurological status
at that time. At least in pernicious anemia it is
maintained that a single dose in excess of 40
micrograms is inefficient in that a large portion
is so rapidly excreted in the urine. Cyanocobalamin
seems preferable to liver extract (Conley et al.,
Am. J. Med., 1952, 13, 284) because it is cheaper
to prepare (from residues from antibiotic produc-
tion, as of streptomycin), less irritating to the
tissues at the injection site, easier to assay for
potency, and much less allergenic than the com-
plex mixture present in liver extracts.

The response to cyanocobalamin in pernicious
anemia is identical with that produced by ade-
quate doses of parenteral liver extract (see under
Liver Extract Injection). The rapidity of morpho-
logical change in the bone marrow is extraordi-
nary. Bone marrow aspiration every 15 minutes
by Etess and Litwins (N. Y. State J. Med., 1951,
51, 2787) revealed a decrease in megaloblasts
from 15 to 1.8 per cent with an increase of normo-
blasts from 49 to 74 per cent of the nucleated
cells 2^2 hours after intramuscular injection of
cyanocobalamin. Metabolic studies by James and
Abbott (Metabolism, 1952, 1, 259) after intra-
muscular injection of 15 micrograms of cyanoco-
balamin followed by 5 micrograms daily showed
a positive nitrogen balance of as much as 6 Gm.

daily. The increase in blood protein (hemoglobin,
etc.) exceeded the dietary nitrogen intake and
hence indicated that tissue nitrogen was being
converted; the globulin fraction of the plasma
proteins showed the greatest increase. Urinary
phosphorus excretion decreased during the first
few days, then increased at the time of the retic-
ulocyte response, and finally returned to normal
amounts. Uric acid excretion also increased in the
urine during the reticulocyte response. These
changes indicate the magnitude of the effect of
B12 on nucleoprotein metabolism in the anemic
case of pernicious anemia. Abnormally large
squamous cells with unusually large nuclei were
observed in the gastric juice aspirated from per-
nicious anemia cases in relapse by Graham and
Rheault (/. Lab. Clin. Med., 1954, 43, 235); cell
size and nuclear chromatin returned to normal
after cyanocobalamin therapy.

The duration of action of cyanocobalamin is
suggested by the studies of the response of cases
in relapse to a single large dose. Walker and
Hunter (Brit. M. J., 1952, 2, 593) injected 15
cases with 1 mg. intramuscularly. Signs of relapse
of the anemia appeared 128 to 358 days later,
with an increase in the megaloblasts in the marrow
about 40 days before a definite decrease in the
erythrocyte count was found. In a patient with
impaired liver function, signs of relapse appeared
in only 81 days and a case of abnormal postero-
lateral column signs showed aggravation of the
neurological signs 6 weeks after the single dose.
Chevallier (Semaine Hop. Paris, 1953, 29, 1953)
called attention to the economy of 1 mg. doses
at long intervals. However, Reisner and Weiner
(Blood, 1953, 8, 81) found in 14 cases that re-
mission lasted only 3 to 7 months and that some
cases with posterolateral column degeneration
signs did not do well on such treatment. Because
of the urinary excretion of most of such doses,
more frequent injections of 30 or at most 50
micrograms is certainly more efficient and per-
haps more effective; in neurological conditions
(v.i.) daily injections of large doses seem to be
more effective. Although there is no disagreement
that much larger doses of cyanocobalamin are
required orally, unless intrinsic factor is also
given, than parenterally, Conley et al. (J. A.M. A.,
1953, 153, 960) have challenged the accepted con-
clusion (v.s.) that some cases of pernicious
anemia respond incompletely or only temporarily
to even large oral doses of B12. They report en-
tirely satisfactory response and clinical course for
20 patients with pernicious anemia treated orally
with cyanocobalamin without any intrinsic factor
for 3^2 years or longer with doses of 5 mg.
initially and then 1 mg. weekly; smaller doses at
more frequent intervals were ineffective in some
of these cases.

Fish Tapeworm Anemia. — The association of
Diphyllobothrium latum (fish tapeworm) infes-
tation and megaloblastic anemia has long been an
intriguing problem in the Scandinavian countries
where this situation is not uncommon. Studies of
the response of such cases to cyanocobalamin,
with or without intrinsic factor, led Bonsdorff and
Gordin (Acta med. Scandinav., 1951, Suppl. 259,
112) to conclude that the location of the worm

Part I

Cyanocobalamin 409

in the jejunum produced anemia by utilizing the
available B12. The same authors (ibid., 1952, 144,
263) demonstrated that ingestion of dried fish
tapeworm with intrinsic factor or the injection of
an extract of fish tapeworm, showing 1 microgram
of B12 activity per Gm. by bacteriological assay,
produced a full therapeutic response. It is sug-
gested that the worm deprives the human of
vitamin B12.

Folic Acid. — Cyanocobalamin Combinations. —
Considering the failure of certain megaloblastic
anemias to respond to oral or parenteral cyano-
cobalamin therapy while some cases respond to
oral or parenteral therapy with folic acid it is not
surprising that combination therapy with both
hematopoietic substances would be studied. In a
case of macrocytic anemia 6 years after total
gastrectomy which showed an incomplete response
to intramuscular cyanocobalamin Conway and
Conway (Brit. M. J., 1951, 1, 158) added folic
acid to the therapy and observed the blood count
to rise to normal. In a group of megaloblastic
anemias other than primary pernicious anemia
Nieweg et al. (Acta med. Scandinav., 1952, 142,
45) obtained satisfactory response with both
agents where B12 alone had failed. All of 7 cases
of pernicious anemia with neurological abnor-
malities treated by Haehner et al. (Munch, med.
Wchnschr., 1952, 94, 14) with 30 micrograms of
B12 and 2.5 mg. of folic acid orally daily showed
optimum responses. However, the danger of pro-
gression of neurological damage in unrecognized
cases of pernicious anemia during use of multi-
vitamin preparations containing small amounts of
folic acid and vitamin B12 (sufficient to prevent
anemia) has been stressed by Conley and Krevans
(New Eng. J. Med., 1951, 245, 529). Studies by
Chodos and Ross (Blood, 1951, 6, 1213) with
combined folic acid and liver extract therapy indi-
cate that folic acid may, in malnourished patients
or those with gastrointestinal abnormalities such
as sprue, hinder the usual response to small doses
of cyanocobalamin while in patients receiving ade-
quate parenteral doses of B12 or in those with
iron deficiency anemia having normal gastric
secretion of hydrochloric acid there is no dele-
terious effect of folic acid. In a group of mal-
nourished patients with megaloblastic anemia,
Sanneman and Beard (Ann. Int. Med., 1952, 37,
755) found that the erythrocyte count did not rise
to normal and the macrocytosis did not decrease
after 10 weeks of seemingly adequate doses of
B12; the addition of parenteral folic acid (1.67
mg. with 15 micrograms of B12 weekly intra-
muscularly) did not cause a further change toward
normal. Treating pernicious anemia patients in
relapse, Reisner and Weiner (New Eng. J. Med.,
1952, 247, 15) found that suboptimal oral doses
of 10 micrograms of B12 and 0.67 mg. of folic
acid daily produced an optimal reticulocyte re-
sponse and that a secondary rise in reticulocytes
could not be produced by parenteral doses. Since
this response was obtained whether the two agents
were ingested simultaneously or 12 hours apart
an effect of folic acid to increase the absorption
of B12 seems unlikely. Some, albeit insufficient,
absorption of B12 persists in many cases of
pernicious anemia. Because of the seriousness of

neurological changes, such suboptimal doses of
both agents, even though often effective, seem
unwise in general. Satisfactory response of symp-
toms and anemia in cases of sprue with macrocytic
anemia were reported by Diez Rivas et al. (Ann.
Int. Med., 1952, 36, 1076) with 1.67 mg. folic
acid and 25 micrograms of B12 by mouth daily
for periods as long as 7 months.

Antibiotics. — Incomplete response of patients
with pernicious anemia to oral administration of
2 to 3 Gm. daily of oxytetracycline was reported
by Lichtman et al. (Proc. S. Exp. Biol. Med.,
1950, 74, 884); aggravation of neurological mani-
festations did not appear during these studies. In
cases showing no response to oral administration
of vitamin B12 the addition of the antibiotic was
followed by reticulocyte response and increase in
the erythrocyte count. Parenteral administration
of oxytetracycline produced no response in such
cases excluding the possibility that B12 was pres-
ent in the antibiotic preparation as an impurity.
In 2 cases with blind loops of intestine following
surgical anastamosis, which often results in severe
megaloblastic anemia, Siurala and Kaipainen
(Acta med. Scandinav., 1953, 147, 197) reported
correction of the anemia with chlortetracycline or
oxytetracycline by mouth. It was thought that a
change in intestinal flora was responsible for the
improvement but the presence of vitamin B12
activity in the antibiotic preparations was not
excluded. Megaloblastic anemia without neuropa-
thy or glossitis was treated in Africans with peni-
cillin in a dose of 200,000 units daily orally. Some
of these cases responded to either penicillin or
B12 by mouth, others to parenteral B12 only and
others to folic acid by mouth but not to other
hematinic or antibiotic substances (Foy and
Kondi, Lancet, 1953, 2, 1280).

Other Macrocytic Anemias. — In certain
other macrocytic anemias with megaloblastic bone
marrow vitamin B12, like liver injection, is often
only partially effective and larger doses are re-
quired to produce an adequate therapeutic effect
(Woodruff et al., Pediatrics, 1949, 4, 723; Furman
et al, Am. Pract. Digest. Treat., 1950, 1, 146).
These conditions include the macrocytic anemias
of infancy (McPherson et al., J. Pediatr., 1949,
34, 529), of pregnancy (Day et al., Proc. Mayo,
1949, 24, 149), certain cases of sprue (Diez-Rivas
et al, Ann. Int. Med., 1952, 36, 583), and the
tropical macrocytic anemia. Folic acid on the con-
trary is efficacious in nearly all of these anemias
and may be administered by mouth (Davis et al,
Blood, 1949, 4, 1361). Neurological abnormalities
are extremely rare in these macrocytic anemias.
In some of these anemias, simultaneous use of
vitamin B12 and ascorbic acid has been successful
(Holly, Proc. S. Exp. Biol. Med., 1951, 78, 238).
The megaloblastic anemia of infants described by
Zuelzer and Ogden (loc. cit.), which responded to
therapy with folic acid but not with vitamin B12,
was found to be caused by a dietary deficiency of
ascorbic acid (May et al, Bull. Univ. Minnesota
Hosp., 1950, 21, 208). Betke and Gantert
(Deutsche med. Wchnschr., 1951, 76, 1341) re-
ported rapid response to intramuscular B12 in an
infant with megaloblastic anemia due to a diet of
goat's milk.

410 Cyanocobalamin

Pari I

Neuropathies. — In peripheral neuropathy,
cyanocobalamin has been therapeutically valuable
in many heretofore difficult situations. In per-
nicious anemia, cyanocobalamin, like liver extract
injection, has relieved the symptoms of burning,
tingling and loss of sensation (Bortz and Battle,
Cleveland Clin. Quart., 1950, 17, 166). Larger
doses are employed than are needed for hemato-
poietic response alone. There is no evidence that
any therapy corrects the demyelinization of the
posterolateral columns of the spinal cord with the
characteristic tabetic-like gait and sensory dis-
turbances. Daily intramuscular injections of 30 to
1000 micrograms for 2 weeks are indicated, fol-
lowed by similar doses 2 or 3 times weekly.
The delirium and other less striking cerebral dis-
orders which occur in pernicious anemia cases in
relapse are corrected by cyanocobalamin (Samson
et al., Arch. Int. Med., 1952, 90, 4); electro-
encephalogram and mental tests improve more
rapidly than the anemia. The improved sense of
well-being so often reported with new and potent
drugs seems really to be a fact with cyano-
cobalamin in patients with a deficiency of the
vitamin. The increased comfort, appetite, body
weight, libido, etc., may mask the lack of objec-
tive neurological improvement. For example, no
objective benefit is found in cases of multiple
sclerosis (Simson et al., Proc. S. Exp. Biol. Med.,
1950, 75, 721; Booth et al., J. A.M. A., 1951, 147,
894), amyotropic lateral sclerosis (Spies and
Stone, South. M. J., 1949, 42, 410) or the cord
lesions in pernicious anemia. Preliminary enthusi-
astic reports have not proven to be valid.

In diabetic neuropathy, striking improvement
was observed in most cases by Sancetta et al.
{Ann. Int. Med., 1951, 35, 1028). Large daily
doses intramuscularly were used for 2 weeks, fol-
lowed by less frequent smaller doses ; relapse fol-
lowed discontinuation of therapy. Sauer and
Dussler {Klin. Wchnschr., 1953, 31, 960) re-
ported relief in 15 of 18 cases with 60 micrograms
daily intramuscularly for 2 weeks after placebo
injections showed no benefit; the much larger
dose of 1 mg. was not superior in effect. The
extensive urinary excretion of large parenteral
doses suggests the use of smaller doses at intervals
of 8 hours. Davidson (/. Florida M. A., 1954, 4,
717) reported symptomatic but not objective im-
provement in diabetic neuropathy with 30 micro-
grams 3 times weekly for 3 to 6 months. Alexander
and Backlar (Proc. S. Exp. Biol. Med., 1951, 78,
181) found less ribonucleic acid in the nervous
tissue of rats deficient in vitamin B12. Chow re-
ported to the New York Diabetes Association
(October 8, 1953) that such rats showed hyper-
glycemia, decreased reduced-glutathione content
of the erythrocytes and atrophy of the pancreas.
In patients with diabetic retinitis, Becker et al.
(J. Clin. Nutrition, 1953. 1, 417) measured the
urinary excretion of vitamin B12 during the 8
hours following an intramuscular dose of 50 micro-
grams of cyanocobalamin; excretion was greater
(19 micrograms) than in normal individuals (9
micrograms) or in diabetic cases without retinitis
(4.2 micrograms). Therapeutic use of testosterone
in such patients was found to decrease the urinary
excretion of vitamin B12 (in animal experiments

cortisone caused an increased excretion of a test
dose of cyanocobalamin). Since retinopathy and
intracapillary glomerulosclerosis tend to occur in
the same diabetic patient, renal function was
studied but did not explain the difference in ex-
cretion of B12.

In neuropathy of malnutrition (Bean et al., Am.
I. Med. Sc, 1950, 220, 431; Menof, South
African M. J., 1951, 25, 294) including alcoholic
polyneuritis (Murphy, Prensa med. Argent., 1954,
41, 804) rapid relief is reported with cyanocobala-
min injections. Cyanocobalamin should supple-
ment but not replace the usual treatment with
thiamine, nicotinamide, riboflavin and a high-pro-
tein and high-calorie diet in these cases. Thera-
peutic value in Korsakoff's psychosis has been
reported (Lereboullet and Pluvinage, Paris Letter,
J.A.M.A., 1952, 148, 667). As in the case of other
essential nutrients a lesser excretion in the urine
following a parenteral dose of vitamin B12 is
found in nutritionally deficient persons (Estrada
et al., I. Lab. Clin. Med., 1954, 43, 406). Using a
microbiological assay for vitamin B12 in the blood
following the oral administration of 1 mg. of the
vitamin, Chow et al. (Fed. Proc, 1954, 13, 453,
464, and 471) reported that only 40 per cent of
old people averaging 70 years of age showed a
rise in the blood level, whereas 90 per cent of
young adults showed a marked rise. Rats fed a
diet low in B12 or very low in fat content showed
a falling blood serum concentration of B12 over
a period of 4 months; rats 3 years of age showed
lower average serum B12 concentrations than
young rats. In conditions of severe illness, trauma
or other stress an increased need for all essential
nutrients is recognized; it has been estimated that
2 to 4 micrograms daily by mouth is required
during stress. Vitamin B12 seems to be essential
for the reduction of the -S-S to the -SH linkage of
coenzyme A in the metabolism of fat (Ling and
Chow, /. Biol. Chem., 1953, 202, 445).

In trigeminal neuralgia (tic douloureux) for
which so many agents have been hailed and found
wanting (except the often mutilating neurosur-
gical procedures) cyanocobalamin therapy relieved
all of 13 patients (with complete remission in 9)
with a dose of 1 mg. intramuscularly 2 to 3 times
weekly for 4 to 8 weeks (Fields and Hoff, Neurol-
ogy, 1952, 2, 131). Some patients complained of
a residual burning sensation in the area previously
involved by the pain for 1 to 2 weeks but re-
sponded completely to daily injections. Atypical
facial pains did not respond regularly to B12 ther-
apy. Surtees and Hughes (Lancet, 1954, 1, 439)
confirmed the value of cyanocobalamin in 15 of
18 patients with trigeminal neuralgia; relief usu-
ally followed the third daily injection of 1 mg.
A total dose of 5 to 43 mg. was required. One
patient with glossopharyngeal neuralgia also was
relieved. Some patients relapsed when injections
were discontinued. Alexander and Davis (North
Carolina M. J., 1953. 14, 206) reported relief in
8 of 17 patients, with complete remission in 6.
Strean (Dental Dig., 1953, 59, 214) mentions
relief obtained in 70 per cent of 200 cases. The
lightning pains in tabes dorsalis often respond to
B12 and benefit by maintenance therapy. Herpes
zoster and postherpetic neuralgia are helped by

Part I

Cyanocobalamin 411

cyanocobalamin, and Leitch {Northwest. Med.,

1953, 52, 291) reported rapid clearing of herpes
simplex. Causalgia, phantom limb and postsym-
pathectomy paresthesias have been relieved by
daily injections of cyanocobalamin. In general, it
seems that large daily injections relieve sensory
nerve discomfort.

Growth Failure. — Undernourished children in
a summer camp grew better with a supplement of
vitamin B12 than without it in the same environ-
ment and on the same diet (Wetzel et al., Science,

1949, 110, 651). In a subsequent careful study
among school children living at home in a pros-
perous community (/. Clin. Nutrition, 1952, 1,
17) those showing retardation of growth rate
showed definite response to the ingestion of 5
micrograms of B12 twice daily. Growth was meas-
ured on a special growth grid devised by the
authors. This method of recording reveals plateaus
of growth which are often not apparent on less
graphic records. Instead of meeting a specific de-
ficiency of a vitamin, it was postulated that B12
acted as a marshaling agent for a variety of
metabolic processes. The value of B12 dietary
supplements in retarded children was confirmed
by Chow (South. M. J., 1952, 45, 604), Salmi
(Clin. Pediatr., 1950, 32, 617), O'Neil and Lom-
bardo (/. Omaha Mid-West. Clin. Soc, 1951, 12,
57) and Wilde (J. Pediatr., 1952, 40, 565) but
denied for premature infants (Downing, Science,

1950, 112, 181; Rascoff et al., J. Pediatr., 1951,
39, 61; Mitchell et al., Pediatr., 1951, 8, 821;
Finberg and Chow, Am. J. Dis. Child., 1952, 84,
165), full-term infants (Chinnock and Rosenberg,
/. Pediatr., 1952, 40, 182) and older children
(Benjamin and Pirrie, Lancet, 1952, 1, 264). In
malnourished, asthenic, anemic children, follow-
ing acute respiratory infections failing to respond
to usual measures, Masi and Mori (Minerva
pediatrica, 1953, 5, 290) gave both vitamin B12
and crude liver extract; with oral administration
appetite and weight improved and with parenteral
administration the response was more rapid and
the anemia improved rapidly. In underweight pre-
pubertal children, Larcomb et al. (J. Pediatr.,

1954, 45, 70) reported gain in weight. Like liver
injection, cyanocobalamin is useful in the treat-
ment of celiac diseases, but, as in the case of the
nutritional macrocytic anemias, combination ther-
apy with cyanocobalamin, folic acid and ascorbic
acid as well as a good diet is preferred. A bio-
assay for vitamin B12 based on the rate of growth
of young rats on a Bi2-deficient ration has been
used (Frost et al., Proc. S. Exp. Biol. Med.,
1949, 72, 102) but the bacteriological assay is
preferred.

Liver Disease. — In epidemic viral hepatitis
among military personnel treated with high-pro-
tein and carbohydrate diets and bed rest. 100
cases receiving 30 micrograms of B12 orally daily
for 5 days showed more rapid improvement than
100 patients on diet and rest alone or 100 receiving
dried yeast and a multivitamin preparation (Camp-
bell and Pruitt, Am. J. Med. Sc, 1952, 224, 252).
Benefit in liver diseases was also reported by
Galeone and Pelocchino (Minerva med., 1951,
26, 842). Mushett (Fed. Proc, 1950, 9, 339) was
unable to protect animals from carbon tetrachlo-

ride poisoning with B12 but its administration
hastened recovery. Kochweser et al. (J. Lab. Clin.
Med., 1950, 36, 694) found some protection with
large doses prior to the administration of carbon
tetrachloride and suggested a vasodilator rather
than a vitamin or nucleic acid metabolism effect
from B12 in liver diseases. On a low-protein diet
in rats, Hove and Hardin (Proc. S. Exp. Biol.
Med., 1951, 77, 502) found that either B12 or
vitamin E would protect against carbon tetrachlo-
ride toxicity. With yeast as the sole source of
protein in a low-protein, high-fat diet Gyorgy
and Rose (ibid., 1950, 73, 372) found that B12
alone did not protect against nutritional hepatic
necrosis; vitamin E and an unidentified factor are
also needed (Schwarz, ibid., 1951, 78, 852). Al-
though vitamin B12 had not been isolated at the
time, the beneficial effect of a special liver extract
in cases of decompensated cirrhosis of the liver,
reported by Labby et al. (J.A.M.A., 1947, 133,
1181), should be recalled. Studies with bacteria
and animals have shown that both vitamin B12
and folic acid are essential to normal nutrition
and that the synthesis of nucleoprotein and the
conversion of choline or cysteine to methionine
fails in their absence (Charkey et al., Proc. S.
Exp. Biol. Med., 1950, 73, 21; Cumha, Arch.
Biochem., 1949, 23, 510, and others). Drill (Ann.
N. Y. Acad Sc, 1954, 57, 654) concludes that
choline, vitamin B12 and folic acid are all re-
quired to decrease the fat in the liver of rats on
a high-fat diet. The requirement for choline in
the diet is dependent on the intake of vitamin B12
in the dog as well as in the rat and the chicken
(Burns and McKibbin, /. Nutrition, 1951, 44,
Aug.). The conversion of glycine to choline re-
quires vitamin B12 (Arnstein and Neuberger,
Biochem. J., 1951, 48, 11). A mutual sparing
action of vitamin B12 and pantothenic acid in the
chicken has been demonstrated (Yacowitz et al.,
J. Biol. Chem., 1951, 192, 141). Shive (/. Cellular
Comp. Physiol., 1951, 38, Suppl. 1, July) con-
cluded that B12 is involved in the biosynthesis of
methionine from homocysteine, of thymidine and
other purines and of the interconversion of glycine
and serine. Rupp et al. (Proc. S. Exp. Biol. Med.,
1951, 76, 432) reported that B12 administration
decreased the catabolism of tissue protein in
hyperthyroid rats.

Miscellaneous. — In osteoarthritis Hallahan
(Am. Pract., 1952, 3, 27) reported relief of pain
in 25 of 27 patients after 3 weeks of 0.1 mg. of
cyanocobalamin intramuscularly weekly; 18 of
the 2 7 showed improvement after only 1 injection.
In 2 patients with osteoporosis pain was relieved
in 3 weeks. In lupus erythematosus, Goldblatt
(/. Invest. Derm., 1951, 17, 303) reported fading
of skin lesions with 15 micrograms intramuscu-
larly weekly. Marcus et al. (ibid., 1953, 21, 75)
observed favorable response in only 3 of 17 pa-
tients with chronic discoid lupus erythematosus.
In seborrheic dermatitis, Andrews et al. (N. Y.
State J. Med., 1950, 50, 1921) described marked
improvement in 16 of 37 patients and some im-
provement in 16 other patients. Relapse occurred
unless metabolic, nutritional and endocrine ab-
normalities were corrected, if present. A variety
of other dermatoses treated did not respond.

412 Cyanocobalamin

Part I

Simon (J. Allergy, 1951, 22, 183) reported gain
in weight and general well-being in a group of
chronic asthmatic patients (see also Caruselli,
Riforma med., 1952, 66, 849) and dramatic relief
in some patients with atopic dermatitis, contact
dermatitis and chronic urticaria. Dieterich {Ann.
West. Med. Surg., 1951, 5, 47) reported a case
of infantile eczema responding to 10 micrograms
orally daily. Rail {Lancet, 1951, 2, 816) reported
marked general improvement in 2 cases of ulcera-
tive colitis. Klemes {hid. Med. Surg., Aug., 1953)
believes that intramuscular vitamin B12 acceler-
ates absorption of calcium deposits in acute sub-
deltoid bursitis. It is reported that cyanocobalamin
will correct porphyrinuria in lead poisoning
(Frank et al., Acta Haematol., 1952, 8, 42) and
alcoholism (Dillaha and Hecklin, /. Invest. Derm.,
1952, 19, 489). The anemia in patients with
pulmonary tuberculosis receiving isoniazid ther-
apy was improved by B12 (Tuczek and Aupe,
Munch, med. Wchnschr., 1952, 94, 1307).

Respiratory Mucous Membrane Absorption.
— Absorption acrbss the respiratory mucous mem-
brane has been demonstrated by Monto and
Rebuck {Arch. Int. Med., 1954, 93, 219). A solu-
tion of 0.1 mg. per ml. of isotonic sodium chloride
solution, or a mixture of 1 mg. in lactose powder,
was used for nasal instillation or pulmonary
inhalation. B12 activity was demonstrated in the
urine by bacteriological assay after administration
by this route. Satisfactory initial response was
obtained with a nasal instillation of a dose of 0.1
mg. of cyanocobalamin in solution or inhalation
of 1 mg. in a powder in 12 patients, and 20 pa-
tients have been maintained satisfactorily for
periods up to 18 months with smaller doses 1 to 3
times weekly. Israels and Shubert {Lancet, 1954,
1, 341) employed a "snuff" in a dose of 0.1 mg.
in 0.135 Gm. of powder daily for 7 days and 1 or
2 times weekly for maintenance.

Animal Protein Factor. — Vitamin B12 ap-
pears to have an even greater role than its thera-
peutic action in the megaloblastic anemias indi-
cates. In nutritional studies an unidentified factor
present in animal protein, but not present in
yeast or in the major seed proteins, has been
found necessary for normal growth and probably
for the maintenance of life (Schweigert, Nutri-
tion Rev., 1949, 7, 225; Bosshardt et al, J. Nutri-
tion, 1949, 37, 31). This factor has been found
in liver, in aqueous extracts of liver (Lewis et al.,
Proc. S. Exp. Biol. Med., 1949. 72, 479), in cow
manure (Bird et al., J. Biol. Chem., 1948, 174,
611); Rubin et al., Proc. S. Exp. Biol. Med.,
1947, 66, 36), and in fish products (Robblee et al.,
J. Biol. Chem., 1948, 173, 117; Pensack et al.,
J. Nutrition, 1949, 37, 353). It does not occur in
vegetable protein diets. This substance, called
animal protein factor (APF), has been found to
be essential for many animal species, including
chickens, pigs, rats and mice. It is of tremendous
significance to the poultry and animal husbandry
industries. Various concentrates obtained as by-
products of the fermentation industry, as in the
manufacture of streptomycin (Rickes et al., Sci-
ence, 1948. 108, 634). are being incorporated in
animal feeds derived from the cheaper vegetable
sources (Catron and Culbertson. Iowa Farm Sci-

ence, 1949, 3, 3; Lindstrom et al., Poultry Sc,

1949, 28, 464) as a source of the needed factor;
such concentrates have been demonstrated to be
effective in the treatment of pernicious anemia
(Meyer et al., Bull. N. Y. Acad. Med., 1949, 25,
464; Meacham et al, J. Lab. Clin. Med., 1950,
35, 713). lY)

Related Compounds. — Reports on the bio-
logical activities of the several analogs of cyano-
cobalamin are confusing and contradictory. The
substances vitamin Bi2=., vitamin Bi2b, and vita-
min B12J now appear to be all hydroxocobalamin
(see under Chemical Structure above) and thus
should have identical biological activities. Vita-
min B120 is nitritocobalamin while the official
vitamin B12 is cyanocobalamin. In view of the
ready interconvertibility of these compounds it
is altogether possible that their human metabolism
is the same. It is not surprising then that Smith
et al. {Biochem. J., 1952, 52, 392), summarizing
their own and other findings, state : "Vitamin Bi2c
and vitamin Bi2b are just as effective as vitamin
B12 itself against pernicious anemia." Final de-
cision as to complete equality of the biological
activities of vitamin B12 and its analogs, under
all conditions of testing, must await evaluation
of data determined under conditions where the
uncertainty of composition of samples under test
and other important variables have been ruled out.

Toxicology. — In mice doses up to 1.6 Gm.
of crystalline B12 per Kg. were given intra-
venously without untoward effects (Winter and
Mushett, /. A. Ph. A., 1950. 39, 360). With a
concentrate containing B12, Traina {Arch. Path.,

1950, 49, 278) reported death in all mice receiv-
ing a dose containing the equivalent of 3 mg. of
Bi2. In humans crystalline cyanocobalamin is very
well tolerated. Conley et al. (J. Lab. Clin. Med.,

1951, 38, 84) gave doses of 10 mg. orally. Daily
doses of 1 mg. (1000 micrograms) have been em-
ployed parenterally or orally for years without
untoward effects. Polycythemia has not been ob-
served (Muehrcke and Kark, Proc. S. Exp. Biol
Med., 1951, 77, 144) although Barnard et al.
{Ann. Allergy, 1951, 9, 360) described erythrocyte
counts up to 6.7 million per cu. mm. with hema-
temesis and melena in a case of Hodgkin's dis-
ease and a case of subleukemic leukemia while
receiving a B12 containing Streptomyces griseus
residue orally daily. Beard et al {Ann. Int. Med.,
1954, 41, 323) found normal blood serum B12
concentrations in cases of lymphocytic leukemia,
greatly increased concentrations (2.57 micrograms
per ml.) in myelocytic leukemia, and slight in-
creases in monocytic leukemia. There was some
correlation with the total leukocyte count but
therapy for leukemia which reduced the white
blood cell count caused no change in the B12
level. Ellis {J.A.M.A., 1954, 154, 702) cited two
cases of leukemia which seemed to be aggravated
by B12 therapy prescribed for anemia, without
determination of etiology, and cautioned against
indiscriminate use of cyanocobalamin. In a pa-
tient who had shown allergic sensitivity to liver
extract injections, Young et al. (J.A.M.A., 1950,
143, 893) reported the development of sensi-
tivity to a B12 concentrate from streptomyces
broth but no reaction to a concentrate derived

Part I

Cyclobarbital 413

from liver; an anaphylactic reaction followed an
injection of B12 concentrate from streptomyces
broth but crystalline cyanocobalamin from the
same source caused no symptoms. A similar case
was reported by Arkless (ibid., 1950, 144, 1586).
Bedford (Brit. M. J., 1952, 1, 690) observed that
such sensitivity was seen only with impure con-
centrates. A patient with contact dermatitis to
cobalt and to nickel showed a tuberculin-type of
reaction to intracutaneous injection of cobalt,
nickel or cyanocobalamin (Rostenberg and Per-
kins, /. Allergy, 1951, 22, 466).

Dosage. — The usual dose is 1 microgram
(0.001 mg., approximately 1/60.000 grain) intra-
muscularly daily with a range of 1 to 20 micro-
grams in the treatment of megaloblastic anemia.
It is customary to employ less frequent injections
and also to give relatively larger doses during the
first 4 to 8 weeks, after which the dose is adjusted
to the therapeutic response obtained. A dose of
15 to 30 micrograms once or twice a week until
remission of the anemia and the symptoms is
obtained is usually adequate for adults or chil-
dren; the dose is then reduced to 15 micrograms
every 2 weeks (Heinle and Bethell, J.A.M.A.,
1953, 151, 42).

If neurological manifestations are present in
pernicious anemia a dose of 10 micrograms daily
is indicated for a period of 3 to 6 months, fol-
lowed by 10 to 20 micrograms weekly (Hall et al.,
J.A.M.A., 1949, 141, 257). Oral administration
in pernicious anemia has not been practical be-
cause of the large doses required and the unsatis-
factory results in some cases (Spies et al., South.
M. J., 1949, 42, 528) unless it is accompanied by
a source of intrinsic factor, in which case a dose
of about 5 micrograms daily is employed. The
dose for sprue, megaloblastic anemia of infancy or
pregnancy and other nutritional macrocytic ane-
mias is similar. There does not appear to be a
maximum safe dose ; doses of 1 mg. are frequently
given in certain neurological disorders.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

CYANOCOBALAMIN INJECTION.
U.S.P. (B.P.)

Vitamin Bi2 Injection (U.S.P. XIV)

"Cyanocobalamin Injection is a sterile solution
of cyanocobalamin in water for injection. It con-
tains not less than 95 per cent and not more than
115 per cent of the labeled amount of anhydrous
cyanocobalamin, as determined by the assay
method described below." U.S.P.

The B.P. defines Injection of Cyanocobalamin
as a sterile solution of cyanocobalamin in injec-
tion of sodium chloride, and requires that the
content of anhydrous cyanocobalamin be not less
than 79.5 per cent and not more than 96.5 per
cent of the content of cyanocobalamin stated on
the label. It is indicated that the solution may be
sterilized by heating in an autoclave to maintain
the temperature of the solution at 115° to 116°
for 30 minutes, or by filtration through a bacteria-
proof filter. The pH of the injection is required
to be between 3.5 and 5.5.

Gakenheimer (Address, Parenteral Drug Asso-

ciation, New York City, October 31, 1952) stated
that the pH of the normal saline solution which
is commonly used as a vehicle for cyanocobalamin
should be adjusted to a pH between 4.5 and 5.0
before dissolving the vitamin. When a bacterio-
static agent is to be used, as in preparing multiple
dose vials, benzyl alcohol or redistilled phenol
may be used; the former has proven to be more
satisfactory than the latter in prolonged acceler-
ated stability tests of cyanocobalamin.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass,
protected from light." U.S.P.

Usual Sizes.— 300, 500, 1000, and 10,000
meg. in 10 ml.

CYCLOBARBITAL. N.F.

S-(l-Cyclohexenyl)-5-ethylbarbituric Acid
0

"Cyclobarbital, dried at 105° for 2 hours, con-
tains not less than 98.5 per cen^of C12H16N2O3."
N.F.

Cyclobarbitone, B.P.C. Phanodorn (Winthrop-Stearns) .

Cyclobarbital, which is 5-(l-cyclohexen-l-yl)-5-
ethylbarbituric acid, may be considered a deriva-
tive of phenobarbital in which two of the three
double bonds of the phenyl group of the latter
barbiturate have been saturated with hydrogen.
Cyclobarbital may in fact be prepared by hy-
drogenation of phenobarbital in the presence of
colloidal platinum catalyst, in alcohol medium
(see U.S. Patent 1,690,796, November 6, 1928).

Description. — "Cyclobarbital occurs as a
white, crystalline, odorless powder, with a bitter
taste. Its solutions are acid to litmus paper. One
Gm. of Cyclobarbital dissolves in about 5 ml. of
alcohol and in about 10 ml. of ether. It is very
slightly soluble in cold water and in benzene.
Cyclobarbital melts between 171° and 174°."
N.F.

Standards and Tests. — Identification. — (1)
and (2) These tests differ immaterially from
identification tests (1) and (2) under Barbital.
Loss on drying. — Not over 1 per cent, when dried
at 105° for 2 hours. Residue on ignition. — Not
over 0.1 per cent. N.F.

Assay. — About 300 mg. of cyclobarbital,
previously dried at 105° for 2 hours, is dissolved
in a sodium hydroxide solution, after which a
measured excess of 0.1 N bromine is added and
the mixture is acidified. After 15 minutes the
excess of bromine is determined through libera-
tion of iodine from iodide, which is titrated with
0.1 iV sodium thiosulfate using starch as indi-
cator. A residual titration blank is performed.
Each ml. of 0.1 N bromine represents 11.81 mg.
of C12H16N2O3. In this assay the bromine satu-
rates the double bond of the cyclohexenyl group,
one molecule of bromine being required for each
molecule of cyclobarbital; the equivalent weight

414 Cyclobarbital

Part I

of the latter is, accordingly, one-half its molecu-
lar weight. N.F.

Uses. — Cyclobarbital (see article on Barbitu-
rates, in Part II, for general discussion) belongs,
according to the classification of Fitch and Tatum
(/. Pharmacol., 1932, 44, 325), in the category
of short-acting barbiturates, resembling pento-
barbital in this respect. The short duration of
action is due to destruction of the compound
in the body. Hirshfelder and Haury (Proc. S.
Exp. Biol. Med., 1933, 30, 1059) confirmed this
general conclusion when they found that bilateral
nephrectomy did not alter the potency of the
compound when tested in dogs. Fretwurst et al.
{Munch, med. Wchnschr., 1932, 79, 1429) re-
ported that 2 to 7 per cent of the compound
was excreted as such and that 12 to 19 per cent
was eliminated as a non-toxic metabolite, tenta-
tively identified as cyclohexenonylethylbarbi-
turic acid. Oettel and Krautwald {Klin.
Wchnschr., 1937, 16, 299) demonstrated that
chronic administration of cyclobarbital to dogs
did not induce withdrawal or abstinence symp-
toms. Its lack of acute toxicity was indicated by
a report of suicide failure after taking presum-
ably 40 tablets (about 8 Gm.), (Huchzermeyer,
Med. Klin., 1935 31, 551).

The value of cyclobarbital as a mild hypnotic
agent in simple insomnia and for preoperative
and postoperative sedation is documented par-
ticularly in the German literature (Hamburger,
Med. Klin., 1929, 25, 757; Goldstein, Deutsche
med. Wchnschr., 1930, 56, 185; Kraus, Allg.
Ztschr. f. Psychiat., 1933, 101, 74). Barlow et al.
{J. Pharmacol., 1931, 41, 367) found cyclobar-
bital to be only slightly less effective, on an equal
dosage basis, than pentobarbital and at least
as good as tribromoethanol as a basal hypnotic
prior to induction of gaseous anesthesia.

Dose. — For mild simple insomnia the adult
dose is 100 mg. (approximately 1^4 grains). The
usual dose is 200 mg., which may be increased
to 400 mg. in intractable or obstinate cases. It
is recommended that the upper limit of dosage
not be repeated more frequently than at 12 -hour
intervals.

Storage. — Preserve "in well-closed contain-
ers." N.F.

CYCLOBARBITAL TABLETS. N.F.

"Cyclobarbital Tablets contain not less than
94 per cent and not more than 106 per cent
of the labeled amount of C12H16N2O3." N.F.

Assay. — The tablets are assayed by the pro-
cedure summarized under Barbital Tablets.

Usual Size. — 200 mg. (approximately 3
grains) .

CYCLOPROPANE. U.S.P., B.P., LP.

Trimethylene, [Cyclopropanum]

h2
C

H2C-

■CH;

"Cyclopropane contains not less than 99 per
cent by volume of C3H6." US.P. The B.P. and

LP. rubrics are the same as that of the U.S.P.

Cyclopropane, first prepared by Freund in
1882, was not discovered to have anesthetic
properties until 50 years later; in 1933 Waters
and his coworkers introduced it into clinical
anesthesia. The gas, a saturated cyclic hydro-
carbon, is isomeric with the open chain unsatu-
rated hydrocarbon propylene and may be con-
verted into the latter.

Cyclopropane was first prepared by the action
of sodium or zinc on 1,3-dibromopropane, result-
ing in removal of bromine and ring closure. A
more economical method for its preparation is
that of chlorinating propane to form 1,3-dichloro-
propane, and then closing the ring by reaction
with sodium, zinc, or magnesium. Propane may
be obtained from natural gas and by the cracking
of petroleum. Depending on the conditions of
manufacture the gas may be contaminated with
propylene, allene, cyclohexane, nitrogen, carbon
dioxide and complex halides; all these are re-
moved by washing with suitable reagents.

Description. — "Cyclopropane is a colorless
gas of characteristic odor resembling that of pe-
troleum benzin. It has a pungent taste. One
liter of Cyclopropane at a pressure of 760 mm.
and a temperature of 0° weighs 1.879 Gm. One
volume of Cyclopropane dissolves in about 2.7
volumes of water at 15°. It is freely soluble in
alcohol, and soluble in fixed oils." U.S.P.

Cyclopropane is 1.42 times as heavy as air; at
20° it liquefies under 75 pounds pressure, boils
at —34° and freezes at —127°. It is almost
twice as soluble in blood as it is in water at the
same temperature. Alkalies do not decompose it,
hence it may be used without possibility of
chemical change in rebreathing apparatus con-
taining soda lime. In the presence of catalysts, as
for example iron filings at 100°, it isomerizes
readily to propylene; Adriani {Chemistry of
Anesthesia) suggests that this change may as-
sume importance if the gas is stored in iron
cylinders in a heated room. Cyclopropane is
soluble in and diffuses readily through rubber.

Standards and Tests. — Acidity or alkalin-
ity.— When 2000 ml. of cyclopropane is passed
through 100 ml. of water containing 0.2 ml. of
0.01 N hydrochloric acid and a mixture of
methyl red and bromothymol blue as indicator
the color becomes no deeper orange-red than a
control containing 0.4 ml. of 0.01 N hydrochloric
acid or no deeper yellow-green than another con-
trol containing no acid. Carbon dioxide. — The
turbidity, if any, produced when 1000 ml. of
cycpropane is passed through 50 ml. of barium
hydroxide T.S. is no greater than that produced
by the equivalent of 1 mg. of sodium bicarbonate
added to another 50 ml. of barium hydroxide T.S.
Halogens. — The products from the combustion
of 500 ml. of cyclopropane are drawn through
a sodium carbonate solution and a one-tenth
aliquot portion of the latter is acidified with
nitric acid and silver nitrate T.S. added: the
opalescence, if any, should not be greater than
that produced by 0.5 ml. of 0.001 N hydro-
chloric acid when treated similarly. Propylene,
allene and other unsaturated hydrocarbons. — Not
over 10 ml. of 0.01 N potassium permanganate is

Part I

Cyclopropane 415

reduced by 1000 ml. of cyclopropane, the volume
of potassium permanganate being estimated by
adding a measured excess of 0.01 N oxalic acid,
then titrating with 0.01 N potassium permanga-
nate. Carbon monoxide. — 250 ml. of cyclopro-
pane and 2 SO ml. of carbon monoxide-free air
are separately shaken with a dilution of blood,
then with a mixture of pyrogallol and tannic
acid. The solution resulting from the cyclopro-
pane should show no pink color and match the
gray color produced in the blank test. This test
depends on the fact that carboxyhemoglobin
possesses a characteristic bright red color which
does not react with pyrogallol and tannic acid to
produce the gray color shown by hemoglobin.
U.S.P.

The following tests of the B.P. are materially
different from those of the U.S. P.: Foreign odor.
— No foreign odor is detectable on allowing 10 ml.
of cyclopropane, liquefied at a temperature not
above —40°, to evaporate from clean filter paper.
Alcohol, water and acidity. — A weighed tube con-
taining potassium hydroxide does not increase
in weight more than 5.6 mg., corresponding to
0.3 per cent w/w of the cyclopropane used, when
1000 ml. of cyclopropane measured at normal
temperature and pressure is passed through the
tube. Limit of unsaturated substances. — Halogen
equivalent to not more than 1.8 ml. of 0.1 N
sodium thiosulfate and corresponding to not over
0.2 per cent w/w of unsaturated substances cal-
culated as propylene is absorbed on passing the
gas issuing from the potassium hydroxide tube
in the preceding test through solution of iodine
monochloride and then titrating the solution with
0.1 N sodium thiosulfate. Limit of halogen-
containing substances. — When the products of
combustion of 1000 ml. of cyclopropane, meas-
ured at normal temperature and pressure, are
absorbed in a sodium peroxide solution, the lat-
ter boiled, acidified with nitric acid, and silver
nitrate solution added, the turbidity should not
be greater than that produced by 7.5 ml. of
0.001 N potassium bromide treated similarly;
the limit corresponds to 0.05 per cent of halogen-
containing substances, calculated as propyl bro-
mide.

Assay. — A sample of 100 ml. of cyclopropane,
measured in a gas burette filled with mercury, is
transferred to a Hempel pipette containing sul-
furic acid to absorb the cyclopropane, after which
the residual gas is returned to the burette. The
operation is repeated until a constant volume of
residual gas is obtained. This volume should not
exceed 1 ml. U.S.P. The B.P. and LP. assays
are the same as the U.S. P. assay.

Uses. — Cyclopropane was introduced as a
surgical anesthetic by Henderson and Lucas
(Anesth. & Analg., 1930, 9, 1) and Waters and
Schmidt (J.A.M.A., 1934, 103, 975) reported on
its clinical use. It has the advantage of being
such a potent anesthetic agent that high tensions
of oxygen can be administered with it; further-
more, the depth of anesthesia can rapidly be con-
trolled. It has the disadvantages of requiring an
experienced person for its administration and of
being explosive in anesthetic mixtures with
oxygen. Prolonged administration of low con-

centrations will produce analgesia without un-
consciousness (Seevers et al., J. Pharmacol.,
1937, 59, 921). It is absorbed and excreted by
the lungs more rapidly than ether but less rapidly
than ethylene (for a general discussion of surgi-
cal anesthesia see under Ether). Using morphine
for preanesthetic medication, the concentration of
cyclopropane in respired air for the several planes
of third stage anesthesia was found to be as fol-
lows: plane 1, 7.4 per cent; plane 2, 13.1 per cent
(without morphine 26 per cent); plane 3, 23.3
per cent; plane 4, 42.9 per cent. The anesthetic
concentration in the blood is equivalent to a pres-
sure of about 150 mm. of mercury; the lethal ten-
sion is equivalent to 300 mm. of mercury. Hence,
the margin of safety is considerable and the low
concentrations required enable the use of adequate
oxygen even in pathological conditions of anoxia.
In fact, it is usually possible to employ air rather
than oxygen as the vehicle for this anesthetic.
However, the diagnostic signs of the several
stages of anesthesia are indistinct; considerable
experience with its use is required to avoid the
respiratory and circulatory paralysis of plane 4
anesthesia.

Induction of anesthesia with cyclopropane is
pleasant and rapid; loss of consciousness occurs
in 1 to 3 minutes and plane 2 of stage 3 appears
in about 5 minutes. Recovery from anesthesia
occurs in a few minutes. Postoperative nausea,
vomiting and abdominal distention is less frequent
than after ether but more common than after
nitrous oxide or ethylene.

Respiration. — Cyclopropane does not irritate
the upper or the lower respiratory tract, except
perhaps in the presence of bronchial asthma;
indeed, with care, Bentolila {Ann. Allergy, 1951,
9, 519) used it to relieve status asthmaticus. In
contrast to ether it does not stimulate respira-
tion. There is no coughing, no hyperpnea, no
laryngeal spasm (except in some persons, with
high concentrations), and no exaggeration of
diaphragmatic motion during plane 3 anesthesia.
The high oxygen tensions often employed and
the quiet breathing characteristic of this anes-
thesia together with the loss of nitrogen in the
rebreathing method of administration favor the
development of massive atelectasis of the lungs.
Jones and Burford (J. A.M. A., 1938, 110, 1092)
proposed the use of an inert gas, helium, in the
anesthetic mixture to prevent collapse of the
pulmonary alveoli. Schmidt and Waters (Anesth.
& Analg., 1935, 14, 1) reported that postoperative
pulmonary complications, such as pneumonia,
were less frequent than after ether anesthesia.
Cyclopropane does not depress respiration until
plane 4 anesthesia is reached and, if this happens,
artificial respiration with oxygen rapidly restores
natural respiration. Rosenfeld and Snyder (Am. J.
Obst. Gyn., 1939, 38, 424) found that cyclopro-
pane was the only one of the drugs commonly used
in obstetrical practice which did not depress
fetal respiratory movements.

Pupils. — The changes in the pupils, like the
respiratory signs, which are of value in the recog-
nition of the stages of ether anesthesia, are also
of little aid with cylopropane. The pupils do not
dilate until plane 4 anesthesia when morphine

416 Cyclopropane

Part I

has been given and only at the end of plane 3
without morphine. Because of the high oxygen
tensions employed, the color of the skin fails as
a danger signal of a dangerously deep anesthetic
level.

Circulation. — The heart rate and rhythm
provide the best criteria of anesthetic danger;
arrhythmia, bradycardia (50 or less per minute)
or marked tachycardia demands immediate de-
saturation of the patient. Except for arrythmia,
cyclopropane has no primary effect on the cardio-
vascular system (Seevers and Waters, Physiol.
Rev., 1938, 18, 447). During anesthesia the
pulse rate is usually about 70 per minute. How-
ever, the incidence of ventricular extrasystoles
and multifocal ventricular tachycardia is high
and somewhat similar to the effect of chloroform.
The frequency of abnormal rhythm increases
with the concentration of the anesthetic. How-
ever, the addition of a small amount of ether
markedly decreases the incidence of arrhythmias
(Greisheimer et pi., Anesth., 1954. 15, 51).
Waters (Brit. M. J., 1936, 2, 1013) reported
that 7.86 per cent of patients showed arrhythmia
during plane 3 anesthesia, in contrast with an
incidence of 2.62 per cent with ether, although
ether showed a higher incidence than cyclopro-
pane during plane 1 anesthesia. Anoxia, anes-
thesia of insufficient depth for the operative
stimuli, epinephrine (Orth et al., J. Pharmacol.,
1939, 66, 1) and similar substances, and pitui-
trin (Am. J. Obst. Gyn., 1944. 48, 109) mark-
edly aggravate this tendency to ventricular
ectopic rhythm. In general a rise in blood pres-
sure tends to lower the threshold for epinephrine-
induced arrhythmia (Murphy et al., Anesth.,
1949, 10, 416). Other sympathomimetic amines,
however, appear to be safe during cyclopropane
anesthesia (Meek. Physiol. Rev., 1941, 21, 324;
Glassman et al., Fed. Proc, 1953. 12, 324) and
may prevent epinephrine-induced extrasystoles
(see under Mephentermine, in Part I). Dibena-
mine (Nickerson and Smith, Anesth., 1949, 10,
562; see under Adrenergic Blocking Agents, in
Part II) and procaine amide and other substances
will control the arrhythmia. On the development of
arrhythmia, cyclopropane should be discontinued
and oxygen used (Allen et al., Anesth., 1945. 6,
261); if arrhythmia persists or if it recurs when
the depth of anesthesia is increased sufficiently for
the operative procedure, another anesthetic must
be employed. Waters (Surgery, 1945. 18, 26)
cautioned against the practice of increasing the
concentration of cyclopropane to correct arrhyth-
mia, which has been advocated by some. These
untoward cardiac effects, however, are functional
and temporary, unless rapid death due to ven-
tricular fibrillation occurs (Waters. 1936. loc.
cit.). In some persons hyperactive autonomic re-
flexes have developed (cessation of respiration or
circulation, laryngeal spasm, etc.). Premedication
with scopolamine and careful administration of
cyclopropane minimize the incidence of these
undesirable reflexes.

Muscle Tone. — Muscular relaxation is suffi-
cient for most procedures if patience is used in
saturating the patient with the level of anesthetic
needed. Relaxation is better than that produced

by nitrous oxide or ethylene but less than with
ether or chloroform. Restricting the size of the
preanesthetic dose of morphine enables the use
of higher concentrations of cyclopropane, result-
ing in greater muscular relaxation, without dan-
gerous respiratory depression. Curare may be used
in combination with cyclopropane anesthesia
(Anesth., 1945, 6, 48). Controlled breathing in
lower plane 3 anesthesia may be employed with
cyclopropane but great care is essential because
of the potency of this anesthetic agent. Bourne
(Lancet, 1934, 2, 20) found that uterine con-
tractions during labor were not depressed by
cyclopropane but Howard et al. (Anesth., 1949,
10, 151) reported decreased force. Pisani (Surg.
Gynec. Obst., 1952, 95, 149) recommended it for
cases of ectopic pregnancy with severe hemor-
rhage.

Liver axd Kidneys. — Liver function is not
impaired with cyclopropane anesthesia (Raginsky
and Bourne. Can. Med. Assoc. J., 1934, 31, 500;
Morrison, Rev. Gastroenterol., 1943, 10, 171)
and. in contrast to other anesthetic agents.
Molitor and Kuna (Anesth. & Analg., 1941. 20,
241) found that the flow of bile was increased.
Changes in blood urea nitrogen, sugar or carbon
dioxide combining power have not been observed.
Studies of renal function show a decrease in blood
flow, glomerular filtration rate and urine flow, and
an increase in filtration fraction (Coller et al.,
Ann. Surg., 1943. 118, 717; Burnett et al., J. Phar-
macol., 1949. 96, 380). No significant change in
fixed acid in the blood was observed (Bunker
et al, J. Pharmacol, 1951, 102, 62).

Admix istratiox. — Preanesthetic medication
with a small dose of morphine sulfate, 4 to 8 mg.,
and 0.4 mg. of atropine sulfate or scopolamine
hydrobromide is recommended by Waters (Sur-
gery, 1945, 18, 26). Cyclopropane is usually
administered by the closed method with a gas-
oxygen machine employing the rebreathing bag
and the absorption of carbon dioxide with soda-
lime. Administration is started with 15 to 40
per cent of cyclopropane and oxygen at least
20 per cent and often more. After ^ to 3 minutes
the cyclopropane is discontinued but oxygen is
continued at a rate of 250 to 400 ml. per minute
until the cyclopropane has become distributed
throughout the body. More cyclopropane is added
to the bag as necessary to induce and maintain the
desired plane of surgical anesthesia. About 4 liters
of cyclopropane are needed for 1 hour of anes-
thesia. It mav be used by the endotracheal method
(Griffith, Can. Med. Assoc. J., 1937, 37, 496).
Waters cautioned against the use of more oxygen
than is needed because the tendency to "blow
off" carbon dioxide may result acapnia. A sudden
decrease in the carbon dioxide tension may pre-
disDOse to fibrillation of the heart (Brown and
Miller. Am. J. Physiol, 1952, 169, 56). E

Untoward Effects. — In addition to arrhyth-
mia (v.s.). so-called cyclopropane shock has
been described. Infrequently this occurs during
the recovery period following a prolonged period
of anesthesia of plane II depth. It resembles
traumatic shock and is very alarming. It is due
to a loss of carbon dioxide during the hyperpneic
recovery period from the anesthesia and is char-

Part I

Decamethonium Iodide

417

acterized by apnea as well as hypotension.
Inhalation of carbon dioxide corrects this syn-
drome. Transfer from cyclopropane and high
oxygen tension during the last part of the opera-
tion to nitrous oxide and lower oxygen tension
expels any accumulated carbon dioxide during
the quiet breathing of cyclopropane anesthesia
and is alleged to prevent the acapneic shock.

Hazard of Explosions. — Explosive mixtures
consist of 2.41 to 10.3 per cent of cyclopropane
in air, 2.45 to 63.1 per cent in pure oxygen and
3 to 28 per cent in nitrous oxide (J.A.M.A., 1952,
149, 96). It is less explosive than ethylene-
oxygen or nitrous oxide-ether-oxygen mixtures;
both Waters (1945, loc. cit.) and Woodbridge
(J. A.M. A., 1939, 113, 2308) concluded from a
long experience with many thousands of anes-
thesias that cyclopropane is safe in the closed
method of administration provided adequate pre-
cautions are taken to keep the gas mixture away
from flames or cauteries. Thomas and Jones
(Anesth. & Analg., 1940, 20, 121) recommended
2 parts of helium with 1 part each of cyclopro-
pane and oxygen to avoid explosions. Fat burns
readily with cyclopropane-oxygen mixtures.

Indications. — Cyclopropane may be employed
for any surgical procedure (Griffith, Pract., 1951,
166, 616). It is particularly valuable where ade-
quate or increased amounts of oxygen are needed,
as in patients with cardiac or pulmonary disease,
hyperthyroidism, hemorrhage (Hershey and
Rovenstine, Anesth., 1944, 5, 149) and to supple-
ment spinal anesthesia which has become inade-
quate prematurely (Dodd and Hunter, Lancet,
1939, 1, 685). It is useful in abdominal surgery
and in obstetrics. It may be employed in youth or
old age (Rovenstine, Geriatrics, 1946, 1, 46). It
is particularly desirable in chest surgery and in
cardiac surgery (McQuiston, Arch. Surg., 1950,
61, 892). Lundy et al. (Proc. Mayo, Aug. 22,
1945) stated "Cyclopropane probablv is used less
often than it should be." Burford (J.A.M.A.,
1938, 110, 1087), Sahler (J.A.M.A., 1942, 118,
1042) and Griffith (Anesth., 1951, 12, 109) have
reviewed the literature on cyclopropane.

Labeling. — Label cyclopropane: "Caution. —
Cyclopropane is flammable and its mixture with
oxygen or air may explode when brought in con-
tact with a flame or other cause of ignition."
U.S.P.

Storage. — Preserve "in cylinders." U.S.P.

DANTHRON. N.F.

Chrysazin, 1,8-Dihydroxyanthraquinone
HO 0 OH

Dioxyanthraquinone. Dorbane (Schenley) ; Istin (Bayer
Products); Istizin (Winthrop).

Danthron, a laxative substance, may be syn-
thesized by heating a mixture of lime and 1,8-
anthraquinonedisulfonic acid, the latter obtained
by sulfonation of anthraquinone in the presence

of mercury. On reducing danthron the official
compound anthralin, a local irritant used in der-
matologic practice, is obtained.

Description. — "Danthron occurs as an orange
colored crystalline powder. Danthron is practi-
cally insoluble in water. It is soluble in alcohol,
in ether, in benzene, in chloroform, and in solu-
tions of sodium hydroxide. Danthron melts be-
tween 190° and 195°." N.F.

Standards and Tests. — Identification. — (1)
A red solution is produced on dissolving about
100 mg. of danthron in 1 ml. of sulfuric acid; on
diluting the solution with water a yellow precipi-
tate is produced. (2) A solution of 50 mg. of
danthron in 10 ml. of ether is shaken with 5 ml.
of ammonia T.S.: the water layer is colored red.
Ultraviolet absorbance. — The absorptivity (1%,

1 cm.) in benzene, at 432 mn, is not less than 420
and not more than 465. Heavy metals. — The limit
is 50 parts per million. Mercury. — The limit is
50 parts per million. N.F.

Uses. — Danthron possesses the characteristic
action of the anthraquinone laxatives. While it
is employed for its cathartic effect in humans
(Marks, Am. J. Digest. Dis., 1953, 20, 240), it is
officially recognized as a veterinary cathartic ; such
uses are discussed in this volume in the section on
Veterinary Uses and Doses of Drugs.

It has been observed that when used as a laxa-
tive in humans the urine frequently is colored red,
indicating absorption of the drug. It is said that
it sometimes imparts laxative properties to the
milk of nursing women.

Danthron has been administered to adult hu-
mans in doses of 130 to 500 mg. (approximately

2 to 7.5 grains), at bedtime, the usual range being
150 to 300 mg.

Storage. — Preserve "in well-closed containers."
N.F.

DECAMETHONIUM IODIDE. B.P.

[(CH3)3-N+(CHo)ioN+(CH3)3]2I-

The B.P. defines Decamethonium Iodide as
decamethylene -1:10- bistrimethylammonium di-
iodide. It is required to contain not less than 99.0
per cent of C16H38N2I2, calculated with reference
to the substance dried to constant weight at 105°.

Decamethonium iodide may be prepared by the
action of methyl iodide on decamethylene di-
amine. In the United States decamethonium bro-
mide is the salt which is commercially available
(Syncurine, Burroughs Wellcome); this salt is
often referred to as C-10.

Description. — Decamethonium iodide occurs
as a white, odorless, crystalline powder, having a
bitter and saline taste. At 20° it is soluble in 10
parts of water and in 50 parts of alcohol. It
melts between 246° and 248°.

Standards and Tests.— Identification. — (1)
The melting point of the picrate formed from this
salt is about 147°. (2) Decamethonium iodide
responds to tests for iodide. Reaction. — A satu-
rated aqueous solution is neutral to litmus. Loss
on drying. — Not over 0.5 per cent, when dried to
constant weight at 105°. Sulfated ash. — Not over
0.1 per cent. B.P.

Assay. — Decamethonium iodide is dissolved in

418

Decamethonium Iodide

Part I

water and the base component precipitated as
decamethonium reineckate, which is finally dried
to constant weight at 80°. Each Gm. of the pre-
cipitate corresponds to 0.5722 Gm. of C16H38N2I2.
B.P.

Uses. — Decamethonium iodide and decame-
thonium bromide are used to produce muscular
relaxation during anesthesia; the former salt ap-
pears to be favored in Great Britain while the
latter is employed in the United States.

Simultaneous preliminary reports by Barlow
and Ing (Nature, 1948, 161, 718) and by Paton
and Zaimis (Nature, 1948, 161, 718) described the
pharmacologic action of polymethylene bis-tri-
methylammonium salts. Barlow and Ing (Brit. J.
Pharmacol. Chemother., 1948, 3, 298) had been
interested in this particular group of compounds
for many years and had found that the bis-quater-
nary ammonium salts were more active than the
mono-quaternary compounds from the stand-
point of their effect on skeletal muscle. Moreover,
the bis-trimethylammonium series was more ac-
tive than the bis-triethylammonium dibromides.
They found that where the number of methylene
groups between the two ammonium groups was of
the order of 3 to 5 the compounds were only
feebly active, but that with increase in chain
length to 10 optimal activity was observed. Also,
they noted that nearly all the bis-quaternary am-
monium salts that they prepared produced aug-
mentation of contraction of the rat diaphragm,
usually at concentrations slightly lower than
those needed to produce inhibition. Whereas
Barlow and Ing (loc. cit.) found these componnds
to be substantially less active than d-tubocurarine
on the isolated rat diaphragm preparation and on
the rabbit head drop, Paton and Zaimis (Brit. J.
Pharmacol. Chemother., 1949, 4, 381) found the
decamethonium compound to be more active than
rf-tubocurarine in the cat. Indeed, there is a 200-
fold difference in the order of activity between
the cat and the rat for the C-10 compound,
whereas that species difference in the order of
activity of J-tubocurarine is 0.5.

Decamethonium is not a true curarimimetic
agent from the standpoint of its mode of action.
In this respect, the action of decamethonium is
analogous to that of acetylcholine in that it pro-
duces a depolarization of the myoneural junction,
which results in neuromuscular blockade (Zaimis,
/. Physiol, 1949, 110, 10P). This action then is
the same as that produced by acetylcholine in the
ordinary transmission of impulses across the
neuromuscular junction, differing only in duration
of action since decamethonium cannot be hy-
drolyzed in the manner of acetylcholine. How-
ever, decamethonium does not share the other
muscarine-like, ganglionic-stimulating actions of
acetylcholine, nor does it produce the profound
effect of acetylcholine on autonomic innervated
organs generally. This difference in mode of action
between decamethonium and (/-tubocurarine can
be illustrated by the fact that d-tubocurarine can
actually antagonize the effects of decamethonium.
This being the case from an experimental stand-
point, it follows that these two agents should not
be employed in sequence in the same patient
(Paton and Zaimis, Lancet, 1950, 1, 568). Dec-

amethonium produces a stimulation of the frog
rectus, like acetylcholine, in contradistinction to
the ability of <f-tubocurarine to block the stimu-
lating effect of acetylcholine thereon. It does not
produce a release of histamine such as had been
observed to follow injection of d-tubocurarine
(Macintosh, quoted by Organe et al., Lancet,
1949, 1, 21). The compound appears to have no
effect on the central nervous system or on spinal
reflexes. Since the mode of action of decame-
thonium is essentially that of acetylcholine, it
follows that cholinesterase inhibitors such as neo-
stigmine and physostigmine do not counteract this
agent. Consequently, they are not useful as an-
tagonists for this compound and are not indicated
for this purpose, as is the case for d-tubocurarine
and gallamine triethiodide. Paton and Zaimis
(Brit. J. Pharmacol. Chemother., 1949, 4, 381)
reported that the bistrimethylammonium pentane
(C-5 analog of decamethonium) antagonized the
neuromuscular blocking action of decamethonium
ion. Clinically, however, the utility of the C-5
compound for this purpose was disappointing
(Grob et al, New Eng. J. Med., 1949, 241, 812).

Therapeutic Uses. — There has been a large
series of papers attesting to the usefulness of
decamethonium salts as muscle relaxants in ab-
dominal surgery and for other purposes wherein
such agents are indicated (see monograph on
Curarimimetic Agents and Their Antagonists, in
Part II). Organe et al (loc. cit.) and Hewer and
his associates (Lancet, 1949, 1, 817) were among
the first to describe the muscle-relaxant action of
this agent in man and its use in general anesthesia.
They indicated its advantages over J-tubocurarine
to be the absence of stimulation of histamine
liberation and better minute-to-minute control of
its effects because of its slightly shorter duration
of action. It did not produce the profound fall in
blood pressure that can be occasioned by an over-
dosage of rf-tubocurarine. On the other hand, it is
not antagonized by cholinesterase inhibitors, and
other agents for this purpose are not entirely
satisfactory. A real disadvantage of decametho-
nium is that in the induction of laryngoscopy the
compound almost always produces some degree of
laryngeal spasm and postintubation reflex apnea
(Gray, Lancet, 1950, 1, 253). Thus, the agent is
inferior to the true curarimimetic agent for this
purpose. Paton and Zaimis (Lancet, 1950, 1, 568)
summarized the status of the clinical trial; in
general the clinical results were essentially an
extension of the laboratory findings with respect
to the compound.

In the United States, Grob et al. (New Eng. J.
Med., 1949, 241, 812) were among the first to
employ this agent. In 172 general anesthesias it
was found to be capable of providing adequate
abdominal relaxation with some interference with
respiration. Its effect was briefer in duration than
that of J-tubocurarine and its action was not
potentiated by ether. Likewise, Harris and Dripps
(Anesthesiology, 1950, 11, 215) found it to be
satisfactory for the production of muscular re-
laxation in a group of 250 surgical patients. In
contradistinction to the aforementioned work of
Gray, they found no instances of bronchospasm
following administration of decamethonium. Fur-

Part I

Decavitamin Capsules 419

thermore, Bourne (Proc. Roy. Soc. Med., 1951,
44, 387) recommended 0.1 ml. per pound of body
weight intravenously of 5 per cent thiopental so-
dium and 0.025 per cent decamethonium iodide to
facilitate tracheal intubation in children for tonsil-
lectomy. It is also miscible with solutions of atro-
pine sulfate.

In electroshock therapy, Hobson and Prescott
(Lancet, 1949, 1, 819) used decamethonium with
thiopental sodium intravenously prior to shock
to modify the severity of the convulsions and
found decamethonium better than d-tubocurarine
because of the characteristics already mentioned.

Perhaps an important clinical difference be-
tween d-tubocurarine and decamethonium con-
sistent with their modes of action is that patients
with myasthenia gravis are exquisitively sensitive
to rf-tubocurarine. These patients were no more
sensitive to decamethonium than were nonmyas-
thenic subjects. Indeed, with subthreshold dosages
of decamethonium the myasthenic patients expe-
rienced transient amelioration of signs and symp-
toms (Pelikan et al., Neurology, 1953, 3, 284).

Toxicology. — In useful dosages, decametho-
nium produces no serious manifestations of toxi-
city other than the overt pharmacodynamic action
occasioned by gross overdosage. Even here, arti-
ficial respiration and an adequate airway are suffi-
cient to handle the apneic patient, since there is
usually no difference in blood pressure. An occa-
sionally unpleasant side effect of the agent is the
appearance of fasciculation or skeletal muscle
cramps at the onset or following its apparent
duration of action. Salivation usually is no prob-
lem with this agent.

Dose. — An initial dose of 1 to 2 mg. of the
compound intravenously may be followed by sub-
sequent injection of ^ to 1 mg. every 5 to 10
minutes as long as curarization is desired. Dosages
in excess of 2 mg. as a single injection intra-
venously are likely to produce respiratory depres-
sion. This compound, like other curarimimetic
agents, should be administered only by a trained
anesthetist familiar with the pharmacology of the
product and under physical conditions suitable for
the maintenance of an adequate airway and posi-
tive pressure artificial respiration. The total dose
will seldom exceed 10 mg.

Supply. — In the United States decamethonium
bromide is available in solution in 10-ml. multiple-
dose vials containing 1 mg. per ml.

DECAVITAMIN CAPSULES. U.S.P.

"Decavitamin Capsules contain, in each Cap-
sule, not less than 1.5 milligrams (5000 U.S.P.
Units) of vitamin A in the form of Oleovitamin A,
10 micrograms (400 U.S.P. Units) of vitamin D
from natural sources or as calciferol or activated
7-dehydrocholesterol or the products produced by
the activation of either ergosterol or 7-dehydro-
cholesterol, 75 milligrams of ascorbic acid, 5 milli-
grams of calcium pantothenate or its equivalent as
racemic calcium pantothenate, 2 micrograms of
cyanocobalamin, 0.25 milligram of folic acid, 20
milligrams of nicotinamide, 2 milligrams of pyri-
doxine hydrochloride, 3 milligrams of riboflavin,

and 2 milligrams of thiamine hydrochloride or
thiamine mononitrate." U.S.P.

Tests and Assay. — An identification test for
vitamin A, utilizing the blue color obtained with
antimony trichloride T.S., is specified. The cap-
sules are required to meet the specifications of the
official weight variation test for capsules. The
assays are based on the following principles:
Vitamin A is determined spectrophotometrically
(see discussion under Oleovitamin A). Vitamin D
is determined by its effect in bringing about calci-
fication in vitamin D-depleted rats, as compared
with the similar effect of a vitamin D reference
standard. Ascorbic acid is titrated to dehydro-
ascorbic acid with dichlorophenolindophenol solu-
tion. Riboflavin is assayed by evaluation of its
fluorescence in ultraviolet light. Thiamine is con-
verted to thiochrome, which in isobutyl alcohol
fluoresces in ultraviolet light and provides a quan-
titative method for its determination. Pyridoxine
hydrochloride is measured by observing the in-
tensity of the blue color it produces with 2,6-
dichloroquinonechlorimide, a reference standard
pyridoxine hydrochloride being used for quantita-
tive comparison. Folic acid is determined by the
cleavage-diazotization procedure discussed under
Folic Acid. Nicotinamide is hydrolyzed to nico-
tinic acid, which is assayed by the colorimetric
procedure, involving interaction with cyanogen
bromide, described under Nicotinic Acid Tablets.
Calcium pantothenate and cyanocobalamin are
determined microbiologically. U.S.P.

Uses. — The action and uses of the components
of this official mixture are discussed under each
constituent. The importance of adequate, and
perhaps optimal, nutrition in health and for
growth, and in recovery from most of the dis-
eases to which man is heir, has gained general
recognition. Many diseases interfere for longer
or shorter periods of time with appetite and the
absorption and utilization of practically all foods.
An increased need is created by the increased
metabolic rate associated with fever. Depletion of
vitamin stores in the body is accelerated by paren-
teral feeding with saline, dextrose and protein
hydrolysates during acute illnesses. The following
rates of depletion have been estimated: vitamin
A, 300 days; thiamine, 3 days; nicotinamide, 15
days; riboflavin, 15 days; ascorbic acid, 9 days.
Although parenteral administration is often re-
quired for short periods, oral administration is to
be preferred as soon as possible and even before
absorption is fully restored to normal. In those
disorders for which no specific therapy is known,
rest and an optimal diet are the major items of
supportive therapy — viz. rheumatoid arthritis,
etc. The restricted diets employed in the manage-
ment of numerous conditions make it difficult and
often impossible to provide adequate amounts of
vitamins from natural foods — viz. low-calorie diets
for obesity, elimination diets for allergic condi-
tions, low-residue and bland diets for gastro-
intestinal disorders and the inadequate diets often
selected by old people.

With the availability of pure vitamins, the dele-
terious effects of imbalance in nutritional factors
have been demonstrated clinically as well as ex-
perimentally. In nutritionally deficient persons

420 Decavitumin Capsules

Part I

large doses of thiamine alone, for example, may
speed up metabolism and aggravate a subclinical
deficiency of nicotinamide or riboflavin to the
point where clinical manifestations of pellagra or
ariboflavinosis appear. This official mixture repre-
sents a balanced and standardized combination of
the vitamins which most commonly are deficient
in patients. It represents the minimum daily re-
quirements of the components.

The average dose is one capsule (or tablet)
daily by mouth.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

Labeling. — "The labeling does not include any
claim for quantities of vitamin in excess of those
specified in the monograph." U.S.P.

DECAVITAMIN TABLETS. U.S.P.

"Decavitamin Tablets contain, in each Tablet,
not less than 1.5 milligrams (5000 U.S.P. Units)
of vitamin A in the form of Oleovitamin A, 10
micrograms (400 U.S.P. Units) of vitamin D from
natural sources or as calciferol or activated 7-de-
hydrocholesterol or the products produced by the
activation of either ergosterol or 7-dehydrocho-
lesterol, 75 milligrams of ascorbic acid, 5 milli-
grams of calcium pantothenate or its equivalent
as racemic calcium pantothenate, 2 micrograms of
cyanocobalamin, 0.25 milligram of folic acid, 20
milligrams of nicotinamide, 2 milligrams of pyri-
doxine hydrochloride, 3 milligrams of riboflavin,
and 2 milligrams of thiamine hydrochloride or
thiamine mononitrate." U.S.P.

ACTIVATED 7-DEHYDRO-
CHOLESTEROL. U.S.P.

Vitamin D3, [7-Dehydrocholesterol Activatum]

CH3
CH-(CH2)3-CH(CH3)2

This substance and calciferol are the synthetic
forms of vitamin D permitted to be used in
preparing the solution known as Synthetic Oleo-
vitamin D, under which title the chemistry,
preparation, and other information concerning
both activated 7-dehydrocholesterol and calciferol
may be found.

Description. — "Activated 7-Dehydrocholes-
terol occurs as white, odorless crystals. It is
affected by air and by light. Activated 7-Dehy-
drocholesterol is insoluble in water. It is soluble
in alcohol, in chloroform, and in fatty oils.
Activated 7-Dehydrocholesterol melts between
84° and 88°." U.S.P.

Standards and Tests. — Identification. — (1)
This is identical with identification test (1) under
Calciferol. (2) The dinitrobenzoyl derivative of
activated 7-dehydrocholesterol melts between
133° and 135°. Specific rotation.— Hot less than

+ 105° and not more than +112°, when deter-
mined in an alcohol solution containing 50 mg. in
each 10 ml. Absorptivity. — The absorptivity
(1%, 1 cm.) in alcohol solution, at a wave length
of 265 mix, is between 450 and 490. U.S.P.

Vitamin D Unit. — Formerly, crystalline cal-
ciferol (vitamin D2) was the standard for evalu-
ating vitamin D activity, 1 mg. representing 40,-

000 units (of antirachitic activity). In 1949 the
World Health Organization of the United Nations
adopted crystalline activated 7-dehydrocholesterol
(vitamin D3) as the international standard,

1 mg. representing 40,000 units (of antirachitic
activity). The U.S.P. Vitamin D Reference
Standard is a solution of crystalline activated
7-dehydrocholesterol in cottonseed oil, containing
10 micrograms of the vitamin per Gm. of solu-
tion, and representing 400 U.S.P. units per Gm.
of solution (the U.S.P. unit is identical with the
international unit). For further discussion of the
equivalence of vitamin D2 and vitamin D3. which
is commonly assumed insofar as the antirachitic
effect on humans is concerned, see Vitamin D
Unit under Calciferol.

The uses and dosage of activated 7-dehydro-
cholesterol are as given in the monographs on
Synthetic Oleovitamin D and Calciferol. In cal-
culating the quantity of activated 7-dehydro-
cholesterol which is equivalent to any dosage
stated in vitamin D units it may be assumed that
100 U.S.P. (or international) units is contained
in 2.5 micrograms of activated 7-dehydrocholes-
terol (or calciferol, since the two pure vitamins
are of identical potency).

Storage. — Preserve "in hermetically sealed
containers under nitrogen, in a cool place and
protected from light." U.S.P.

DEHYDROCHOLIC ACID.

[Acidum Dehydrocholicum]

U.S.P.

"Dehydrocholic Acid, dried at 105° for 2
hours, contains not less than 98.5 per cent and
not more than 101 per cent of C24H34O5." U.S.P.

3,7,12-Triketoeholanic Acid. Cholan-DH (Maltbie); De-
cholin (Ames); Dehychol (United Drug); Oxycholin (Blue
Line); Procholon (Squibb).

Dehydrocholic acid represents cholic acid
(3,7,12-trihydroxycholanic acid, see under Ox Bile
Extract) in which the three CHOH groups of
the latter have been oxidized to ketone groups
through controlled oxidation with chromium tri-
oxide. The cholic acid is obtained by hydrolysis
of natural bile acids. A specially purified grade
of dehydrocholic acid for parenteral use is avail-
able (for information concerning purification of
the acid see /. A. Ph. A., 1950. 39, 595).

Description. — "Dehydrocholic Acid occurs as
a white, fluffy, odorless powder, having a bitter
taste. Dehydrocholic Acid is almost insoluble in
water and is slightly soluble in ether. One Gm.
dissolves in about 100 ml. of alcohol and in about
35 ml. of chloroform, the solutions in these
solvents usually being slightly turbid. It is soluble
in glacial acetic acid and in solutions of alkali
hydroxides and carbonates. Dehydrocholic Acid
melts between 231° and 240°. The higher the
melting temperature the greater is the purity, but

Part I

Deslanoside

421

the range between the beginning and end of melt-
ing is not greater than 3°." U.S. P.

Standards and Tests. — Specific rotation. —
Not less than +30° and not more than +32.5°,
calculated on the dried basis, when determined
in dioxane solution containing 200 mg. of de-
hydrocholic acid in each 10 ml. Loss on drying
— Not over 1 per cent, when dried at 105° for
2 hours. Residue on ignition. — Not over 0.3 per
cent. Odor on boiling. — No odor is apparent on
boiling dehydrocholic acid with water. Barium. —
No turbidity results when diluted sulfuric acid is
added to a saturated solution of dehydrocholic
acid. Heavy metals. — The limit is 20 parts per
million. U.S.P.

Assay. — About 500 mg. of the acid, previously
dried at 105° for 2 hours, is dissolved in neu-
tralized alcohol, the solution diluted with water
and titrated with 0.1 N sodium hydroxide, using
phenolphthalein as indicator. Each ml. of 0.1 N
sodium hydroxide represents 40.25 mg. of
C24H34O5. U.S.P.

Uses. — This unconjugated, oxidized bile acid
(see discussion under Ox Bile Extract) is used
for its hydrocholeretic action. Natural bile salts
are advocated for replacement therapy when bile
in the intestine is deficient or absent (.see Bockus,
Gastroenterology, Vol. Ill, 1946). The unconju-
gated, oxidized bile acids or their salts are used
to flush the biliary tract with a thin watery bile.

Natural bile and conjugated bile salts of either
hydroxy or keto form are indicated in patients
with biliary fistulas, with stone or other obstruc-
tion in the common bile duct during the preopera-
tive period, and with deficient bile formation, as
in cases of calculous or non-calculous chronic
cholecystitis, to improve the absorption of essen-
tial food materials and to alleviate gastrointes-
tinal symptoms due to a deficiency of bile in
the intestine. In cases of non-calculous cholecyst-
itis or other circumstances in which stasis and
ascending infection of the hepatic ducts is pres-
ent or suspected, the unconjugated, oxidized bile
acids, such as dehydrocholic acid, or their sodium
salts are employed to increase flow of a thin bile.
Best and Hicken {J. A.M. A., 1938, 110, 1257,
and correction on p. 1499) reported on a biliary
flush regimen for the patient suspected of having
small stones in the common bile duct, without
complete obstruction, before resorting to surgery.
The regimen consists of: three tablets (250 mg.
each) of dehydrocholic acid after each meal and
at bedtime for 3 days; 8 Gm. of magnesium
sulfate in water each morning; 30 Gm. of olive
oil or 40 per cent cream before breakfast and
supper and also at bedtime daily; 0.65 mg. of
glyceryl trinitrate under the tongue before each
meal during the first and third day; 0.65 mg. of
atropine sulfate, dissolved in a little water, before
each meal during the second day. This regimen
may be repeated at weekly intervals, if indicated;
10 ml. of a 20 per cent solution of sodium dehy-
drocholate may be given once daily, if oral
administration fails.

Dehydrocholic acid is contraindicated in cases
of complete mechanical obstruction of the biliary
tract, and also in cases of severe hepatitis.

The usual dose is 500 mg. (approximately

lYz grains) by mouth 3 times daily after meals,
with a range of 250 mg. to 500 mg. The maximum
single dose of 750 mg. and the maximum dose
during 24 hours of 3 Gm. should seldom be ex-
ceeded. The duration of treatment is from a
few days to 4 or 6 weeks.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep. — Dehydrocholic Acid Tablets,
U.S. P.; Sodium Dehydrocholate Injection, N.F.

DEHYDROCHOLIC ACID TABLETS.

U.S.P.

"Dehydrocholic Acid Tablets contain not less
than 94 per cent and not more than 106 per cent
of the labeled amount of C24H34O5." U.S.P.

Usual Sizes. — 120 and 250 mg. (approxi-
mately 2 and 4 grains).

N.F. DENTIFRICE. N.F.

N.F. Tooth Powder, [Dentifricium]

Thoroughly triturate 2 Gm. of soluble sac-
charin, 4 ml. of peppermint oil, 2 ml. of cinnamon
oil, and 8 ml. of methyl salicylate with about half
of a 935-Gm. portion of precipitated calcium car-
bonate; mix 50 Gm. of hard soap, in fine powder,
with the remainder of the precipitated calcium
carbonate, combine the two powders and pass the
product through a fine sieve. N.F.

This product is a pleasantly flavored and effec-
tive dentifrice utilizing the soft abrasive action
of precipitated calcium carbonate and the de-
tergent effect of soap; it is harmless and suited
for daily use in brushing the teeth. If it is
desirable in special cases to impart an antiseptic
property, it may be mixed with from 15 to 25
per cent of its weight of sodium perborate.

DESLANOSIDE. U.S.P.

Desacetyl-lanatoside C

"Caution. — Deslanoside is extremely poison-
ous." U.S.P.

Deslanoside is the desacetyl derivative of lanat-
oside C and is obtained by removing the acetyl
group from that glycoside of Digitalis lanata.
Deslanoside has the therapeutic action of its par-
ent glycoside but has the advantage of being more
stable in solution than lanatoside C. Injections of
lanatoside C have been characterized by instabil-
ity, which apparently will be obviated by use of
deslanoside in preparing such dosage forms. Lan-
atoside C continues to be officially recognized, by
the N.F., for use in preparation of tablets. For
further information see under Lanatoside C.

422

Deslanoside

Part I

Description. — "Deslanoside occurs as colorless
or white crystals or as a white, crystalline powder.
It is odorless. It is hygroscopic, absorbing about
7 per cent of moisture when exposed to air.
Deslanoside melts indistinctly between 220° and
235°. Deslanoside is insoluble in water. One Gm.
dissolves in about 600 ml. of alcohol and in about
30 ml. of methanol. It is very slightly soluble in
chloroform." U.S.P.

Standards and Tests. — Identification. — This
is identical with the test for lanatoside C. Specific
rotation. — Not less than +7.0° and not more than
+8.5°, when determined in anhydrous pyridine
solution containing 200 mg. in each 10 ml., but
calculated to the dried basis. Loss on drying. —
Not over 8 per cent, when dried in vacuum over
phosphorus pentoxide to constant weight. Residue
on ignition. — The residue from 100 mg. is negli-
gible. U.S.P.

Uses. — The uses of deslanoside are those of
lanatoside C when administered intravenously;
solutions of deslanoside are more stable than
those of lanatoside C but have the same actions,
qualitatively and quantitatively (the difference in
molecular weights is negligible for therapeutic
purposes). For uses see under Lanatoside C.

The usual initial (digitalizing) dose of deslano-
side is 1.6 mg. intravenously, with a usual range
of 1.2 to 1.6 mg. The usual daily maintenance
dose, also given intravenously, is 0.4 mg., with a
range of 0.2 to 0.6 mg.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DESLANOSIDE INJECTION. U.S.P.

"Deslanoside Injection is a sterile solution of
deslanoside in 10 per cent, by volume, of alcohol
and may contain glycerin. Deslanoside Injection
contains not less than 90 per cent and not more
than 110 per cent of the labeled amount of
C4-H74O19." U.S.P.

Assay. — The injection is assayed colorimetri-
cally by interaction with an alkaline picrate solu-
tion; the principle of this assay is the same as
that employed in the assay of digitoxin (see un-
der this title for explanation). U.S.P.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass, protected from light."
U.S.P.

Usual Sizes. — 0.4 mg. in 2 ml.; 0.8 mg. in
4 ml.

DESOXYCORTICOSTERONE
ACETATE. U.S.P. (B.P.) (LP.)

Deoxycortone Acetate, [Desoxycorticosteroni Acetas]

CH0OCOCH3
1 Z *

The B.P. defines Deoxycortone Acetate as 21-
acetoxy-4-pregnene-3:20-dione; the LP. recog-

nizes Desoxycortone Acetate as 21-acetoxy-3-20-
diketo-pregnene-4.

B.P. Deoxycortone Acetate; Deoxycortoni Acetas. I.P.
Desoxycortone Acetate; Desoxycortoni Acetas. ^■'-Preg-
nene-21-ol-3,20-dione Acetate; 11-Desoxycorticosterone Ace-
tate; 21-Hydroxyprogesterone Acetate; 21-Oxyprogesterone
Acetate. Cortate (Schering) ; Doca (Roche-Organon);
Percorten (Ciba). Sp. Acetato de Desoxicorticosterona.

Of the 28 steroid compounds which have been
isolated from the adrenal cortex (see under Supra-
renal) the one most active in maintaining life in
adrenalectomized animals is desoxycorticosterone.
In 1937 the compound was prepared in Reich-
stein's laboratory by transformation of the stig-
masterol or cholesterol degradation product 3-oxy-
A"'-etiocholenic acid; in 1938 Reichstein and his
associates isolated the compound from an ether-
soluble beef adrenal concentrate. It differs from
corticosterone, another of the adrenal cortex hor-
mones but which is not as effective in life-main-
taining ability as is desoxycorticosterone, in hav-
ing a hydrogen atom in place of the hydroxyl
group found in corticosterone at carbon atom 11
(for explanation of ring numbering see under
Sterids, Part II). The B.P. states that the sub-
stance may be prepared by the action of glacial
acetic acid on 21-diazo-4-pregnen-3:20-dione,
which may be obtained by oxidation of the prod-
uct of reaction of diazomethane on the acid
chloride of 3-hydroxy-5-etiocholenic acid.

Desoxycorticosterone differs from progesterone
in having a hydroxyl group replace a hydrogen in
the methyl group in position 21; desoxycorticos-
terone may, therefore, be correctly designated as
21-hydroxyprogesterone. By treatment of proges-
terone with lead tetraacetate desoxycorticosterone
may be obtained in poor yield. The relationship
of the two compounds is further emphasized in
the fact that desoxycorticosterone also possesses
marked progestational activity. For further infor-
mation concerning the chemistry of desoxycorti-
costerone see the excellent review by Kuizenga in
the A.A.A.S. volume on The Chemistry and
Physiology of Hormones (1944).

The official desoxycorticosterone acetate is pro-
duced by esterification of the primary alcohol
radical of desoxycorticosterone (at position 21).

Description. — "Desoxycorticosterone Acetate
occurs as a white, or creamy white, crystalline
powder. It is odorless and is stable in air. Desoxy-
corticosterone Acetate is practically insoluble in
water. It is sparingly soluble in alcohol, in ace-
tone, and in dioxane. It is slightly soluble in
vegetable oils. Desoxycorticosterone Acetate
melts between 155° and 161°." UJS.P. It is also
soluble in propylene glycol.

Standards and Tests. — Identification. — (1)
To a solution of 5 mg. of desoxycorticosterone
acetate in 0.5 ml. of methanol add 0.5 ml. of
silver ammonium nitrate T.S.: the latter is re-
duced in the cold, but more rapidly on heating,
forming a black precipitate. (2) The absorptivity
(1%, 1 cm.) in alcohol solution, at 240 mji, is
between 430 and 460. Specific rotation. — Not less
than +168° and not more than +176°, when de-
termined in a dioxane solution containing 100 mg.
in each 10 ml. U.S.P. The B.P. and I.P. limit
loss on drying to constant weight, at 105° and
100°, respectively, to 0.5 per cent. The I.P.

Part I

Desoxycorticosterone Acetate 423

specifies, as one of its identification tests, that
desoxycorticosterone obtained by hydrolysis of
the acetate shall melt, after recrystallization, be-
tween 140° and 143°.

Uses. — Until the advent of cortisone, desoxy-
corticosterone acetate was the mainstay in the
treatment of Addison's disease, in which malady
it restores electrolyte balance, plasma volume,
and blood pressure. It does not, however, correct
the fundamental disturbance of carbohydrate
metabolism, or restore muscle weakness to nor-
mal, or significantly reduce pigmentation (Thorn
et al, Ann. Int. Med., 1942, 16, 1053; New
Eng. J. Med., 1953, 248, 232). It is significant
that synthesis of desoxycorticosterone acetate
provided an unlimited quantity of a very active
mineralocorticoid at a price that most patients
could afford. Prior to the availability of the
more potent glycocorticoids — cortisone and hy-
drocortisone— it was necessary in some patients
and, indeed, in most cases of Addison's disease
when infections or gastrointestinal upsets oc-
curred, to supplement desoxycorticosterone ther-
apy with extracts of adrenal cortex (see under
Adrenal Cortex Injection). After bilateral
adrenalectomy, which is now possible with the
aid of cortisone, some patients require desoxy-
corticosterone as well as cortisone.

It remains questionable whether desoxycorti-
costerone is the natural mineralocorticoid
secreted by the adrenal cortex. In view of the
marked activity of this steroid on electrolyte
metabolism it is difficult to establish the trace
amounts sufficient to maintain normal balance.
Hechter et al. (Recent Progress in Hormone
Research, 1951, 6, 215) found this steroid in the
venous blood of perfused beef adrenal glands but
Thorn et al. (loc. cit., 1953) found that urinary
excretion of sodium was completely suppressed
by intravenous infusion of hydrocortisone at a
rate of 12 mg. per hour. A steroid, first named
electrocortin and later renamed aldosterone, hav-
ing substantially greater activity on electrolyte
metabolism than desoxycorticosterone, has been
isolated from adrenal venous blood (Simpson
et al., Lancet, 1952, 2, 226) and also from the
amorphous residue of adrenal extracts remaining
after separation of the several crystalline com-
ponents (Pfiffner, Advances Enzymology, 1942, 2,
325; Mattox et al., Proc. Mayo., 1953, 28, 569);
the new steroid differs from free desoxycorti-
costerone in having an aldehyde (in place of a
methyl) at the 18-position and also in having an
additional OH group, attached at the 11-position
(see also below). Nevertheless, desoxycorticos-
terone is still the most potent mineralocorticoid
available for therapeutic use.

Action. — Absorption. — Desoxycorticosterone
acetate is readily absorbed after intramuscular
or subcutaneous injection, or when it is in contact
with oral mucous membrane. By mouth its ac-
tivity is feeble; Kuizenga et al. (Am. J. Physiol.,
1940, 130, 298) reported it to have by this route
only %5 of the effect of an intramuscular injec-
tion, for the reason that it is destroyed in the
gastrointestinal tract (Thorn et al., J. Clin.
Endocrinol., 1941, 1, 967). Percutaneous and
rectal absorption are also poor.

Intermediary Metabolism. — Information on
this subject is meager. Transformation to corti-
costerone, when desoxycorticosterone was per-
fused through beef adrenal gland, was observed
by Hechter et al. (loc. cit.). On incubation with
surviving rat liver slices formation of four differ-
ent allopregnanes occurred; three were 3-hydroxy
compounds, with androgenic activity being
demonstrated (Schneider, /. Biol. Chem., 1952,
199, 235).

Excretion. — Following administration to men
or women with Addison's disease, to a hypogonad
male (Horwitt et al, ibid., 1944, 155, 213), and
also to normal men (Cuyler et al., Endocrinology,
1940, 27, 177) desoxycorticosterone is in part
excreted in the urine as pregnane-3a,20a-diol.
With the small doses employed therapeutically,
there is no increase in urinary 17-ketosteroids
but large doses are converted, in primates, to 17-
ketosteroids.

Kidney Function. — The chief action of this
steroid is to effect retention of sodium and chlo-
ride ions, and water, in the body and to increase
excretion of potassium. There is no constant
effect on calcium or phosphorus metabolism. In
patients with Addison's disease it restores elec-
trolyte and water balance, increases the subnormal
plasma volume and extracellular fluid volume,
increases body weight, and corrects vascular
hypotension (Thorn et al., J. Clin. Inv., 1939,
18, 449; Loeb, Bull. N. Y. Acad. Med., 1940,
16, 47). Renal plasma flow, glomerular filtration
rate, urea and endogenous creatinine clearance,
tubular reabsorption of sodium, and elimination
of potassium are increased; the changes in renal
function may be secondary to restoration of
body sodium and water (Pitts, Adrenal Cortex,
Tr. Third Conf., 1951, New York). Although
there is action on the function of the renal
tubule cell, this accounts for only a small part
of the effect on electrolytes. In the adrenalecto-
mized dog a change of only 2 per cent in the
tubular handling of sodium filtered through the
glomerulus was observed (Roemmelt et al., Am.
J. Physiol., 1949, 159, 124).

In patients with "salt-losing" nephritis, desoxy-
corticosterone does not benefit either sodium or
potassium excretion (Thom et al., New Eng. J.
Med., 1944, 231, 76). During administration of
ammonium chloride as an acid load for the kid-
ney, it is observed that desoxycorticosterone
affects tubular exchange of sodium, potassium and
water, and also affects excretion of ammonia
(Jimenez-Diaz, Lancet, 1936, 2, 1135). It also
alters the action of mercurial diuretics, and of
vasopressin.

Its effects on potassium and sodium are related.
In the human with rigidly restricted intake of
sodium, it has no effect on potassium excretion
or water excretion or distribution in the bodv
(Seldin et al., J. Clin. Inv., 1951, 50, 673). The
effect on urinary electrolyte excretion appears
within 2 to 4 hours after intramuscular or in-
travenous injection. In patients with Addison's
disease, the electrolyte effect is produced with a
dose of 1 to 3 mg. per day, whereas individuals
with normal adrenal function require a dose of
10 mg. or more daily and the effect does not

424 Desoxycorticosterone Acetate

Part I

persist on prolonged administration (Relman and
Schwartz, Yale J. Biol. Med., 1952, 24, 540).
Prolonged use of large doses results in a diabetes
insipidus-like syndrome of increased water intake
and urine output (Zierler and Lilienthal, Am. J.
Med., 1948, 4, 186); perhaps the retention of
sodium results in thirst.

In sweat and saliva similar decrease in sodium
and chloride and an increase in potassium are
found in both normal and adrenal-insufficiency
patients. Similar action on the secretions of the
gastrointestinal tract seems probable since ad-
ministration of the steroid decreases the amount
of sodium removed from the body following in-
gestion of a cation exchange resin (Berger et al.,
Proc. S. Exp. Biol. Med., 1951, 76, 601).

The action of desoxycorticosterone seems to be
a very fundamental one on cells of the body.
Since the increase in extracellular fluid often
exceeds the amount of water retained in the
body, there must be a transfer of water from
the cells to the extracellular space. An increase
in intracellular sodium and a decrease in potas-
sium is found in both animals and man. The
action is not only on renal function, since it is
observed also in the nephrectomized animal
(Woodbury, Fed. Proc, 1951, 10, 149). In the
normal human, studies of sodium balance and
measurements of "sodium-space" with the radio-
active isotope sodium-24 snowed that the latter
increased and continued to do so even after the
initially negative sodium balance ceased on con-
tinued administration of the steroid (Luft and
Sjorgren, Acta endocrinol., 1952, 10, 49). This
indicates a direct effect on the cellular storage
of sodium, aside from the action on the excretion
of sodium.

Other Actions. — Weak inhibition of pituitary
corticotropin formation has been demonstrated,
but therapeutic doses have no such action (Sayers
and Sayers, Ann. N. Y. Acad. Sci., 1949, 50,
522). The patient with Addison's disease who is
being maintained on desoxycorticosterone still
shows fasting hypoglycemia, inability to excrete
water normally, and an abnormal electroen-
cephalogram; these abnormalities are corrected
by cortisone. Desoxycorticosterone has no effect
on blood eosinophil count or on inflammatory or
allergic lesions. A progestin-like action has been
observed in animals but not in humans.

Therapeutic Indications. — Addison's Dis-
ease.— The clinical features of adrenal insuffi-
ciency are great muscular weakness, vascular
hypotension, bronze pigmentation of the skin,
and increased susceptibility to infection. The
outstanding abnormalities include: increased ex-
cretion of both sodium and chloride, with a con-
sequent reduction in the sodium chloride content
of both blood and tissues; an increase in blood
serum potassium and urea nitrogen but a marked
decrease in blood volume and body weight. The
proportion of blood sugar is also diminished, un-
less large quantities of carbohydrates are ingested,
which is improbable because loss of appetite,
with nausea, are among the earliest symptoms.
The glycogen stores of the body are reduced.
Intestinal absorption, protein metabolism, and
the function of other endocrine glands are im-

paired. According to Rowntree {J. A.M. A., 1940,
114, 2526) the average duration of life in un-
treated cases due to tuberculosis of the adrenal
gland was about 1 year, while in cases of idio-
pathic, simple atrophy of the gland it was about
3 years.

In advanced cases diagnosis can often be made
on the basis of clinical findings, but in less
severe situations laboratory studies are usually
required. The rigorous test of Cutler, Power and
Wilder {J. A.M. A., 1938, 111, 117) involving
measurement of sodium excretion in the urine
while on a restricted sodium diet (1.5 Gm. of
sodium chloride daily), accompanied by adminis-
tration of potassium salts, has been abandoned
because of the significant risk of inducing an
acute adrenal insufficiency. Determination of
blood sugar following a 24-hour fast may likewise
induce an acute Addisonian crisis. The simplified
test of the patient's ability to excrete a large
dose of water, as advocated by Robinson, Power
and Kepler {Proc. Mayo, 1941, 16, 577) has
been most useful (see U.S.D., 24th ed., p. 1172).
A simplification of this water-loading test, de-
vised by Softer and Gabrilove (Metabolism,
1952, 1, 504), is equally valuable. In the morn-
ing the fasting patient empties the bladder and
discards the urine. Then 1500 ml. of tap water
is ingested within a period of 20 minutes. The
urine is collected for 5 hours without ingestion
of food or liquids. The individual with normal
adrenal and pituitary function will excrete 1200
to 1900 ml. during the 5 hours; persons with
adrenal insufficiency excrete less than 780 ml.
Normal water excretion after administration of
50 mg. of cortisone indicates adrenal disease, or
after corticotropin indicates pituitary disease
with normal adrenal glands. Care must be ob-
served in interpreting this simple test in patients
with renal or hepatic disease. The response to
corticotropin (q.v.) is the most specific test.
Prior to the development of these tests, a thera-
peutic trial in which 5 mg. of desoxycorticos-
terone acetate in oil was injected intramuscularly
every other day for 5 doses, followed by 5
injections of oil containing no hormone, was
employed by Thorn. Improvement of the asthenic
symptoms and signs during the first course of
injections, with relapse during use of the placebo
injections, suggested presence of adrenal insuffi-
ciency. It is to be noted, however, that patients
with idiopathic asthenia seldom have adrenal
insufficiency.

The dose of desoxycorticosterone acetate in
Addison's disease is discussed in the next sec-
tion. The many aspects of the management of
Addison's disease are discussed by Knowlton
(Med. Clin. North America, 1952, 36, 721).

Other Diseases. — In cases of total or sub-
total bilateral adrenalectomy for severe essential
hypertension or in certain cases of inoperable
metastatic malignancy, cortisone and an increased
sodium chloride intake (up to 10 Gm. daily) in
the diet often provide adequate substitution
therapy. Some cases require desoxycorticosterone
acetate to maintain normal electrolyte metabo-
lism.

In orthostatic hypotension, desoxycorticos-

Part I

Desoxycorticosterone Acetate 425

terone has been used with some symptomatic
benefit, although the decrease in blood pressure
on standing usually persists to some degree at
least.

Controversy exists regarding the therapeutic
value of desoxycorticosterone in epilepsy (Aird
and Gordon, J. A.M. A., 1951, 145, 715; McQuar-
rie et al., J. Clin. Endocrinol., 1942, 2, 406); in
traumatic shock (Swingle and Parkins, Am. J.
Physiol, 1935, 134, 426; Rosenthal, Pub. Health
Rep., 1943, 58, 513); and in cases of severe
diarrhea to minimize electrolyte disturbance. It
has no value in inflammatory or allergic disorders,
hyperkalemic lower nephron nephrosis, or in
"salt-losing" nephritis. Bell and Stuart (Proc. S.
Exp. Biol. Med., 1951, 77, 550) corrected hyper-
heparinemia with 25 mg. intramuscularly daily.
It was used beneficially in malnourished, dehy-
drated infants (Bigler and Traisman, Am. J.
Dis. Child., 1951, 82, 548). As cortisone became
available, interest waned in the report of Lewin
and Wassen (Lancet, 1949, 1, 993) of the tran-
sient and variable improvement in cases of ar-
thritis following intramuscular injection of
desoxycorticosterone acetate and intravenous in-
jection of ascorbic acid.

Other Mineralocorticoids. — Of the many
related steroids which may have an effect on
electrolyte metabolism several have had some
clinical evaluation.

Corticosterone, known also as Kendall's Com-
pound B, is A4-pregnene-3,20-dione-ll,21-diol,
and is found in adrenal cortical extracts in high
concentration (Mason et al., J. Biol. Chem.,

1936, 114, 613; Reichstein, Helv. Chim. Acta,

1937, 20, 953). Both it and hydrocortisone were
found to be the principal steroids obtained when
isolated beef adrenal glands were perfused with
corticotropin (Hechter et al., Recent Progress in
Hormone Research, 1951, 6, 215); it has also
been found in human adrenal venous blood. It
has mineralocorticoid and some glycocorticoid
action, and is effective in management of Addi-
son's disease (Thorn et al., J. Clin. Inv., 1940,
19, 813). Use of this steroid for treatment of
adrenal insufficiency has been suggested (Conn
et al., Trans. A. Am. Phys., 1951, 64, 269). A
daily dose of 25 mg., intramuscularly, affected
urinary sodium excretion in a patient with Addi-
son's disease similarly to 20 mg. of cortisone
acetate or 2 mg. of desoxycorticosterone acetate
administered intramuscularly; in a case with
normal adrenal function 200 mg. was more active
than the same dose of cortisone acetate. There
was an increase in potassium excretion, an in-
crease in body weight, and a decrease in the
red blood cell hematocrit. As with desoxycorti-
costerone this initial action on electrolyte metabo-
lism did not persist on continued use in normal
subjects. Corticosterone produced the same effects
on carbohydrate metabolism as cortisone but
the former was much less active. In the castrated,
adrenalectomized patient with metastatic carci-
noma of the prostate, a dose of 300 mg. daily, by
mouth, was more effective on electrolyte metabo-
lism than 37.5 mg. of cortisone daily, also by
mouth. The Pettenkofer reaction in the urine,
which is increased following injection of cortico-

tropin, confirms the idea that corticosterone is a
natural steroid of the adrenal cortex. The daily
maintenance dose in some cases of adrenal insuf-
ficiency is 25 to 50 mg. intramuscularly, or 50
to 100 mg. orally.

11-Dehydrocorticosterone, known also as Ken-
dall's Compound A, is A4-pregnene-3, 11,20-
trione-21-ol; it was the first adrenal steroid with
glycocorticoid action available in sufficient quan-
tity for clinical trial (Turner et al., J. Biol.
Chem., 1946, 162, 571). It has both mineralo-
corticoid and glycocorticoid actions (Forsham
et al., Am. J. Med., 1946, 1, 105; Sprague et al.,
ibid., 1948, 4, 175); like corticosterone it has
more effect on electrolyte than on carbohydrate
metabolism. It has been used effectively in treat-
ment of Addison's disease (Homburger et al.,
ibid., 163). The daily maintenance dose in Addi-
son's disease is 40 to 100 mg., intramuscularly.

ll-Desoxy-17 -hydroxy corticosterone, known
also as Reickstein's Compound S, is A4-pregnene-
3,20-dione-17B,21-diol. It acts like desoxycorti-
costerone but is much less potent (Clinton and
Thorn, Science, 1942, 96, 343; Gaunt et al., Endo-
crinology, 1952, 50, 521). In the normal human
a daily dose of 400 mg. by mouth, or 200 mg.
intramuscularly, produced no effect (Fajans et al.,
J. Lab. Clin. Med., 1951, 38, 911) or only a slight
effect (Pearson et al., J. Clin. Inv., 1951, 30, 665)
on electrolytes, calcium and phosphorus excretion,
carbohydrate metabolism, blood lipids and choles-
terol, total nitrogen excretion, and uric acid and
creatinine clearances through the kidney. A weak
inhibition of corticotropin but no effect on im-
paired excretion of a large dose of water in adrenal
insufficiency was reported by Gaunt et al. (loc.
cit.). It had no effect on blood eosinophil count
(Terry and London, Proc. S. Exp. Biol. Med.,
1950, 73, 251). The extensive studies on this
rather inactive steroid resulted from its availabil-
ity during the period when very little cortisone
was to be had. Presently this steroid has no recog-
nized therapeutic use.

^-Desoxycorticosterone, chemically A1 -alio -
pregnene-3,20-dione-21-ol is an isomer of the
official desoxycorticosterone which is less active
in sustaining life in the adrenalectomized rat
(Leathern, Proc. S. Exp. Biol. Med., 1950, 74,
855).

Aldosterone (Electrocortin) . — This substance, a
steroid having the structure of 11,21-dihydroxy-
3,20-diketo-4-pregnene-18-al, has been referred to
in the second paragraph under Uses. While it
is an aldehyde, in solution it is thought to exist
as a hemiacetal (with the hydroxyl at carbon 11)
(Simpson et al., Experientia, 1954, 10, 132). It
has been isolated from beef and hog adrenal
glands (Simpson et al., ibid., 1953, 9, 333; Mattox
et al., Proc. Mayo, 1953, 28, 569; Knauff et al.,
J.A.C.S., 1953, 75, 4868) and appears to be iden-
tical with a sodium-retaining corticoid present in
human urine (Luetscher et al., J. Clin. Endocrinol.,
1954, 14, 812). Aldosterone promotes the renal
excretion of potassium and the retention of sodium
and chloride and water (Desaulles et al., Schweiz.
med. Wchnschr., 1953, 83, 1088; Gross and Gysel,
Acta endocrinol., 1954, 15, 199; Kekwick and
Pawan, Lancet, 1954, 2, 162 ; Mach et al., Schweiz.

426

Desoxycorticosterone Acetate

Part I

med. Wchnschr., 1954, 84, 407; Swingle et al.,
Proc. S. Exp. Biol. Med., 1954, 86, 147). It is 25
to 50 times as active as desoxycorticosterone in
this respect. It is therapeutically effective in pa-
tients with Addison's disease in daily doses of 0.1
to 0.2 mg. In doses of 0.1 to 1 mg. daily intra-
muscularly for 6 days, Ward et al. {Proc. Mayo,
1954, 29, 649) observed no antirheumatic activity
in patients with rheumatoid arthritis, no effect on
the metabolism of protein or carbohydrate, and no
change in the blood eosinophil count or the urinary
17-hydroxycorticoid excretion.

Toxicology. — The untoward effects of desoxy-
corticosterone are those of excessive hormone ac-
tion. These include increase in blood volume and
blood pressure, pronounced retention of sodium
chloride and lowering of serum potassium, edema,
and an increase in the size of the heart (Loeb,
Bull. N. Y. Acad. Med., 1942, 18, 263). Intra-
cellular potassium may be replaced by sodium,
with resulting muscular weakness or even paralysis
and heart failure, with histological changes in the
myocardium (Gobdof and MacBryde, /. Clin.
Endocrinol., 1944, 4, 30. Careful regulation of
sodium, potassium and water intake is important
in the therapeutic program (Thorn, ibid., 1941,
1, 76). Fatal pulmonary edema and congestive
heart failure have occurred. McGavack (Am.
Heart J., 1944, 27, 331) reported that the size
of the heart was correlated with the clinical con-
dition of the patient with Addison's disease under
treatment with desoxycorticosterone. Perera and
Blood (Ann. Int. Med., 1947, 27, 401) and others
have observed hypertension in patients with Addi-
son's disease, and also in normal persons, in the
course of prolonged treatment with desoxycorti-
costerone acetate, which condition could not be
connected with abnormal retention of sodium ion,
with increase in blood volume, or with an ab-
normally labile peripheral vascular system as
measured by the cold pressor test. A functioning
adrenal cortex is essential for the existence of
experimental or clinical hypertension (Schroeder,
Am. J. Med., 1951, 10, 189). The hypotension in
cases of Addison's disease produced by bilateral
adrenalectomy in patients with essential hyper-
tension is changed to the pre-existing hypertensive
level by administration of desoxycorticosterone
acetate (Thorn et al., Ann. Int. Med., 1952, 37,
972). Selye et al. (J.A.M.A., 1944, 124, 201) pro-
duced in rats a polyarthritis with large doses of
desoxycorticosterone acetate; histologically this
resembled that seen in acute rheumatic fever. Fre-
quently Aschoff bodies appeared in the heart, also
periarteritis nodosa lesions. Peschel et al. (Endo-
crinology, 1951, 48, 399) found that the myo-
cardial lesions were due to potassium deficiency.
Dosage and Dosage Forms. — Desoxycorti-
costerone acetate is most generally employed. Sev-
eral esters differ in duration of action (Miescher
et al., Nature, 1938, 142, 435). The acetate in
0.5 per cent concentration in sesame or peanut oil
for intramuscular injection is effective in Addi-
son's disease (Levy-Simpson, Lancet, 1938, 2,
557; Thorn et al, J. Clin. Inv., 1939, 18, 449).
Action on urinary electrolytes appears within 2
hours after intramuscular injection and the effect
of a dose of 1 to 3 mg. persists for more than 24

hours. Hence, a single daily injection is adequate
(Thorn et al., Am. J. Med., 1951, 10, 595). In
crises of Addison's disease, 5 mg. or more is
required.

Pellets. — Following the successful use of pel-
lets of estrogens or androgens implanted sub-
cutaneously for prolonged therapeutic effect
(Deanesly and Parkes, Proc. Roy. Soc, 1937,
124, 279), pellets of desoxycorticosterone acetate
were used successfully (Thorn et al., Bull. Johns
Hopkins Hosp., 1939, 64, 339). Because of a more
constant therapeutic action, the avoidance of the
daily injection otherwise required, and the greater
efficiency of the steroid, pellets became the stand-
ard therapeutic procedure until the availability
of cortisone modified therapy. A pellet containing
125 mg. is absorbed at the rate of 0.3 to 0.4 mg.
daily; the physiological effect of this continuous
action is equivalent to the effect of 0.5 mg. in oil
intramuscularly once daily (McGavack and Rein-
stein, Endocrinology, 1946, 39, 77). A 75-mg.
pellet implanted subcutaneously is absorbed at a
rate of about 0.24 mg. daily and is equivalent in
action to 0.3 mg. in oil intramuscularly once
daily. To estimate the number of pellets to im-
plant, the daily requirement of the steroid is
determined by intramuscular injection in oil,
using body weight, hematocrit, blood pressure
and size of the heart as a guide to adequate sub-
stitution therapy. For each 0.5 mg. in oil re-
quired intramuscularly daily, 1 pellet of 125 mg.
is implanted, or for each 0.3 mg. in oil daily a
75 mg. pellet is indicated. However, if more than
4 pellets are indicated, one less than the calcu-
lated number is employed in order to avoid the
untoward effects of overdosage. In the average
case 2 to 4 pellets are sufficient, although as many
as 8 have been used. Absorption continues for
8 to 15 months after implantation. Sodium chlo-
ride, in 1 Gm. enteric-coated tablets, should be
prescribed daily, commencing 5 or 6 months after
implantation.

Shipley (Am. J. Med. Sc, 1944, 207, 19) made
an incision 1 cm. long in the infrascapular region,
using aseptic surgical technic, for implantation
of pellets. Pockets radiating in various directions
were made with a hemostat in the subcutaneous
tissue. As many as 8 pellets could be inserted
easily through one incision. With care neither
infection nor spontaneous extrusion of pellets
occurs. A pellet implanter, consisting of a special
trocar which fits the size of the pellets accurately,
is a convenience (Perloff, /. Clin. Endocrinol.,
1951, 11, 737).

Transmucosal oral absorption occurs but is
seldom the preferred method of administration.
A solution of free desoxycorticosterone in pro-
pylene glycol and 20 per cent ethyl alcohol was
shown to be effective (Anderson et al., J. A.M. A.,
1940, 115, 2167); 5 mg. divided into several
applications daily was equivalent to the action of
1 mg. daily absorbed from pellets. A tablet con-
taining 2 mg. of desoxycorticosterone acetate in
a glycol and wax base has been developed; these
"buccalets" are held under the tongue or prefer-
ably in the buccal pouch (between the upper lip
and the gum above the bicuspid teeth) . The aver-
age daily dose by this route was found to be 4.8

Part I

Dextrose

427

mg. (Anderson et al., J. Clin. Endocrinol, 1949,
9, 1324). Transmucosal absorption is inadequate
in instances of adrenal crisis.

A repository type injection has been prepared
from microcrystalline desoxycorticosterone tri-
methyl acetate (Ciba) suspended in isotonic
saline solution with methylcellulose and Tween
20; following intramuscular injection it exerts its
effect in 48 hours and persists for 5 or 6 weeks
(see Thorn and Jenkins, Schweiz. med. Wchnschr.,
1952, 82, 697). For intravenous use desoxycorti-
costerone glucoside (Ciba), which is more soluble
in water, has been developed (Miescher et al.,
Helv. Chim. Acta, 1942, 25, 40). A 1 per cent
solution, in 10 per cent dextrose with 10 per cent
of acetamide as a stabilizer, has been used intra-
venously; its action is more rapid and transient
than that following intramuscular administration
of desoxycorticosterone acetate in oil (Meier and
Gross, Deutsche med. Wchnschr., 1950, 75, 1150).
In Addisonian crises a dose of 100 to 300 mg.
intravenously is equivalent to 15 to 20 mg. of
desoxycorticosterone acetate in oil injected in-
tramuscularly.

The U.S.P. gives the following doses: by intra-
muscular injection, 5 mg. daily, with a range of
2 to 5 mg.; by the buccal route. 2 mg. up to 4
times daily, the range being 2 to 4 mg.; by im-
plantation, 75 mg. for each mg. of daily intra-
muscular dose.

Storage. — Preserve "in well-closed, light re-
sistant containers." U.S.P.

DESOXYCORTICOSTERONE

ACETATE INJECTION.

U.S.P. (B.P.) (LP.)

"Desoxycorticosterone Acetate Injection is a
sterile solution of desoxycorticosterone acetate in
oil. It contains not less than 90 per cent and not
more than 115 per cent of the labeled amount of
C23H32O4." U.S.P. The B.P. injection is prepared
in ethyl oleate or a suitable fixed oil; the injec-
tion is sterilized by heating it in its final contain-
ers at 150° for 1 hour or, if the volume in each
container exceeds 30 ml., for a longer time to
insure maintaining the contents at 150° for 1
hour; no assay rubric is provided. The LP. injec-
tion is prepared and sterilized similarly, except
that the temperature of 150° during sterilization
is to be maintained for 2 hours.

B.P. Injection of Deoxycortone Acetate; Injectio
Deoxycortoni Acetatis. LP. Injection of Desoxycortone
Acetate; Injectio Desoxycortoni Acetatis.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass, protected from light."
U.S.P.

Usual Sizes. — 5 mg. in 1 ml.

DESOXYCORTICOSTERONE
ACETATE PELLETS. U.S.P. (B.P.)

"Desoxycorticosterone Acetate Pellets consist
of desoxycorticosterone acetate compressed in the
form of pellets, without the presence of any
binder, diluent, or excipient." U.S.P.

The B.P. recognizes Implants of Deoxycortone
Acetate as sterile cylinders prepared by fusion or
heavy compression of deoxycortone acetate with-

out the addition of any other substance; they are
distributed singly in sterile containers, which are
then sealed so as to exclude microorganisms.

B.P. Implants of Deoxycortone Acetate.

For method of use, and dosage, of these pellets
see the article on Desoxycorticosterone Acetate.

Storage. — Preserve "in tight containers hold-
ing one Pellet each." U.S.P.

Usual Sizes. — 75 and 125 mg.

DEXTROSE. U.S.P. (B.P.) (LP.)

D-Glucose, [Dextrosum]

CH2OH-CH-(CHOH)3-CHOH

HoO

"Dextrose is a sugar usually obtained by the
hydrolysis of starch. It contains one molecule of
water of hydration, or is anhydrous." U.S.P. The
B.P., under the title Dextrose, recognizes the
anhydrous sugar and, under the title Dextrose
Monohydrate {Dextrosum Hydratum), separately
recognizes the hydrate. The LP. Glucose is a
monohydrate.

B.P. Dextrose Monohydrate; Dextrosum Hydratum.
I. P. Glucose; Glucosum. Anhydrous Glucose; Corn, Grape,
Honey or Starch Sugar. Glucosum (Fr.) ; Saccharum Amyl-
aceum (Ger.). Fr. Glucose officinal; Dextrose; Glycose.
Ger. Traubenzucker ; Starkezucker; Glykose. Sp. Glucosa;
Dextrosa; Azucar de uva.

Dextrose is an aldohexose-type of monosac-
charide occurring as a natural constituent of many
plants, its abundance (up to 30 per cent) in grapes
having led to its common designation as grape
sugar. It is the fundamental building unit of such
complex substances as starch, cellulose and cello-
biose, and it is a component, along with other
monosaccharides, of sucrose, lactose and certain
other sugars.

Dextrose is commonly prepared by acid hy-
drolysis of corn starch, the process being similar
to that employed in the manufacture of liquid
glucose (q.v.) except that the reaction is carried
to completion of the conversion of starch to dex-
trose. After hydrolysis the liquid is neutralized,
decolorized by passage through bone black, and
concentrated to the point of crystallization. The
sugar is available commercially in anhydrous form
and as a monohydrate.

A freshly prepared aqueous solution of the
monohydrate has a specific rotation of +109.6°,
this changing slowly to a constant value of
+52.3°. Tanret, in 1895, prepared a stereo-
isomeric form of the sugar by crystallization from
a very concentrated solution of ordinary dextrose
at 110° and found this isomer to have an initial
specific rotation of +20.5°, also changing to a
final value of +52.3° on standing. From this ob-
servation of the phenomenon of mutarotation it
was concluded that solutions of dextrose represent
an equilibrium mixture of two stereoisomeric
forms, designated a//>/*a-dextrose and beta-dex-
trose, respectively. The composition of this equi-
librium mixture is 35 per cent of the alpha form
and 65 per cent of the beta (Isbell and Pigman,
Bur. Standards J. Research, 1933, 10, 337). For

428

Dextrose

Part I

further discussion and explanation of this type of
isomerism, as well as of the evidence for the
existence principally of ring forms of dextrose
(with small amounts of open-chain forms) in
solution, see Textbook of Biochemistry, West and
Todd, 1955, or Outlines of Biochemistry, Gortner
and Gortner, 1949, or General Biochemistry,
Fruton and Simmonds, 1953.

Description. — 'Dextrose occurs as colorless
crystals or as a white, crystalline or granular
powder. It is odorless, and has a sweet taste. One
Gm. of Dextrose dissolves in about 1 ml. of water
and in about 60 ml. of alcohol. It is more soluble
in boiling water and in boiling alcohol. The spe-
cific rotation of Dextrose, previously dried at
105° for 16 hours, determined in a solution con-
taining 10 Gm. of the dried Dextrose and 0.2 ml.
of ammonia T.S. in each 100 ml., is not less than
+52.5° and not more than +53°." U.S.P.

Dextrose monohydrate dissolves in its water of
crystallization at about 86°; the anhydrous sugar
melts with decomposition at about 147°, caramel
being produced at higher temperatures.

Standards and Tests. — Identification. — A
copious red precipitate, of cuprous oxide, forms
on adding a few drops of a 1 in 20 solution of
dextrose to 5 ml. of hot alkaline cupric tartrate
T.S. Color of solution. — A solution containing
25 Gm. of dextrose in 50 ml. has no more color
than a mixture of 0.3 ml. of cobaltous chloride
C.S., 0.9 ml. of ferric chloride C.S., 0.6 ml. of
cupric sulfate C.S., and 48.2 ml. of water. Acidity.
— Not over 0.3 ml. of 0.02 N sodium hydroxide
is required to neutralize a solution of 5 Gm. of
dextrose in 50 ml. of carbon dioxide-free water,
using 3 drops of phenolphthalein T.S. as indica-
tor. Water. — When dried at 105° for 16 hours the
anhydrous form loses not over 0.5 per cent of its
weight, while the hydrous form loses not less than
7.5 per cent and not more than 9.5 per cent of
its weight. Residue on ignition. — Not over 0. 1 per
cent. Chloride. — The limit is 180 parts per million.
Sulfate. — The limit is 250 parts per million.
Arsenic. — The limit is 1.3 parts per million. Heavy
metals. — The limit is 5 parts per million. Dextrin.
— When 1 Gm. of finely powdered dextrose is
boiled with 15 ml. of alcohol under a reflux con-
denser it dissolves completely. Soluble starch,
sulfites. — A yellow color results when a drop of
iodine T.S. is added to a solution of 1 Gm. of
dextrose in 10 ml. of water. U.S.P.

The B.P. limits loss of weight on drying to con-
stant weight at 105° to 2.5 per cent for the an-
hydrous sugar, and between 6.0 and 10.0 per cent
for the monohydrate. The LP. loss on drying to
constant weight at 100° is not less than 8.0 per
cent and not more than 10.0 per cent. The B.P.
and LP. both limit arsenic to 1 part per million
and lead to 2 parts per million.

When the structure of dextrose (D-glucose) is
shown by an open chain type of formula, it is seen
that it consists of an aldehyde (CHO) group at
one end of the chain, a primary alcohol (CH2OH)
group at the other end, and four secondary alco-
hol (CHOH) groups between these terminal
groups. While this formula does not represent the
form in which dextrose ordinarily exists, at least
in solution, it does explain how three different

and important acids may be obtained by oxidizing
one or more of the terminal groups without
splitting the molecule of dextrose. If dextrose is
treated with strong nitric acid both the aldehyde
and the primary alcohol groups are oxidized to
carboxyl (COOH) groups, giving rise to saccharic
acid (more exactly designated D-saccharic acid).
Controlled oxidation, which may be effected by
biologic, electrolytic or chemical means, brings
about a selective oxidation of the aldehyde group
to carboxyl, producing gluconic acid (more
exactly, x>-gluconic acid). If the aldehyde group
of dextrose is protected against oxidation by prior
conversion to glycoside, oxidation of resulting
compound converts the primary alcohol group to
carboxyl, and from the product glucuronic acid
(d- glucuronic acid) may be obtained by hydrolysis.

Uses. — The natural sugar occurring in blood
is dextrose. It is obtained primarily from food
carbohydrates which undergo hydrolysis, catalyzed
by digestive enzymes, to simple 6-carbon sugars
which are absorbed after phosphorylation in the
intestine. The metabolism of dextrose consists of
its assimilation, storage, distribution and utiliza-
tion by the tissues. Each of these processes is
regulated by a variety of hormones and enzymes
which govern the rate and direction of its dis-
position by the body. The actual blood-sugar
levels are regulated by several factors, including
the rate of absorption (influenced by thyroxin),
the extent of storage within the liver (as glycogen)
and its release from this organ, the rate of utiliza-
tion for formation of energy, and the variables
of other routes of disposal. Within the usual
physiologic limits of blood-sugar content, this
substance does not appear in significant amounts
in the urine because of an active transport mech-
anism which is provided for its reabsorption
within the tubules from the glomerular filtrate.

Dextrose is the principal source of energy for
the body. It is oxidized by an intricate series of
reactions, each of which provides a small pocket
of energy which is stored within the tissues as
adenosinetriphosphate and creatine phosphate.
The energy thus produced is available for me-
chanical work, osmotic work, cellular biosynthesis
and secretion, and body heat. The enzymatic reac-
tions involved may convert dextrose to CO2 and
H2O, or, if sufficient oxygen is not present, to
lactic acid which can be resynthesized to glycogen
by the fiver. In addition to providing energy (4
Calories per Gm.), dextrose is readily converted
to fat, which provides a rich store of energy in
concentrated form (9 Calories per Gm.). Dex-
trose is also stored within the liver and muscles
as glycogen. When a rapid rise in blood sugar is
demanded by the body, glycogen is quickly liber-
ated as D-glucose by the action of hepatic enzymes
activated by epinephrine or the hyperglycemic-
glycogenolytic factor of the pancreas. When the
supply of dextrose is insufficient, the body mobi-
lizes its fat stores which are converted to acetate
with production of energy by the same oxidative
pathways employed in the combustion of the dex-
trose. When the products of fat breakdown ex-
ceed the rate of their combustion by the tissues,
ketonemia and acidosis result. The restoration of
normal dextrose combustion will correct this con-

Part I

Dextrose Injection 429

dition by depressing the rate of ketone-body
formation.

Another important use of dextrose in the total
body economy is the sparing of proteins, which
in the absence of dextrose may be deaminated to
provide carbon moieties from their constituent
amino acids. These deaminated fragments may
undergo oxidation in order to release energy. Dex-
trose is also the probable source of glucuronates
(see chemical discussion above), necessary for
detoxification of certain noxious substances and
steroid hormones by the liver. It probably pro-
vides the basic substances required for the for-
mation of hyaluronates and chondroitin sulfates,
the supporting structures of the organism. It can
be converted to a pentose essential for the forma-
tion of nucleoprotein by the cells. It is quite
apparent that, in addition to its importance as
the primary source of energy for the body, dex-
trose has a multitude of other essential roles in
the body economy.

It is important to realize the relationship be-
tween the utilization of dextrose and the B vita-
mins which form the coenzyme systems in its
metabolism. The administration of dextrose with-
out an adequate provision of these vitamins will
exhaust tissue stores of these factors, leading to
deficiency states. Similarly, the utilization of glu-
cose will cause the intracellular movement of
potassium so that provisions for replacement of
this element during periods of dextrose adminis-
tration may require consideration under certain
conditions. The level of blood-sugar appears to
be one factor in governing the rate of production
of certain hormones: hyperglycemia invokes an
outpouring of insulin; hypoglycemia causes re-
lease of epinephrine and through this latter mech-
anism the pituitary-adrenal cortex axis is stimu-
lated. From the anterior pituitary and adrenal
cortex, the anti-insulin factors which tend to re-
store the blood sugar to normal are liberated.
An excess of energy-yielding dextrose may im-
prove the efficiency of myocardial and skeletal
muscle performance, although Ingle (Am. J.
Physiol., 1951, 165, 473; found that the fluid
load administered during the glucose infusion is
an important factor. For discussion of the value
of intravenous injections of dextrose solutions,
see under Dextrose Injection and Dextrose and
Sodium Chloride Injection, [v]

Labeling. — "Label Dextrose to indicate
whether it is hydrous or anhydrous." U.S.P.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Off. Prep.— Dextrose Injection, U.S.P. , B.P.,
LP.; Dextrose and Sodium Chloride Injection;
Anticoagulant Sodium Citrate, Citric Acid and
Dextrose Solution, £/.S./,.;Hypophosphites Syrup;
Compound Hypophosphites Syrup; Sodium Chlo-
ride and Dextrose Tablets, N.F.; Injection of
Bismuth, B.P.

DEXTROSE INJECTION.
U.S.P. (B.P.) (LP.)

[Injectio Dextrosi]

"Dextrose Injection is a sterile solution of dex-
trose in water for injection. It contains not less

than 95 per cent and not more than 105 per cent
of the labeled amount of C6H12O6.H2O. Bacterio-
static agents must not be added to Dextrose In-
jection." U.S.P.

The B.P. recognizes the same preparation; the
solution is to be sterilized, immediately after
preparation, by heating in an autoclave or by
filtration through a bacteria-proof filter. The LP.
requirement of the content of dextrose, as mono-
hydrate, is the same as that of the U.S.P.;
sterilization by heating in an autoclave at 115°
for 15 minutes or by bacteriological filtration is
permitted.

B.P. Injection of Dextrose. LP. Injection of Glucose;
Injectio Glucosi. Dextrose Ampuls; Glucose Ampuls.
Ampullae Dextrosi; Injectio Glucosae. Fr. Solute injectable
hypertonique de glucose; Solute injectable isotonique
de glucose. Sp. Inyeccion de glucosa, isotonica ; Inyeccion
de glucosa, hipertonica; Inyeccion de Dextrosa.

Dextrose solutions, if made from the pure
sugar, do not discolor on autoclaving but they do
become acid in reaction, for which reason Wil-
liams and Swett (J.A.M.A., 1922, 78, 1024) pro-
posed adding to them a buffering mixture of
monopotassium and dipotassium phosphate. Other
substances, as for example sodium citrate in 0.25
per cent concentration, have been used for the
same purpose. But any advantage that may be
gained by maintaining the pH constant is offset
by pronounced coloration of the solution, often
mistaken for caramelization, which occurs on heat
sterilization; the higher the temperature and the
longer the time of sterilization the more intense
the coloration. Buffered solutions of this type may
be prepared by separately sterilizing the dex-
trose and the solution of the buffering agent, then
mixing the solutions under the most rigid precau-
tions to avoid contamination, followed by bac-
terial filtration of the product. Some manufac-
turers supply a separate container of buffer,
which is to be mixed with the dextrose solution
just before use. The Council on Pharmacy and
Chemistry of the American Medical Association
voted, however, to discontinue acceptance of dex-
trose solutions with buffers and to omit them
from N.N.R. because of lack of evidence for the
value or necessity of buffering them (J.A.M.A.,
1942, 119, 499).

Though it has been stated that the coloration
of dextrose is due to impurities in it, such as
levulinic acid and hydroxymethyl furfural, the
experiments of Englis and Hanahan (J.A.C.S.,
1945, 67, 51) indicate that even pure samples of
dextrose develop color on heating of their solu-
tions in the presence of a buffer; these workers
found that dextrose undergoes a considerable con-
version to ketoses, chiefly levulose, on autoclaving
the solutions in the presence of a phosphate buffer
at an initial pH of 6.4 to 6.6.

It is well known that monosaccharides are un-
stable in alkaline solution. Even in slightly alka-
line solution dextrose undergoes intramolecular
rearrangements to form six other hexoses, in-
cluding levulose and mannose. In more strongly
alkaline solutions dextrose rearranges to form a
series of unsaturated enol compounds which are
unstable and readily undergo cleavage at the
double bond. The 3,4-enediol form of dextrose,

430 Dextrose Injection

Part I

for example, yields glyceric aldehyde and dihy-
droxyacetone. It is asserted that dextrose can
form 116 different compounds as the result of
rearrangements and cleavages occurring in alka-
line solutions, and depending also on whether
oxygen is present or absent.

Dextrose solutions are likely to show mold
growth which is not macroscopically visible for
months after preparation; tests for molds utiliz-
ing the common culture media for molds may re-
quire several weeks of incubation before presence
of such organisms may be established. It is there-
fore imperative that in manufacturing dextrose
solutions every precaution be taken to insure free-
dom from bacterial and mold contamination of
the solution and its containers; as a further safe-
guard against accidental contamination the con-
tainers filled with solution should be sterilized by
autoclaving.

Standards and Tests. — Identification. — The
injection responds to the identification test under
Dextrose. pH. — Between 3.5 and 6.5. Heavy
metals. — The limit is 5 parts per million. Pyrogen.
— The injection, diluted if necessary to contain
not more than 5 per cent of dextrose, meets the
requirements of the Pyrogen Test. U.S.P.

Assay. — A volume of injection equivalent to
2 to 5 Gm. of dextrose is mixed with 0.2 ml. of
ammonia T.S. and sufficient water to make 100
ml. After 30 minutes the angular rotation, ob-
served in a 200-mm. tube and at 25°, is deter-
mined. The rotation is multiplied by 1.0425 to
obtain the weight of C6H12O6.H2O represented in
the volume of injection taken for analysis. U.S.P.

Uses. — Dextrose is injected intravenously
either in a 5 per cent solution, which is approxi-
mately isotonic with the blood, a 10 per cent
solution, or as a highly concentrated solution,
from 25 to 50 per cent (see also under Dextrose
and Sodium Chloride Injection). The therapeutic
uses of these solutions are very different. The
5 or 10 per cent solutions are used like the iso-
tonic injection of sodium chloride for increasing
the volume of blood either in combating circu-
latory failure due to hemorrhage or surgical shock,
in counteracting the dehydration which often
occurs as the result of disease — excessive vomit-
ing or purging, especially in children (Sanford
and Heitmeyer. J. A.M. A., 1928, 90, 737), lack of
sufficient fluid intake, fever — and for maintaining
caloric intake. According to Fantus (J. A.M. A.,
1934, 102, 2165) dextrose solution is better in
cases of dehydration than sodium chloride, unless
there is also loss of electrolytes, because as dex-
trose is oxidized in the body a larger percentage
of water becomes available to the system. When
water alone is needed parenterally. 5 per cent
dextrose in distilled water is the fluid of choice.
A 5 per cent dextrose solution causes no deforma-
tion of the red blood cells. Dextrose solution is
also superior to salt solution in circulatory failure
because of its greater viscosity and because the
sugar has a roborant effect on the heart and prob-
ably other bodily functions. When nutrition is the
object of treatment, 10 per cent dextrose is pre-
ferred. For subcutaneous administration (hypo-
dermoclysis) , the isotonic 5 per cent solution in

distilled water is used. Objections have been raised
to hypodermoclysis with solutions which do not
contain sodium chloride in dehydrated patients
(Abbott et al., Surgery, 1952, 32, 305; Mateer
et al, Am. J. Med. Sc, 1953, 226, 139) because
of the tendency to produce hyponatremia as
sodium diffuses from the blood into the non-
sodium containing pool of dextrose solution in the
subdermal injection site.

Hypertonic solutions, 25 to 50 per cent, are
used partly because of their dehydrating effects
and partly because they are believed to strengthen
the heart muscle. In some conditions, such as
pulmonary edema, the concatenation of these two
actions is of great value. The dehydrating effect
results from the increase of the osmotic density
of the blood and a consequent passage of water
from the surrounding tissues into the blood ves-
sels; the increase in the volume of blood which
results tends to augment the output of urine and
other secretions. Increased cerebrospinal fluid
pressure is depressed for 2 to 4 hours after intra-
venous injection of 50 ml. of 50 per cent dextrose
solution. In circulatory failures which are pri-
marily of cardiac origin an increased volume of
blood shows an added strain upon the heart.
Murphy and colleagues {J. A.M. A., 1941, 116,
104) found that although intravenous injection
of large volumes of approximately isotonic solu-
tions had deleterious effects on cases of heart dis-
ease, small quantities (50 ml.) of a 50 per cent
dextrose solution were often beneficial. The simul-
taneous administration of insulin has been advo-
cated by some for the purpose of increasing the
utilization of the dextrose, but others have pointed
out that the resulting increased consumption of
carbohydrate in the muscles may actually result
in a decreased rather than an increased deposit
of glycogen in the liver. The conjoint administra-
tion of dextrose and insulin may be of lifesaving
importance in the treatment of diabetic coma.
Root (I.A.M.A., 1945. 127, 557) attributed many
of the fatalities in diabetic coma to the use of
dextrose and fists the following arguments against
its use: no more than 5 to 10 Gm. of carbohydrate
can be or need be oxidized per hour to check
ketone formation; glucose neutralizes the action
of insulin; a rise in blood-sugar is produced which
makes it difficult to determine the required dose
of insulin; excessive hyperglycemia is harmful to
the pancreas; glycosuria increases depletion of
salt and water; hyperglycemia in the presence of
acidosis may result in anuria; and excessive glu-
cose damages the fiver. Peters ( Yale I . Biol. Med.,
1945, 17, 705) listed the following advantages in
the use of dextrose in diabetic coma : supplying
the body with dextrose prevents the destruction
of protein and the resulting overproduction of
ketones ; it diminishes the drain on the inadequate
glycogen stores; it builds up the stores of glyco-
gen in the liver and muscles; and it avoids hypo-
glycemic reactions resulting from large doses of
insulin.

The amount of dextrose that the normal indi-
vidual can metabolize is about 800 mg. per kilo-
gram per hour, which would correspond in an
average man to approximately 1 liter of a 5 per

Part I

Dextrose and Sodium Chloride Injection 431

cent solution ; unless insulin is administered simul-
taneously any excess of glucose much above this
amount will appear in the urine (see Titus and
Lightbody, Am. J. Obst. Gyn., 1929, 18, 208).
When using concentrated solutions of dextrose it
is important that these should be injected very
slowly so as not to cause a local rise in the osmotic
tension of the blood at the point of injection.
Dextrose has been combined with solutions of
protein hydrolysates in concentrations of 5 to 10
per cent to increase the caloric value of these
preparations for parenteral nutrition. These hy-
pertonic solutions may produce local phlebitis.

A number of serious reactions have been re-
ported following the intravenous injections of
dextrose which can be attributed to errors in
technique. It has been claimed that dextrose may
produce allergic reactions in corn-sensitive per-
sons (Editorial, J. A.M. A., 1950, 144, 1379);
however, this is refuted (Feinberg et al. and
Loveless, ibid., 1951, 145, 666; Ratner, ibid.,
1369).

Dilute dextrose solutions are occasionally in-
jected intraperitoneally, especially in children,
and more infrequently intramuscularly. The 20 to
50 per cent solution has been used to cause irri-
tation in the pleura when an adhesive pleuritis
is desired; this agent causes less febrile reaction
than beef broth which has also been used. The
50 per cent solution is used to sclerose varicose
veins. In the treatment of acute alcoholism, in-
travenous dextrose — 1 liter of 10 per cent solution
or 50 ml. of 50 per cent solution — is used; un-
modified insulin, 20 units, and thiamine hydro-
chloride, 100 mg., are added to the infusion.
Glesne (Anesthesiol., 1950, 11, 702) recom-
mended dextrose injection intrathecally or intra-
venously in the management of post-spinal punc-
ture headache, E

The dose of 5 per cent dextrose injection, by
intravenous or hypodermic administration, de-
pends on the needs of the patient. It is about 500
ml., with a range of 100 to 1000 ml. The maxi-
mum safe dose is 1000 ml. and the total dose in
24 hours should seldom exceed 2000 ml. For doses
of other solutions see above.

Storage. — "Preserve Dextrose Injection in
single-dose containers, preferably of Type I, Tvpe
II, or Type IV glass." U.S.P.

Usual Sizes. — 5 per cent, in 250, 500, and
1000 ml.; 10 per cent, in 5, 250, 500, and 1000
ml; 20 per cent, in 500, and 1000 ml; 25 per
cent, in 50 ml.; 50 per cent, in 20, 50, 100, and
500 ml.

DEXTROSE AND SODIUM CHLO-
RIDE INJECTION. U.S.P.

[Injectio Dextrosi et Sodii Chloridi]

"Dextrose and Sodium Chloride Injection is a
sterile solution of dextrose and sodium chloride
in water for injection. It contains not less than
95 per cent and not more than 105 per cent of
the labeled amount of C6H12O6.H2O and of NaCl.
It contains a bacteriostatic agent only when la-
beled for use as a sclerosing agent." U.S.P.

Sp. Inyeccion de Dextrosa y Cloruro de Sodio.

Standards and Tests. — Identification. — The
injection responds to the identification test pro-
vided for Dextrose, and to tests for sodium and
for chloride. Heavy metals. — The limit is 5 parts
per million. Pyrogen. — The solution, diluted if
necessary to contain not more than 0.9 per cent
of sodium chloride and not more than 5 per cent
of dextrose, meets the requirements of the official
Pyrogen Test. pH. — The pH is between 4.0 and
6.0. U.S.P.

Assay. — For sodium chloride. — A volume of
solution representing about 200 mg. of sodium
chloride is diluted with distilled water to about
50 ml.; while agitating, 50 ml. of 0.1 N silver ni-
trate, then 3 ml. of nitric acid and 5 ml. nitroben-
zene are added and the excess of silver nitrate
titrated with 0.1 N ammonium thiocyanate, using
ferric ammonium sulfate T.S. as indicator. Each
ml. of 0.1 N silver nitrate represents 5.845 mg.
of NaCl. The purpose of the nitrobenzene is to
prevent the silver chloride from reacting with the
thiocyanate. For dextrose. — A volume of injec-
tion equivalent to 2 to 5 Gm. of dextrose is
mixed with 0.2 ml. of ammonia T.S. and sufficient
water to make 100 ml. After 30 minutes the an-
gular rotation, observed in a 200-mm. tube and at
25°, is determined. The rotation is multiplied by
1.0425 to obtain the weight of C6H12O6.H2O
represented in the volume of injection taken for
analysis. U.S.P.

Uses. — Parenteral Nutrition. — The devel-
opment of fluids for parenteral use providing
water, electrolytes, dextrose, vitamins, proteins,
amino acids and other nutrients has been one of
the big advances in therapeutics of the last two
decades. First it was recognized that the serious
features of many diseases were the result of nu-
tritional disturbances and that many complica-
tions following surgical procedures were of this
nature. After much investigation it has become
possible to correct these disturbances and to main-
tain patients in water, chemical and nutritional
balance as long as necessary by parenteral means
(Butler and Talbot, New Eng. J. Med., 1944, 231,
585, 621). The uses of parenteral fluids include
replacement of water loss, provision of caloric
intake, restoration of chemical balance, prevention
and treatment of hypoproteinemia, control of
shock, administration of adequate vitamins and
provision of indicated chemotherapy (see also
under Dextrose Infection). Many advances in
fluid and electrolyte therapy have been made by
pediatricians (Gamble, Extracellular Fluid, Har-
vard University Press, 1951).

Dehydration. — Next to oxygen, water is the
most immediately vital substance. A loss of 10
per cent of body water results in serious disorder
(Coller and Maddock, Ann. Surg., 1935, 102,
947) and a loss of 20 per cent is usually fatal.
Because of vomiting or diarrhea many patients
have lost considerable fluid when they come under
treatment. During surgical procedures losses of
1000 to 1500 ml. due to perspiration and evapora-
tion from the skin and lungs are not uncommon.
The amount of fluid secreted by the gastrointesti-

432 Dextrose and Sodium Chloride Injection

Part I

nal tract in 24 hours is estimated to be from 7000
to 8000 ml. (saliva, bile, gastric juice, pancreatic
juice, intestinal secretions) which is an amount
exceeding the usual total blood volume of the
adult. Blood loss, vomitus, drainage from intes-
tinal fistulas or diarrhea, and massive exudation
from inflamed surfaces, as in extensive burns,
pneumonia, etc., greatly increase dehydration.
Under normal circumstances, the daily require-
ment for water intake is about 2500 ml., of
which 1500 ml. is needed to replace vaporization
from the skin and lungs and 1000 ml. to replace
excreted urine. In the presence of fever daily
losses are increased, so that 3500 ml. is a better
estimate of the needs. To this increased need
must be added the abnormal fluid losses already
mentioned, which may reach enormous propor-
tions. Furthermore, previous fluid losses must be
corrected. A patient with the common signs of
dehydration, such as dry hot skin, dry tongue,
sunken eyes, fever, and scanty urine, may be
assumed to have lost an amount of fluid equal to
6 per cent or more of the body weight, which
amounts to 3 to 4 liters for the adult of average
size. The sum of these several needs not infre-
quently amounts to 7 liters or more. In the case
of young and otherwise robust patients even
7000 ml. of parenteral fluids may be given safely
at a rate of 1000 ml. per hour. For older individ-
uals and particularly those with circulatory defi-
ciency an attempt to replace so much fluid in a
single day is inadvisable. When volumes of fluid
of 3500 ml. or less are to be given, a rate of
intravenous injection of 300 to 500 ml. per hour
is usually safe. When larger volumes are re-
quired, Coller and Maddock (Am. J. Stirg., 1939,
46, 426) advocated continuous injection for 20
out of the 24 hours at a rate of 200 ml. per hour.
In the presence of shock or hemorrhage, however,
many cases will tolerate and benefit by the rapid
injection (up to 30 ml. per minute) of the first
liter of solution. Although normal kidneys are
capable of excreting the daily waste products of
body metabolism in about 500 ml. of concentrated
urine (specific gravity about 1.030), a volume of
1000 to 1500 ml. of urine daily may be necessary
in the presence of impaired renal function due
to disease or secondary to circulator}* or metabolic
disturbances. Although there are many causes of
oliguria, dehydration should be considered first
and corrected.

Sodium Chloride. — The sodium chloride me-
tabolism of seriously ill patients is profoundly
affected. There may be no intake of food and
water by mouth so that no new salt becomes
available. Renal tubular reabsorption of salt,
however, effectively retains this substance under
these conditions. There may be abnormal losses
of salt from the body as a result of vomiting
and diarrhea, which are by far the most common,
drainage from the intestinal and biliary tract
through tubes and fistulas, copious wound secre-
tions, withdrawal of considerable volumes of
ascitic fluid and prolonged sweating. The usual
salt intake in the average diet under normal con-
ditions is 5 to 6 Gm. daily. It should be empha-
sized that 1000 ml. of isotonic sodium chloride

solution contains 9 Gm. of salt and the injection
of 3 liters of this solution daily introduces 27 Gm.
of salt, which, unless needed, results in salt re-
tention and in local and visceral edema. In re-
storing and maintaining water and electrolyte
balance, laboratory determinations of hematocrit,
blood-chlorides, carbon dioxide and plasma-pro-
teins should be made daily until the situation has
become stabilized (see Carr, Surg. Gynec. Obst.,
1944, 79, 438). Patients with gastric suction
should be given normal saline or Ringer's solution
to replace, volume for volume, the amount si-
phoned from the stomach or intestine, and the
balance of the fluid requirement should be ad-
ministered in the form of dextrose in distilled
water. The losses of potassium sustained in such
circumstances must also be replaced (see under
Potassium Chloride).

Dextrose. — Dextrose should be supplied to all
patients given parenteral fluids (Bassett, West. J.
Surg., 1938, 46, 212). When no food is taken by
mouth, the glycogen supply of the body rapidly
becomes exhausted. Endogenous fat, which then
forms the main source of energy, is mobilized,
leading to ketonemia and starvation acidosis.
Dextrose also protects the liver from damage and
supplies calories.

Protein. — Protein deficiency is common due to
diminished and restricted food intake, deficient
absorption, increased metabolic demands, plasma
loss in trauma and bums and blood loss in hemor-
rhage and at operation. Blood plasma and amino
acid solutions have become available in sufficient
quantity to deal effectively with hypoproteinemia
by the parenteral route. In general, amino acids
are indicated for restoring and maintaining tissue
proteins and plasma for depleted serum proteins.
In the presence of hypoproteinemia (less than 5.5
Gm. per 100 ml.), fluids tend to leave the blood
vessels due to the decreased osmotic pressure of
the blood and the intravenous administration of
saline aggravates this tendency. Proper control of
fluid and electrolyte balance with parenteral
saline and dextrose is difficult unless serum pro-
tein is maintained at a normal level (Coller et al.,
Ann. Surg., 1945. 122, 663). The practical diffi-
culty of supplying sufficient calories in the form
of parenteral solutions to prevent the utilization
of the injected amino acids for energy rather
than the restoration of protein is discussed under
Amino Acids, in Part II.

Vitamins. — Parenteral vitamins are also neces-
sary in patients receiving only parenteral fluids.
This is particularly true of the B vitamins, which
are stored in the body for only short periods of
time, but vitamins C and A. D and K are also
important in the presence of disease.

Indications. Sodium Chloride. — Many solu-
tions are used parenterally. Isotonic sodium chlo-
ride solution is employed to provide the daily
salt requirements. In patients who have not lost
a great deal of electrolyte, 500 to 1000 ml. daily,
with or without 5 per cent dextrose, will furnish
sufficient sodium chloride. It is also used to re-
place, volume for volume, fluids lost by vomiting
or gastric suction drainage. To correct hypo-

Part I

Diallylbarbituric Acid 433

chloremia, the following formula serves as a
helpful approximation of the dose required:

0.5 Gm. X

body weight

kilograms

580 mg. \_\

per cent

(

plasma sodium
chloride in
mg. per cent ,

100

(Gm. sodium
chloride
required

The isotonic sodium chloride solution is also
used in instances of acidosis or alkalosis particu-
larly where dehydration is severe. Unfortunately,
there is a prevailing tendency to give salt solution
to all patients needing fluids parenterally. This
practice often results in the administration of
excess salt and the development of edema. Fluid
requirements over and above the amount of
sodium chloride required should be administered
in the form of S per cent dextrose in distilled
water.

Dextrose. — Dextrose solutions are used for
temporary replacement of blood volume in shock,
for antiketogenic effect in organic acidosis, for
caloric value, for replenishing the glycogen supply
of the liver and as a source of water without salt.
In the absence of dehydration the 5 per cent
dextrose solution in distilled water or isotonic
sodium chloride solution causes diuresis. Dextrose
solution in distilled water will neither relieve nor
prevent dehydration in patients who have lost or
are losing considerable amounts of electrolytes.
The 5 per cent solution without salt is employed
to provide water after any electrolyte deficiency
has been corrected with isotonic sodium chloride
solution with or without dextrose according to
the needs of the patient. For hypodermic injec-
tion (hypodermoclysis), the 2.5 per cent dextrose
solution in isotonic sodium chloride solution or
the 5 per cent dextrose solution in distilled water
is used.

Variants. — Ringer's solution is perhaps prefer-
able to sodium chloride solution alone in that it
provides small amounts of calcium and potassium
which may also be depleted. It has less tendency
to cause abnormal water retention. Hypertonic
saline solutions (2 to 5 per cent) are rarely given
intravenously and only in conditions of extreme
and dangerous hypochloremia such as seen in
cholera. Hypertonic dextrose solutions are not
used in treating dehydration. For patients re-
quiring larger amounts of carbohydrates and cal-
ories, the 10 per cent dextrose solution in dis-
tilled water is useful as in cases of liver damage,
severe hyperthyroidism or severe malnutrition.
Injection at a rate of 200 to 300 ml. per hour
produces only a minimal amount of glycosuria
and diuresis. The 25 to 50 per cent dextrose
solutions are used to produce dehydration of the
brain and other tissues, to produce diuresis and
to provide carbohydrate and calories. Ethyl alco-
hol to the extent of 5 to 10 per cent has been
added to dextrose solutions (Moore and Karp,
Surg. Gynec. Obst., 1945, 80, 523) to induce hyp-
notic, analgesic, vasodilator and caloric effects;
not more than 3000 ml. of the 5 per cent alcohol

and dextrose solution should be given in each 24
hours. When large amounts of dextrose are given,
thiamine, nicotinamide and riboflavin should be
given to ensure metabolism of the dextrose. In
the presence of acidosis, sodium bicarbonate in
distilled water or sodium lactate solution with or
without saline or dextrose is used (see under
Sodium Lactate). For alkalosis, which does not
respond to attempts to correct the deranged bal-
ance of water and electrolytes, ammonium chlo-
ride has been used cautiously (see under Am-
monium Chloride). Dextrose is combined with
citric acid and sodium citrate as a preservative
for whole blood (Strumia, /. Clin. Inv., 1947, 26,
278). The intravenous use of plasma and of
amino acid solutions is discussed elsewhere.

Other Routes. — In lieu of suitable veins, the
5 per cent dextrose solution in distilled water or
in isotonic sodium chloride solution has been in-
jected into the marrow cavity of the sternum in
adults or of the tibia of infants (Tocantins and
O'Neill, Surg. Gynec. Obst., 1941, 73, 281); rates
of injection with the reservoir elevated 3 to 6
feet above the bone as rapid as is safe with the
intravenous route have been obtained. Peritoneal
lavage with these solutions has effectively reduced
the concentration of blood urea nitrogen and
other catabolites in the treatment of temporary
renal insufficiency such as occurs after hemolytic
transfusion reactions or bichloride of mercury
poisoning (Abbott and Shea, Am. J. Med. Sc,
1946, 211, 312). Peritonitis has been difficult to
prevent in this method of treatment.

Sclerosing Agent. — A 25 per cent dextrose
and 15 per cent sodium chloride solution has been
employed as a sclerosing agent in the treatment
of varicose veins; with tourniquets applied to
confine the solution to the portion of the vein to
be injected, from 5 to 20 ml. \z injected slowly
and with caution. Extravasation causes severe
pain and perhaps sloughing, [vj

Dose. — The usual dose of a 5 per cent dextrose
and isotonic sodium chloride solution, intrave-
nously or hypodermically, is 500 ml., with a range
of 100 to 1000 ml. The maximum safe dose is
1000 ml. and the total dose in 24 hours should not
exceed 5000 ml.

Storage. — "Preserve Dextrose and Sodium
Chloride Injection in single-dose containers, pref-
erably of Type I or Type IV glass. Dextrose and
Sodium Chloride Injection for use as a sclerosing
agent may be dispensed in multiple-dose con-
tainers." U.S.P.

DIALLYLBARBITURIC ACID. N.F.

»-y2cH=.
>_/ ch*ch=

CH„

"Diallylbarbituric Acid, dried at 105° for 4
hours, contains not less than 98.5 per cent of
C10H12N2O3." N.F.

Allobarbitone, B.P.C. Dial (.Ciba).

The synthesis of 5,5-diallylbarbituric acid, as
reported by Johnson and Hill (Am. Chem. J.,

434 Diallylbarbituric Acid

Part I

1912, 46, 537), may be achieved by interaction
of diethyl diallylmalonate and urea (see also U. S.
Patent 1,042,265, October 22, 1912).

Description. — "Diallylbarbituric Acid occurs
as white, odorless, glistening, small crystals, or as
a white crystalline powder, with a slightly bitter
taste. A saturated aqueous solution is acid to
litmus paper. It is stable in air. Diallylbarbituric
Acid is soluble in alcohol and in ether. It is
slightly soluble in cold water and sparingly soluble
in hot water. It is freely soluble in solutions of
fixed alkali carbonates. Diallylbarbituric Acid
melts between 171° and 173°." N.F.

Standards and Tests. — Identification. — Tests
(1) and (2) are identical with identification tests
(1) and (2) under Barbital and Cyclobarbital,
while test (3) involves discharge of the color of
bromine T.S.. and reduction of potassium per-
manganate T.S. to form a yellow color. Loss on
drying. — Not over 1 per cent, when dried at 105°
for 4 hours. Residue on ignition. — Not over 0.1
per cent. Chloride. — No opalescence is produced
on adding diluted nitric acid and silver nitrate
T.S. to a saturated aqueous solution of diallyl-
barbituric acid. Sulfate. — No turbidity develops
on adding diluted nitric acid and barium nitrate
T.S. to a saturated solution of diallylbarbituric
acid. Heavy metals. — The limit is 20 parts per
million. AT.F.

Assay. — The assay is identical with that de-
scribed under Bute thai. Each ml. of 0.1 N sodium
hydroxide represents 20.82 mg. of C10H12N2O3.
N.F.

Uses. — Diallylbarbituric acid was first reported
in the Swiss medical literature and is one of the
earlier barbiturates. Castaldi (Arch. farm, sper.,
1915, 19, 289), in reporting on the pharmacologic
properties of diallylbarbituric acid stated that
when administered orally to man it produces sleep
without any noteworthy posthypnotic phenomena.
According to Tatum (Physiol. Rev., 1939, 19,
472), diallylbarbituric acid ranks among those
barbiturates having intermediate duration of ac-
tion (for general discussion of the class, see the
monograph on Barbiturates, in Part II).

In general, diallylbarbituric acid has demon-
strated utility as an hypnotic agent in neuro-
psychiatry (Becker, Therap. d. Gegenw., 1927,
68, 566; Hoven, /. de neurol. et de psychiat.,
1929, 29, 39), as a "basal anesthetic" before the
induction of general anesthesia for surgery (Klein-
dorfer and Halsey, /. Pharmacol., 1931, 43, 449).
and during labor in obstetrics (Birnberg and
Livingston, Am. J. Obst. Gyn., 1934, 28, 107;
King, et al., J. Med., 1937, 18, 190; Van Del.
/. Missouri M. A., 1942, 39, 100). The onset of
action of diallylbarbituric acid when administered
orally is relatively slow. It is excreted in urine of
man and dog in amounts up to 30 or 40 per cent
of an ingested dose over a period of 2.5 to 11 days
(Reiche and Halberkann, Munch, med. Wchnschr.,
1929, 76, 235; Paget and Desodt. /. pharm. chim.,
1933, 18, 207; Koppanyi et al., Arch, internat.
pharmacodyn. therap., 1933, 46, 76).

When it is desired to administer diallylbar-
bituric acid in aqueous solution by intramuscular
or, rarely, by intravenous injection urethan and
monoethyl urea are added for purposes of solu-

bilization and stabilization. King et al. (J. Med.,
1937, 18, 190) showed that urethan has very little
value as an hypnotic agent in human medicine.
The diallylbarbituric acid and urethan solution is
employed frequently in the laboratory as an anes-
thetic agent for small animals.

Dose. — The sedative dose is 30 mg. (approxi-
mately ]/2 grain) 3 or 4 times daily. As an hyp-
notic agent the adult dose is 100 to 300 mg. one-
half to one hour before sleep is desired.

Storage. — Preserve "in well-closed contain-
ers." N.F.

DIALLYLBARBITURIC ACID
TABLETS. N.F.

"Diallylbarbituric Acid Tablets contain not less
than 94 per cent and not more than 106 per cent
of the labeled amount of C10H12N2O3." N.F.

Assay. — A representative sample of powdered
tablets, equivalent to about 200 mg. of diallyl-
barbituric acid, is placed in a Soxhlet extraction
apparatus and the acid is extracted with ether,
following which the ether is evaporated and the
residue of diallylbarbituric acid is weighed. In the
presence of stearic acid or other lubricants which
may be present in the residue the diallylbarbituric
acid is titrated, after dissolving it in sodium hy-
droxide solution, with 0.1 N silver nitrate to the
first definite yellow-brown color which persists for
1 minute. Each ml. of 0.1 N silver nitrate repre-
sents 20.82 mg. of C10H12N2O3. N.F.

Usual Sizes. — 30 and 100 mg. (approximately
K and IK grains).

DIBUCAINE HYDROCHLORIDE.
U.S.P. (B.P.)

2-Butoxy-N-(2-diethylaminoethyl)cinchoninaraide

Hydrochloride, Dibucainium Chloride,

[Dibucainae Hydrochloridum]

0-CH2(CH2)2CH3

0 = C-NH-CH2CH2N(C2H5)2

CI"

The B.P. defines Cinchocaine Hydrochloride
as the hydrochloride of the 2-diethylaminoethyl-
amide of 2-butoxycinchoninic acid, and requires
it to contain not less than 97.5 per cent of
C20H29O2N3.HCI, calculated with reference to
the substance dried at 80° at a pressure not ex-
ceeding 5 mm. of mercury for 5 hours.

B.P. Cinchocaine Hydrochloride; Cinchocainae Hydro-
chloridum. Xupercaine Hydrochloride (Ciba).

This local anesthetic may be prepared from
2-hydroxycinchoninic acid by interaction with
phosphorus pentachloride to produce 2-chloro-
cinchoninic acid hydrochloride, which is condensed
with asymmetric-N-diethylethylenediamine. then
treated with sodium butylate and the dibucaine
base finally converted to the hydrochloride (see
U. S. Patent 1,825,623). Isatin may also be used
as the starting compound for the synthesis of
dibucaine.

Description. — 'Dibucaine Hydrochloride oc-
curs as colorless or white crystals or as a white,

Part I

Dibucaine Hydrochloride 435

crystalline powder. It is odorless, is somewhat
hygroscopic, and darkens on exposure to light. Its
solutions are acid to litmus, having a pH of 5 to 6.
One Gm. of Dibucaine Hydrochloride dissolves in
about 2 ml. of water. It is freely soluble in alco-
hol, in acetone, and in chloroform. Dibucaine Hy-
drochloride melts between 95° and 100°." N.F.

Standards and Tests. — Identification. — (1)
A white precipitate of dibucaine base results
when sodium hydroxide T.S. is added to a solu-
tion of dibucaine hydrochloride. The dibucaine,
extracted with ether and finally dried over phos-
phorus pentoxide, melts between 64° and 66°.
(2) Dibucaine hydrochloride responds to tests for
chloride. Loss on drying. — Not over 1 per cent,
when dried for 5 hours at 80° in vacuum over
phosphorus pentoxide. Residue on ignition. — The
residue from 250 mg. is negligible. U.S.P. The
B.P. describes an identification test in which a
solution of potassium perchlorate is added to a
solution of dibucaine hydrochloride; the resulting
precipitate of dibucaine perchlorate, recrystallized
from water and dried at 80°, melts at about 132°.
The loss on drying at 80° at a pressure not ex-
ceeding 5 mm. of mercury, for 5 hours, is not
over 2.5 per cent.

Assay. — The U.S. P. does not provide an assay
as such but requires that the content of nitrogen,
determined by the Kjeldahl method, be not less
than 10.8 per cent and not more than 11.2 per
cent; also that the content of chloride, deter-
mined by the Volhard procedure, be not less than
9.1 per cent and not more than 9.5 per cent. The
B.P. assay utilizes 300 mg. of sample, from which
the base is liberated with sodium hydroxide, ex-
tracted with ether, the ether evaporated, and the
residue of dibucaine dried to constant weight at
105°. Each Gm. of residue corresponds to 1.106
Gm. of C20H29N3O2.HCI.

Incompatibility. — Dibucaine hydrochloride
solutions are incompatible with alkalis or alkaline-
reacting salts, dibucaine base being precipitated.

Uses. — Action. — Dibucaine is one of the most
active and one of the most toxic of the useful
local anesthetic agents (see monograph on Local
Anesthetics, in Part II, for a general discussion).
In mice the acute LD50 (dose calculated to kill
50 per cent of the animals) intravenously for pro-
caine is 78 ± 5 mg./kg., for cocaine 25 ± 4
mg./kg. and for dibucaine 6.5 ± 0.7 mg./kg.; in
rabbits the acute intravenous LD50 for procaine
is 41 ± 2 mg./kg., for cocaine 11 ± 1 mg./kg.
and for dibucaine 2.8 ± 0.5 mg./kg. (Beyer et al.,
J. Pharmacol., 1948, 93, 388). These data are in
reasonably good agreement with the earlier report
by Wahl and Knoefel (Proc. S. Exp. Biol. Med.,
1931, 29, 368) that dibucaine is six times as toxic
as cocaine when administered to rabbits. Mac-
donald and Israels (/. Pharmacol., 1932, 44, 353)
indicated that dibucaine is 10 times as active as
cocaine by the intradermal wheal test and 25
times as acitve as cocaine when tested for topical
anesthetic activity on the rabbit cornea.

Therapeutic Uses. — The principal uses for
dibucaine have been as a topical ointment for the
relief of pruritus or pain accompanying excoria-
tions of the skin or minor burns, and as a spinal
anesthetic agent. In the first instance it is most

reliable and in the second indication it produces
a prolonged analgesia. However, its use as a spinal
anesthetic agent should be limited to these anes-
thetists who are familiar with the agent and with •
this type of use (Gifford and Wilkinson, Can.
Med. Assoc. J., 1941, 44, 128; Fisher and Whit-
acre, Anesth., 1947, 8, 584; Held, Gynaecologia,
Basel, 1950, 130, 364; Schnitz, /. Arkansas M.
Soc, 1951, 47, 209; Braga, Ann. ostet. gin.,
Milano, 1952, 74, 131).

Toxicology. — Dibucaine hydrochloride is gen-
erally too irritating to employ as a 1 per cent
solution topically or parenterally, but this concen-
tration is not usually required for a satisfactory
duration of action (see usual concentrations em-
ployed in following paragraph). Keyes and Mc-
Lellan (J.A.M.A., 1931, 96, 2085) collected re-
ports on 16 human fatalities from dibucaine;
death from dibucaine poisoning has been the sub-
ject of recent editorial comment (Brit. M. J.,
1952, 2, 672). Dibucaine produces the central
nervous system stimulation which is more or less
characteristic of local anesthetic agents. In addi-
tion, it produces cardiac arrhythmias when ad-
ministered to anesthetized dogs intravenously in
doses of 1 mg./Kg. It has been reported to pro-
duce cardiac fibrillation under these conditions
when administered intravenously in a dose of
2 mg./Kg. (Beyer and Latven, /. Pharmacol.,
1952, 106, 37). Subcutaneously, in man, 135 ml.
of a 1 in 1000 solution has caused death.

Dose and Dosage Forms. — The dose for in-
filtration anesthesia ranges from 1 to 50 ml. of
a 1 in 1000 solution; 0.1 ml. of epinephrine hydro-
chloride solution (1 in 1000) may be added to
100 ml. of the dibucaine hydrochloride solution.
For spinal anesthesia, 1.5 to 2 ml. of a 1 in 200
buffered solution of dibucaine hydrochloride, or
6 to 15 ml. of a 1 in 1500 solution in isotonic
sodium chloride solution, or 1 to 2 ml. of a 1 in
400 solution containing 5 per cent dextrose to
make it hyperbaric, may be used. The patient
must not remain in sitting posture for more than
one minute following injection since a high con-
centration in the conus may result in severe nerve
damage. For surface anesthesia of mucous mem-
branes aqueous solutions containing from 0.1 to
2 per cent of dibucaine hydrochloride are used,
as follows : in the nose and throat, up to 5 ml. of
2 per cent solution, containing 2 drops of 1 in
1000 epinephrine per ml.; for the conjunctiva,
1 to 3 drops of 1 in 1000 solution containing
epinephrine in the proportion of 1 or 2 drops of
1 in 1000 solution in 10 ml. of dibucaine hydro-
chloride solution; for the urinary bladder and
urethra, up to 30 ml. of this same solution; for
open or granulating wounds, up to 20 ml. of 1 in
4000 to 1 in 2000 solution.

Dibucaine base is supplied, in several prepara-
tions under the name Nupercainal (Ciba), in a
water-washable cream base in 0.5 per cent con-
centration, and in a petrolatum-lanolin base in
1 per cent concentration, for various surface uses
where a local anesthetic is indicated. An oph-
thalmic ointment containing 0.5 per cent of the
base in white petrolatum is also supplied. For
proctological purposes, a 0.5 per cent solution of
dibucaine base in oil, with 1 per cent phenol and

436 Dibucaine Hydrochloride

Part I

10 per cent benzyl alcohol is available; this solu-
tion is used intramuscularly (not subcutaneously).
Lozenges containing 1 mg. of dibucaine have been
used. Tablets containing 50 mg. of dibucaine
hydrochloride are supplied for preparing solutions.
Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DIBUCAINE HYDROCHLORIDE
INJECTION. U.S.P.

"Dibucaine Hydrochloride Injection is a sterile
solution of dibucaine hydrochloride in water for
injection. It contains not less than 90 per cent
and not more than 110 per cent of the labeled
amount of C20H29X3O2.HCI." U.S.P.

The U.S.P. requires that the pH of the injec-
tion shall be between 4 and 6.

Assay. — A volume of injection, representing
about 30 mg. of dibucaine hydrochloride, is con-
centrated by evaporation, the solution is saturated
with sodium chloride, then made alkaline with
sodium hydroxide, and the liberated dibucaine
base extracted with ether. After washing the ether
extract, a measured excess of 0.02 AT sulfuric acid
is added, the ether is evaporated, and the excess
of acid is titrated with 0.02 N sodium hydroxide.
Each ml. of 0.02 N acid represents 7.599 mg. of
C20H29N3O2.HCI. U.S.P.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." U.S.P.

Usual Sizes. — 5, 10. and 13 mg.

DIBUTYL PHTHALATE.
C6H4(COOC4H9)2

B.P.

The B.P. defines Dibutyl Phthalate as the di-n-
butyl ester of benzene-o-dicarboxylic acid. It is
required to contain not less than 99.0 per cent
and not more than the equivalent of 100.5 per
cent w/w of C16H22O4. B.P.

Dibutyl phthalate may be prepared by the
esterification of phthalic acid anhydride and
n-butyl alcohol in the presence of hydrogen chlo-
ride or concentrated sulfuric acid as an esterifying
agent.

Description. — Dibutyl phthalate is a clear,
colorless, or faintly colored, liquid; it is odorless
or possesses not more than a faint odor. It is
soluble in 2500 parts of water, and is miscible
with alcohol and with ether. The weight per ml.,
at 20°, is between 1.042 and 1.049 Gm. B.P.

Standards and Tests. — Refractive index. —
Between 1.492 and 1.495, at 20°. Acidity.— Not
over 6.2 ml. of 0.01 N sodium hydroxide is re-
quired for neutralization of 20 ml., previously
mixed with 50 ml. of neutralized alcohol, using
phenolphthalein as indicator. Water. — No opales-
cence is observed when 1 volume is mixed with
19 volumes of carbon disulfide, at 15°. Sulfated
ash. — Not over 0.02 per cent. B.P.

Assay. — About 1.5 Gm. is dissolved in neu-
tralized alcohol, any acid in the ester is neutralized
with 0.1 JV alcoholic potassium hydroxide, and
this solution is refluxed with 50 ml. of 0.5 N alco-
holic potassium hydroxide, on a water bath, for
1 hour. The excess alkali is titrated with 0.5 A7
hydrochloric acid, using phenolphthalein as indi-
cator. A residual titration blank is performed.

Each ml. of 0.5 N alcoholic potassium hydroxide
represents 69.58 mg. of C16H22O4. B.P.

Uses. — Dibutyl phthalate is employed as an
insect repellent. It is generally considered to be
slightly less effective than the similarly employed
dimethyl phthalate, except against the trombidid
mite (the insect vector of scrub typhus), which
is more susceptible to the action of the dibutyl
ester than that of the dimethyl ester. For protec-
tion of troops against scrub typhus impregnation
of clothing with one fluidounce of dibutyl phthai-
ate afforded protection until exposure ended at
22 days, the clothes having been cold-water
washed 8 times in that period; dimethyl phthalate
and DDT provided less protection (see McCul-
loch, Med. J. Australia, 1946, 1, 717).

DICHLOROPHENARSINE HYDRO-
CHLORIDE. LP.

Dichlorophenarsini Hydrochloridum

CI -As -CI

HC*

f9x

II
.C.NHg.HCI

"Dichlorophenarsine Hydrochloride, dried in a
vacuum desiccator over phosphorus pentoxide for
24 hours, contains not less than 25.3 per cent and
not more than 27 per cent of total arsenic (As).

"Dichlorophenarsine Hydrochloride is usually
distributed as a mixture with buffering agents and
suitable substances to render its solution physio-
logically compatible with human blood. The label
must indicate the names of the admixed sub-
stances, and the composition of the mixtures (con-
taining Dichlorophenarsine Hydrochloride as the
only active therapeutic agent) shall be approved
by the National Institutes of Health. Mixtures
contain total arsenic equivalent to not less than
92.5 per cent and not more than 107.5 per cent of
the labeled amount of Dichlorophenarsine Hydro-
chloride. Mixtures also meet the requirements for
identification, loss on drying, completeness of
solubility, and storage." U.S.P. XIV.

The LP. requires not less than 25.3 per cent
and not more than 27.0 per cent of total arsenic,
and not less than 25.0 per cent and not more than
27.0 per cent of trivalent arsenic, calculated with
reference to the substance dried in a vacuum
desiccator over phosphorus pentoxide for 24
hours.

3-Amino-4-hydroxyphenyldichloroarsine Hydrochloride.
Clorarsen (Squibb) ; Dichlor-Mapharsen (Parke, Davis);
Dichlorophenarsine Hydrochloride (Abbott; Winthrop). Sp.
Clorhidrato de Dichlorofenarsina.

This compound represents oxophenarsine hydro-
chloride (see under this title) in which the arsine-
oxide oxygen is replaced by two atoms of chlorine.
In an alkaline aqueous solution dichlorophenarsine
hydrochloride undergoes hydrolysis to form first
monochlorophenarsine and then the hydrated form
of oxophenarsine.

D e s c r i p t ion. — "Dichlorophenarsine Hydro-
chloride occurs as a white, odorless powder. Di-
chlorophenarsine Hydrochloride is soluble in

Part I

Dienestrol

437

water, solutions of alkali hydroxides and carbon-
ates, and in dilute mineral acids." U.S.P. XIV.

Standards and Tests. — Identification. — (1)
A salmon-colored precipitate, changing rapidly to
yellow, is formed when 250 mg. of sodium hydro-
sulfiate is added to a solution of 50 mg. of di-
chlorophenarsine hydrochloride in 3 ml. of dis-
tilled water. (2) A nearly white to yellow
precipitate is formed on adding 1 ml. of hydro-
chloric acid and 1 drop of hypophosphorus acid
to a solution of 10 mg. of dichlorophenarsine
hydrochloride in 1 ml. of distilled water. Dif-
ference from oxo phenar sine hydrochloride. — On
gently boiling a mixture of 50 mg. of dichloro-
phenarsine hydrochloride and 5 ml. of acetone
in a test tube loosely plugged with cotton, the
escaping vapors turn blue litmus paper red. Loss
on drying. — Not over 0.5 per cent, when dried in
a vacuum desiccator over fresh phosphorus pent-
oxide for 24 hours. Completeness of solubility. —
It is completely soluble in distilled water in a con-
centration as great as is recommended for intra-
venous administration. Percentage of trivalent
arsenic. — A solution of 250 mg. of dichloro-
phenarsine hydrochloride, previously dried for 24
hours in a vacuum desiccator over phosphorus
pentoxide, in 20 ml. of distilled water is acidified
with diluted sulfuric acid and titrated with 0.1 N
iodine to a pale yellow color. Each ml. of 0.1 N
iodine represents 3.746 mg. of trivalent arsenic.
The test shows not less than 25 per cent and
not more than 21 per cent of trivalent arsenic.
U.S.P. XIV.

Assay. — From 130 to 150 mg. of dichloro-
phenarsine hydrochloride, previously dried in a
vacuum desiccator over phosphorus pentoxide for
24 hours, is subjected to wet oxidation with 30
per cent hydrogen peroxide in a sulfuric acid
solution; the arsenic is oxidized to the pentava-
lent state while the carbon is oxidized to carbon
dioxide. Hydrazine sulfate is next added to
reduce the arsenic to the trivalent state, and the
excess of the reductant is decomposed by boiling,
following which the arsenic is quantitatively oxi-
dized by titration with 0.1 N potassium bromate,
using methyl orange T.S. as indicator. In this
titration the red color of the methyl orange is dis-
charged by the bromine which is liberated when
the potassium bromate solution is added in ex-
cess; the yellow color seen in the solution at the
end point is not due to methyl orange but rather
to elemental bromine. Each ml. of 0.1 N potas-
sium bromate represents 3.746 mg. of arsenic
(As) or 14.52 mg. of dichlorophenarsine hy-
drochloride. U.S.P. XIV. The LP. assay is the
same as the LP. assay for acetarsone.

Uses. — 3-Amino-4-hydroxyphenyldichloroar-
sine hydrochloride was used by Chesterman
and Todd in 1927 as a remedy for yaws, and
Levaditi, in 1931, made some trials of it in
syphilis but found it unsatisfactory. According
to Tompsett et al. (/. Pharmacol., 1941, 73, 412)
this unfavorable opinion was due to the high
acidity of the drug; they reported that if prop-
erly buffered with sodium citrate, above pH 5.2,
it gave excellent results. According to these
workers, when this mixture is dissolved in water
the chlorine atoms probably are successively re-

placed by hydroxyl groups, forming a mixture
of monochlorophenarsine and the hydrated form
of oxophenarsine.

Dichlorophenarsine is effective in the treatment
of syphilis by intravenous injection (Kampmeier
and Henning, Am. J. Syph. Gonor. Ven. Dis.,
1943, 27, 208; Plotke et al., Am. J. Syph. Gonor.
Ven. Dis., 1950, 34, 425). The indications, contra-
indications and untoward reactions are identical
with those of oxophenarsine hydrochloride (q.v.).
It is used in similar treatment schedules. It has
been employed in intensive methods (J. A.M. A.,
1945, 127, 1070).

The usual dose for an adult male is 68 mg.
(approximately 1 grain) and for a woman 45 mg.
(approximately 24 grain) dissolved in 10 ml. of
sterile distilled water containing suitable buffers
and administered intravenously. For infants and
children, the usual dose is 1 mg. per kilogram
of body weight and the initial dose should be
about one half of this dose. The 68 mg. dose
yields an amount of "arsenoxide" equivalent to
60 mg. of oxophenarsine hydrochloride; the 45
mg. dose is equivalent to 40 mg. of the latter
drug. Rapid injection should be accomplished,
the 10 ml. being injected in about 10 seconds.
It is given at intervals of four to five days.

Storage. — "Preserve Dichlorophenarsine Hy-
drochloride at a temperature preferably not
above 25°, in hermetic containers of colorless
glass which have been sterilized prior to filling,
and from which the air has been excluded either
by the production of a vacuum or by displace-
ment with a non-oxidizing gas." U.S.P. XIV.

DIENESTROL. U.S.P. (B.P.)

3,4-Bis(p-hydroxyphenyl)-2,4-hexadiene

-Ot-rO"

CH CH
I I

CH3 CH3

"Dienestrol, dried at 105° for 4 hours, contains
not less than 98 per cent of CisHisCh." U.S.P.
The B.P. defines Dienoestrol as 3 :4-di-/>-hydroxy-
phenyl-2 :4-hexadiene, and requires it to contain
not less than 99.0 per cent of OsHisCte.

B.P. Dienoestrol. Hexadienestrol; Dehydrostilbestrol.
Restrol (Central Phartnacal) .

This synthetic estrogen differs from diethyls til-
bestrol only in that the two CH3CH2— groups
of the latter are replaced by the unsaturated
CHaCH= groups. It was first synthesized by
Dodds and coworkers (Nature, 1938, 142, 34)
by dehydration of 3,4-di(/>-hydroxyphenyl)-3,4-
hexanediol; it has been synthesized also by other
reactions (see Solmssen, Chem. Rev., 1945, 37,
481). Dienestrol may be quantitatively hydroge-
nated to hexestrol, which also is official.

Description. — "Dienestrol occurs as colorless
or white, needle-like crystals or as a white, crys-
talline powder. It is odorless. Dienestrol is almost
insoluble in water. It is soluble in alcohol, in
acetone, in ether, in methanol, in propylene gly-
col, in chloroform, in fatty oils, and in solutions

438

Dienestrol

Part I

of fixed alkali hydroxides. It is slightly soluble in
chloroform, and in fatty oils. Dienestrol melts
between 227° and 231°." US.P. The B.P. gives
the melting point as between 232° and 234°.

Standards and Tests. — Identification. — (1)
The diacetate obtained in the assay melts be-
tween 11S° and 122°. (2) A blue color is pro-
duced immediately on adding to a solution of
10 mg. of dienestrol in 0.5 ml. of alcohol. 1 ml.
of hydrochloric acid and 50 mg. of vanillin; the
color persists on dilution with water but disap-
pears on addition of alkali (diethylstilbestrol
produces no color). Loss on drying. — Not over
0.5 per cent, when dried at 105° for 2 hours.
Residue on ignition. — Not over 0.15 per cent.
US.P. The B.P. gives the absorbance of a 0.0005
per cent w/v solution in isopropyl alcohol, at
227 mn, for a 1-cm. layer of solution, as between
0.520 and 0.545.

Assay. — About 500 mg. of dienestrol, previ-
ously dried at 105° for 2 hours, is boiled with
a mixture of acetic anhydride and pyridine,
whereby the two hydroxyl groups are acetylated.
The diacetate is precipitated by dilution with
water, the precipitate is collected in a tared Gooch
crucible, washed with water, and dried to con-
stant weight in a vacuum desiccator. The weight
of the diacetate, multiplied by 0.7601, represents
the equivalent of CisHisCh. U£.P.

Uses. — This stilbene derivative has the ac-
tion and uses of diethylstilbestrol; it seems to
be more active than diethylstilbestrol and in
clinical use, in treatment of menopausal symp-
toms and to inhibit lactation, it appears to be
generally better tolerated.

Assays on rats show similar activity for dienes-
trol and diethylstilbestrol when injected subcu-
taneously but greater activity for dienestrol
when administered orally (Dodds et al., Proc.
Roy. Soc, 1939, 127, 140). In mice, dienestrol
was more active when given orally than when
injected; diethylstilbestrol, on the other hand,
was only one-fourth as active when given orally
as when injected (Emmens, /. Physiol., 1938,
94, 22).

Dienestrol is effective in controlling the symp-
toms of the menopause (Bames, Brit. M. J.,
1944, 1, 79; Yiviano, Am. J. Obst. Gyn., 1948,
56, 921); also in suppressing lactation in non-
nursing mothers (Barnes, Brit. M. J., 1942, 1,
601; Rakoff et al, J. Gin. Endocrinol., 1947, 7,
68S). Local application of a cream containing
0.1 mg. of dienestrol per Gm. was found to be
effective in atrophic (senile) vaginitis; about 0.5
mg. of estrogen was applied to the vagina
(McLane, Am. J. Obst. Gyn., 1949, 57, 1018;
Rakoff et al., loc. cit.). Even with large doses of
dienestrol it was difficult to induce withdrawal
bleeding in amenorrheic cases, and in this re-
spect the estrogen is less effective than
diethylstilbestrol (Rakoff et al., loc. cit.); with
a dose of 2.5 mg. twice daily orally Trimborn
et al. (Deutsch. med. Wchnschr., 1950, 75, 1661)
succeeded in bringing on such bleeding in 3 to 4
weeks.

Considering the effectiveness of dienestrol in
controlling menopausal symptoms and lactation,
along with the large doses required for action on

the endometrium, it has been suggested that this
estrogen is a more active pituitary inhibitor but
a less active endometrial stimulator than diethyl-
stilbestrol. The greater inhibition of growth in
immature mice observed with dienestrol, as com-
pared with diethylstilbestrol. is compatible with
this suggestion (Noble, Lancet, 1938, 2, 192).

From 5 to 20 mg. of dienestrol, given four
times daily orally, controls functional uterine
bleeding (Bishop, Brit. M. J., 1949, 1, 165).

Toxicology. — In all published reports, the
clinically effective doses of dienestrol in meno-
pause have been well tolerated; Rakoff and his
associates treated 25 patients for 4 to 16 months
each without untoward side effects. Large doses,
however, cause the usual side effects of estro-
genic therapy (Fergusson, Lancet, 1946, 2, 551).

Dose. — The usual oral dose is 0.5 mg. (ap-
proximately Viae grain) daily, with a range of 0.1
to 1.5 mg. The maximum safe dose is perhaps
15 mg. daily, by mouth, in palliative therapy
of inoperable postmenopausal mammary carci-
noma (Walpole and Peterson, Lancet, 1949, 2,
783), although larger doses have been given
(v.s). For intramuscular injection, 2.5 to 5 mg.
in aqueous suspension has been administered
once or twice weekly in the menopause (Albeaux-
Femet et al., Presse med., 1949, 57, 1031). For
topical application, a water-miscible cream con-
taining 0.1 mg. per Gm. is used in an amount
representing about 0.5 mg. of dienestrol.

Storage. — Preserve 'in tight, light-resistant
containers." US.P.

DIENESTROL TABLETS. U.S.P. (B.P.)

"Dienestrol Tablets contain not less than 90
per cent and not more than 110 per cent of the
labeled amount of CisHisOl'." U.S.P. The corre-
sponding limits of the B.P. are 89.0 and 110.0
per cent.

B.P. Tablets of Diencestrol; Tabellae Dienoestrolis.

Assay.— Both the U.S.P. and the B.P. utilize,
as the basis of the assay for dienestrol. the charac-
teristic color reaction of phenols with molybdo-
phosphotungstate. which is also utilized in the
assay of Diethylstilbestrol Injection and is dis-
cussed under that title. In the case of dienestrol
tablets the quantitative evaluation of the color
is made in a spectrophotometer, and is compared
with the color produced by a known quantity of
reference dienestrol. U.S.P.

Usual Sizes. — 0.1 and 0.5 mg. (approximately
Yeoo and V120 grain).

DIETHYLCARBAMAZINE
CITRATE. U.S.P.

Diethylcarbamazine Dihydrogen Citrate, Diethylcarba-

mazinium Citrate, l-Diethylcarbamyl-4-methylpiperazine

Dihydrogen Citrate

A~~\

CH,-N N-C0-N(C.HJ«

3 \ /

H2C6H50f
"Diethylcarbamazine Citrate contains not less

Part I

Diethylcarbamazine Citrate 439

than 98 per cent of Cio^iN.sO.CgHsOt, calcu-
lated on the dried basis." U.S.P.

Hetrazan (Lederle).

Diethylcarbamazine may be prepared by inter-
action of diethylcarbamyl chloride and piperazine,
followed by treatment of the 1-diethylcarbamyl-
piperazine thereby produced with formic acid and
then with alkali. For details of synthesis see
Kushner et al. (J. Org. Chem., 1948, 13, 151).
The official salt is the citrate of this base.

Description. — "Diethylcarbamazine Citrate is
a white, crystalline powder. It is odorless or has
a slight odor, and is slightly hygroscopic. Diethyl-
carbamazine Citrate is very soluble in water and
sparingly soluble in alcohol. It is practically in-
soluble in acetone, in chloroform, and in ether.
Diethylcarbamazine Citrate melts between 135°
and 138°." U.S.P.

Standards and Tests. — Identification. — (1)
Not less than 18.8 ml. of 0.1 N sodium hydroxide
is required for the titration of 250 mg. of diethyl-
carbamazine citrate in 5 ml. of water, in the
presence of 25 ml. of chloroform to extract the
diethylcarbamazine base, using phenolphthalein as
indicator. (2) l-Diethylcarbamyl-4-methylpipera-
zine ethiodide melts at about 152°. (3) The con-
tent of iodine in the derivative prepared for the
preceding test is between 34.7 and 36.7 per cent.
Loss on drying. — Not over 1 per cent, when dried
at 100° for 4 hours. Residue on ignition. — Not
over 0.1 per cent. Heavy metals. — The limit is 20
parts per million. U.S.P.

Assay. — About 750 mg. of diethylcarbamazine
citrate is dissolved in water, alkalinized with so-
dium hydroxide, and the liberated diethylcarba-
mazine base extracted with several portions of
chloroform. After washing the chloroform ex-
tracts, the base is extracted with 25 ml. of 0.1 N
sulfuric acid, the chloroform layer washed, and
the acid extract and washings titrated with 0.1 N
sodium hydroxide, using bromocresol green T.S.
as indicator. Each ml. of 0.1 TV sulfuric acid repre-
sents 39.14 mg. of C10H21N3O.C6H8O7. U.S.P.

Uses. — This antifilarial and anthelmintic drug
is used in the treatment of infestations with
Wuchereria bancrofti, Loa loa, Onchocerca vol-
vulus, Ascaris lumbricoides and Ancylo stoma
braziliense (larva migrans). It is rapidly absorbed
and excreted in the urine (Lubran, Nature, 1949,
164, 1135). The oral LD50 is 660 mg. per Kg. in
mice and 1.38 Gm. per Kg. in rats (Harned et al.,
J. Lab. Clin. Med., 1948, 33, 216).

Following demonstration of the effectiveness of
this compound against microfilariae in cotton rats
(Hewitt et al, Ann. N. Y. Acad. Sc, 1948, 50,
128), it was administered to humans with filariasis
due to Wuchereria bancrofti. In daily doses of
0.5 to 2 mg. per Kg. of body weight, Santiago-
Stevenson et al. (J.A.M.A., 1947, 135, 708) gave
the drug to 26 patients for 3 to 21 days and ob-
served rapid disappearance of microfilariae from
the blood stream of the patients; nodular swell-
ing occurred over the lymphatics, suggesting that
the drug acted also on adult worms. Kenney and
Hewitt (Am. J. Trop. Med., 1949, 29, 89; 1950,
30, 217) and Hawking and Laurie (Lancet, 1949,
2, 146) confirmed this observation. Manson-Bahr

(/. Trop. Med. Hyg., 1952, 56, 169) found that
infestation was not transmitted to the mosquito
biting a patient who was receiving this drug; he
concluded that diethylcarbamazine citrate was an
effective prophylactic agent in endemic areas. The
mechanism of action on the parasite is unknown
but Hawking et al. (Brit. J. Pharmacol. Chemo-
ther., 1950, 5, 217) observed accumulation and
phagocytosis of microfilariae in the liver. Since
all adult worms may not be destroyed, relapses
may occur.

In loiasis, the filariasis caused by Loa loa,
Murgatroyd and Woodruff (Lancet, 1949, 2, 147)
and Shookhoff and Dwork (Am. J. Trop. Med.,
1949, 29, 589) used the drug with good results.
Dead worms were found under the skin of several
patients following treatment with 2 to 6 mg. per
Kg. daily for 7 to 21 days. Liver biopsy 12 hours
before and 12 hours after administration of the
drug showed a change from 0 to 105 microfilariae
per 100 sq. mm.; the parasites were surrounded
by phagocytes. Reactions, presumably due to de-
struction of large numbers of parasites and an
allergic response, occur particularly in patients
with heavy infestations. Headache, lumbar aching,
anorexia accompanied by nausea and vomiting,
arthralgia, abdominal pain, dyspnea, fever, eosin-
ophilia, maculopapular rash and urticaria are re-
ported. These are seldom severe enough to cause
discontinuation of the drug but antihistaminic
drugs may be needed.

In Onchocerca volvulus infestations, Mazzotti
(Am. J. Trop. Med., 1951, 31, 628) found that
microfilariae disappeared rapidly from the blood
on treatment with the drug; dead parasites were
found in tissue biopsies. Systemic and focal reac-
tions were more frequent and more severe than
with the preceding two types of filariasis. Micro-
filariae disappeared from intraocular tissues dur-
ing treatment. Relapse of symptoms of infestation
did not occur for 4 to 8 months in several cases.
La Grange (Ann. Soc. Beige Med. Trop., 1949,
29, 19) and Wanson (ibid., 85) also reported suc-
cessful use of the compound. To minimize the
severity of the reactions, a single dose of 2 mg.
per Kg. is recommended the first day, followed by
two doses the second day and three doses daily
thereafter for 10 to 21 days. If severe ocular
reactions occur the drug should be discontinued
until symptoms subside to avoid destruction of
vision. The average dose for adults will be 100
to 150 mg. 1 to 3 times daily, and 50 to 100 mg.
1 to 3 times daily for a child.

For treatment of ascariasis in children, Ettel-
dorf and Crawford (J.A.M.A., 1950, 143, 797)
used 6 mg. per Kg. of body weight 3 times daily
for a week or longer. The worms usually passed
without the use of purgatives or fasting. If this
dose failed it was increased to 10 mg. per Kg.
Only 1 of 15 children developed anorexia, nausea
and vomiting and there was no headache, backache
or skin rash. Using 2-mg. per Kg. doses 3 times
in 24 hours, followed by a saline purge, Oliver-
Gonzales et al. (South. M. J., 1949, 42, 65)
removed all worms in 3 of 6 cases. However,
Hoekenga (ibid., 1951, 44, 1125) was less suc-
cessful: ova were absent from the feces 1 and
3 weeks after treatment with a dose of 300 mg.

440 Diethylcarbamazine Citrate

Part I

3 times in one day in 3 of 8 cases, with a single
dose of 1 Gm. in 5 of 15, and with 200 mg. 3
times daily for 3 days in 9 of 15 cases. Most of
these patients were adults in Central America.
Loughlin et al. {Lancet, 1951, 2, 1197) eradicated
ova in most but not all cases with doses of 13 mg.
per Kg. per day in the form of a syrup for 3 or 4
days. The lack of untoward effects and the elimi-
nation of the need for fasting and purging make
this drug useful in debilitated patients.

For creeping eruption (larva migrans) due to
the migration of Ancylostoma braziliense, van de
Erve (/. Invest. Dermat., 1949, 12, 69) relieved
13 of 17 cases with a dose of 0.5 to 4 mg. per Kg.
of body weight 3 times daily for 4 to 20 days. He
recommended a dose of 2 mg. per Kg. 3 times
daily for 10 to 21 days. In a case of fulminating
trichinosis, McCabe and Zatuchni {Am. J. Digest.
Dis., 1951, 18, 205) were able to control symp-
toms with diethylcarbamazine citrate but Magath
and Thompson {Am. J. Trop. Med. Hyg., 1952, 1,
307) reported the drug to be ineffective in ex-
perimental trichinosis.

Toxicology. — Diethylcarbamazine citrate is
very well tolerated. The only common untoward
reactions are associated with the allergic response
to the release of protein from destroyed parasites
at the onset of treatment. In heavily infested
patients a small initial dose is advisable with in-
creases in daily dose as the condition of the
patient warrants.

The usual dose is 2 mg. per Kg. of body weight
3 times daily by mouth for 7 to 21 days. For a
patient weighing 50 kilograms, the usual dose
would be 100 mg. three times daily. The range
of dose is 0.5 to 20 mg. per Kg. 1 to 3 times daily.
The maximum safe dose of 20 mg. per Kg. will
seldom be indicated or required.

Storage. — Preserve "in tight containers."
U.S.P.

DIETHYLCARBAMAZINE CITRATE
TABLETS. U.S.P.

"Diethylcarbamazine Citrate Tablets contain
not less than 95 per cent and not more than 105
per cent of the labeled amount of C10H21N3O.Ce-
HsOt." U.S.P.

Usual Size. — 50 mg.

DIETHYLSTILBESTROL.
U.S.P. (B.P.) (LP.)

Stilboestrol, [Diethylstilbestrol]

"Diethylstilbestrol, dried at 105° for 2 hours,
contains not less than 98.5 per cent of C18H20O2."
U.S.P.

The B.P., under the title Stilboestrol, recognizes
this product as 3:4-di-£-hydroxyphenyl-3-hexene,
and requires not less than 99.0 per cent of
C18H20O2 with reference to the substance as is.
The LP. defines Diethylstilboestrol as 3:4-[4:4'-
dihydroxyphenyl]-hexen-3, and requires not less
than 98.5 per cent of C18H20O2, calculated with

reference to the substance dried at 100° for
4 hours.

B.P. Stilboestrol; Stilboestrol. LP. Diethylstilboes-
trolum. 7>u»ii-diethylstilbestrol. 7Ya».j-4,4'-dihydroxy-or,a'-
diethylstilbene. n,0-Diethyl-4,4'-stilbenediol. 3,4-Bis-(p-hy-
droxyphenyl)-3-hexene. Sp. Dietilestilbestrol.

Diethylstilbestrol was first synthesized in 1938
by Dodds and coworkers {Nature, 1938, 141,
247) starting with anisaldehyde, />-CH30CeH4-
CHO, and successively converting it to anis-
oin, desoxyanisoin, ethyl desoxyanisoin, 3,4-bis-
(/>-anisylj-3-hexanol, diethylstilbestrol dimethyl
ether and diethylstilbestrol. Kharasch and Klein-
man {J.A.C.S., 1943, 65, 11) succeeded in pre-
paring it from anethole, />-CH30C6H.tCH:CH-
CH3, in the form of the hydrobromide, by con-
densation with sodamide in liquid ammonia, fol-
lowed by demethylation of the product with
potassium hydroxide in glycol. For a compre-
hensive summary of these and other methods
which have been proposed for the synthesis of
diethylstilbestrol see the review of Solmssen
{Chemical Reviews, 1945, 37, 481).

Theory requires and experiments confirm the
existence of cis and trans isomers of diethyl-
stilbestrol. In the course of their researches,
Dodds et al. did obtain two isomeric forms, one
melting at 171°, identical with the official sub-
stance, the other melting at 151° and having
only a fraction of the estrogenic activity of
diethylstilbestrol; this second substance was
designated ^-diethylstilbestrol. Since a trans
configuration for diethylstilbestrol closely re-
sembles the structure of estradiol Dodds and
his associates reasoned the two substances are
cis-trans isomers, the cis compound being the
relatively inactive one, the trans the active di-
ethylstilbestrol. Subsequent researches have con-
firmed this assumption.

Description. — "Diethylstilbestrol occurs as a
white, odorless, crystalline powder. Diethylstil-
bestrol is almost insoluble in water; it is soluble
in alcohol, in chloroform, in ether, in fatty oils,
and in dilute alkali hydroxides. Diethylstilbestrol
melts between 169° and 172°." U.S.P. The B.P.
gives the melting point as between 168° and 171°;
the LP. melting range is between 167° and 173°.

Standards and Tests. — Identification. — (1)
An orange color, disappearing upon dilution with
about 10 volumes of distilled water, results when
10 mg. of diethylstilbestrol is dissolved in 1 ml.
of sulfuric acid. (2) A green color, changing to
yellow, results when 1 drop of a 1 to 10 dilution
of ferric chloride T.S. is added to a solution of
20 mg. of diethylstilbestrol in 2 ml. of diluted
alcohol. (3) The diacetate obtained in the assay
melts between 121° and 124°. Acidity or alkalin-
ity.— A solution of 100 mg. of diethylstilbestrol
in 5 ml. of 70 per cent alcohol is neutral to
litmus paper. Loss on drying. — Not over 0.5
per cent, when dried at 105° for 2 hours. Residue
on ignition. — Not over 0.05 per cent. U.S.P.

The B.P. employs as the basis for identification
certain color reactions with brominated deriva-
tives of diethylstilbestrol, these reactions being
the same as given by dienestrol. Both the B.P. and
the LP. provide a test limiting the amount of
the dimethyl ether of diethylstilbestrol which

Part I

Diethylstilbestrol 441

may be present; this test is based on the insolu-
bility of the ether in sodium hydroxide solution,
an opalescent solution resulting if it is present.

Assay. — About 500 mg. of diethylstilbestrol,
previously dried for 2 hours at 105°, is boiled
with acetic anhydride in a pyridine reaction
medium under a reflux condenser for 5 minutes.
Water is added to precipitate the diacetate
formed during the reaction and, after standing
for 1 hour, the precipitate is filtered on a Gooch
crucible, washed with distilled water, and dried
between 75° and 80° for 18 hours, and weighed.
The weight of the diacetate, multiplied by 0.7615,
represents its equivalent of C18H20O2. U.S.P.

Uses. — Diethylstilbestrol provides an inex-
pensive, orally active estrogen. For clinical pur-
poses, there seem to be no significant differences
between the actions and uses of this compound
and other estrogens, though in animals certain
differences have been found, such as the failure
of diethylstilbestrol to cause the ovipositor re-
action of the female bitterling and also to an-
tagonize the action of androgens on comb growth
of capons. Diethylstilbestrol was released for
general use in the United States with consider-
able trepidation and only after careful evaluation
over a period of many years. While no catastrophe
from its use has been recognized it is perhaps too
early to be able to evaluate fully any effect it
may have on the incidence of carcinoma of the
female generative tract or breast (Henry, Can.
Med. Assoc. J., 1945, 53, 31).

Diethylstilbestrol is well absorbed from the
gastrointestinal tract and seems to be inactivated
to a lesser extent by the liver than is the case
with natural estrogens. It is the most active of
the available stilbene derivatives. Sublingual ad-
ministration in propylene glycol is effective in
doses only twice the amount required parenterally
(Castrodale et al., J. Clin. Endocrinol., 1942, 2,
569). The oral dose is only 2 to 5 times that
required parenterally. Although a comparison of
estrogenic substances on any one function does
not necessarily apply to other functions, Brad-
bury et al. (Fertil. Steril., 1953, 4, 63) studied
the doses necessary to augment the action of
25 mg. of progesterone in maintaining decidual
changes in the endometrium of normal women
and found that 0.5 to 1 mg. of diethylstilbestrol
daily had the same effect as 2.5 to 5 mg. of con-
jugated estrogens; 5 mg. of sodium estrone sul-
fate was found to be ineffective. From results
of oral administration in the human, diethylstil-
bestrol appears to be about four times as active
as estradiol and about ten times as active as
estrone (see under Estradiol).

In studies of the distribution of diethylstilbes-
trol labeled on the alpha-carbon atom of one of
the ethyl groups with radioactive carbon- 14 the
highest concentration of radioisotope in tissues
was found in the liver; most of the labeled mate-
rial was excreted in the feces, with only traces
appearing in expired air.

Therapeutic Uses. — In the female diethylstil-
bestrol is used in a variety of disorders, as in
the following: the menopause (Davis and Boyn-
ton, /. Clin. Endocrinol., 1941, 1, 339; Mac-
Bryde et al., J.A.M.A., 1941, 117, 1240), where

it is used either alone or in combination with
methyltestosterone (Greenblatt et al., J. Clin.
Endocrinol., 1950, 10, 1547); senile vaginitis
(Finkler and Antopol, Endocrinology, 1939, 25,
925; Gray and Gordinier, Am. J. Obst. Gyn.,
1941, 41, 326); postmenopausal delayed wound
healing (Sjosted, Acta endocrinol., 1953, 12,
260); osteoarthritis (Grorud, /. Clin. Endocrinol.,
1951, 11, 748); functional uterine bleeding (Cuy-
ler et al., ibid., 1942, 2, 438; Hamblen et al.,
ibid., 1941, 1, 211; Karnaky, ibid., 1945, 5, 2 79)
and often in the cyclic therapy alternating an
estrogen and progesterone during the month to
restore a normal menstrual rhythm; the premen-
strual tension state or mastalgia; engorged tender
breasts postpartum in non-nursing mothers
(Morton and Miller, Am. J. Obst. Gyn., 1951,
62, 1124); threatened and habitual abortion
(Smith and Smith, New Eng. J. Med., 1949,
241, 562), although its benefit in threatened
abortion has been denied (Robinson and Shet-
tles, Am. J. Obst. Gyn., 1952, 63, 1330); dys-
menorrhea (Hulme and Holmstrom, Obst. Gynec,
1953, 1, 579); endometriosis (Karnaky, South.
M. J., 1952, 45, 1166); vomiting of early preg-
nancy (Bertling and Burwell, Am. J. Obst. Gyn.,
1950, 59, 461). In general, diethylstilbestrol has
been used wherever estrogens are indicated.

Cancer. — Diethylstilbestrol is used in the
management of cases of inoperable carcinoma,
particularly of the prostate and the breast. The
survival rates of 540 patients with the former
neoplasm, covering a period of 3 years, have been
reviewed by Nesbit and Baum (J.A.M.A., 1950,
143, 1317). Of 273 patients treated other than
by castration or with estrogens, 78 per cent were
dead at the end of 3 years, with almost 50 per
cent dying within 12 months. Of those treated
with diethylstilbestrol 50.3 per cent were dead
at the end of 3 years; 46.6 per cent of the cas-
trated patients died in the same period. In those
subjected to both orchiectomy and diethylstilbes-
trol therapy the mortality rate was only 34 per
cent. Diethylstilbestrol therapy may bring symp-
tomatic relief in patients with extensive metas-
tases but has little effect in prolonging life
(Reynolds et al., Arch. Surg., 1950, 61, 441).
An extensive literature has accumulated on estro-
genic therapy in carcinoma of the prostate (see,
for example, Kahle et al., J. Urol., 1942, 48, 83,
99; Flocks et al., ibid., 1951, 66, 393).

In carcinoma of the breast incurable by surgical
resection, definite amelioration is obtained with
androgenic therapy (see under Testosterone Pro-
pionate) and the hypothetically irrational use of
estrogens likewise has produced symptomatic re-
lief and partial and temporary regression of the
neoplasm (Walker and others, Proc. Roy. Soc.
Med., 1944, 37, 731; Nathanson, Cancer Re-
search, 1946, 6, 484; Arhelger, J. -Lancet, 1950,
70, 6). Definite improvement appears in about
50 per cent of patients after 2 to 5 months of
hormone treatment; the effect persists for 6
months or more. Biopsy studies by Emerson
et al. {Cancer, 1953, 6, 641) revealed incom-
plete regression of the neoplastic cells and re-
placement with dense scar tissue; it was suggested
that diethylstilbestrol therapy stimulated the

442 Diethylstilbestrol

Part I

usual reactive response to the cancer cells by
the connective tissues. Symptoms due to metas-
tases in bone are often not relieved by diethyl-
stilbestrol. Symptomatic improvement is greatest
in patients past the menopause, and in those with
tumors of lesser grades of malignancy. Some
improvement may occur in cases of chorio-
epithelioma or carcinoma of the urinary bladder.
A case of senile, sebaceous adenoma of the skin
showed improvement (Lobitz and Cole, Arch.
Derm. Syph., 1952, 66, 358). It may be empha-
sized that diethylstilbestrol does not cure cancer,
but it often brings gratifying relief in incurable
cases.

In the male, diethylstilbestrol is useful in the
prevention and treatment of the orchitis of
mumps (Hoyne et al, J. A.M. A., 1949, 140, 662);
while confirming the prophylactic effect, the
therapeutic value was denied by Norton (ibid.,
1950, 143, 172). In cases of infertility due to
oligospermia in the male, pregnancies have fol-
lowed use of 0.1 mg. of diethylstilbestrol daily
during the two weeks before ovulation of the fe-
male (Herrold, /. Urol, 1952, 68, 775).

Dermatologic Use. — Good results in acne vul-
garis following topical application of a paste
containing diethylstilbestrol have been reported
(Phillip, N. Y. State J. Med., 1951, 51, 1313)
but no benefit from oral administration was seen
(White and Lehmann, Arch. Derm. Syph., 1952,
65, 601). In two cases of cutaneous blastomy-
cosis, oral therapy with 3 mg. daily produced
healing in 3 to 4 months (Curtis and Harrell,
Arch. Int. Med., 1952, 66, 676). A patient with
Sjogren's syndrome was benefited by diethylstil-
bestrol. testosterone and pilocarpine (Cooperman,
Ann. West. Med. Surg., 1950, 4, 344).

Cholesterol Metabolism. — In atherosclerosis,
several considerations, including the lesser inci-
dence of coronary occlusion in women prior to
the menopause than in men in spite of the hyper-
cholesterolemia associated with pregnancy, stimu-
lated studies of the relation of estrogenic
substances to hypercholesterolemia and athero-
sclerosis. Implantation of diethylstilbestrol in
young chickens results in an increased concentra-
tion of cholesterol in blood and a greater degree
of atheromatosis of the aorta, even on a normal
or low cholesterol diet; this suggested that en-
dogenous cholesterol formation was increased.

Since estrogens cause in women an increase in
phospholipids, it may be that plasma lipoprotein
giant molecules are actually stabilized as a result
of estrogenic action (Ahrens and Kunkel, /.
Exp. Med., 1949, 90, 409). In baby chickens fed
cholesterol and fat, Pick et al. (Circulation, 1952,
8, S58) observed in those birds daily receiving
estradiol benzoate intramuscularly a lesser de-
gree of coronary atheromatosis, associated with
a marked increase in blood phospholipid and a
slight increase in cholesterol concentration; it
appeared even that pre-existent atheromas disap-
peared during estrogen therapy. A greater increase
in "readily extractable" cholesterol in the blood
plasma of chicks was obtained after administering
diethylstilbestrol than when fat and cholesterol
were fed (Forbes and Patterson, Proc. S. Exp.

Biol. Med., 1951, 78, 883). Following their ob-
servation that the amount of cholesterol present
in blood as alpha lipoprotein (blood fractions
IV, V and VI) was greater, and that beta lipo-
protein (fractions I and III) was less, in young
women than in young men, Barr et al. (Trans.
A. Am. Phys., 1952, 65, 102) gave daily doses
of estrogens equivalent to 10,000 rat units to
patients with advanced atherosclerosis, in whom
the percentage of cholesterol as alpha lipopro-
tein was low; an increase in the proportion of
cholesterol as alpha, and a decrease as beta, lipo-
protein was produced, along with an inconstant
decrease in total plasma cholesterol and a con-
stant enlargement of breasts and loss of libido
in the men. In postmenopausal women, Eilert
(Metabolism, 1953, 2, 137) found a decrease in
cholesterol and an increase in lipid phosphorus in
the blood after estrogenic therapy. In males
castrated because of carcinoma of the prostate,
Gertler et al. (Geriatrics, 1953, 8, 500) observed
a marked rise in blood serum lipid phosphorus
following administration of diethylstilbestrol.
However, Glass et al. (Metabolism, 1953, 2,
133) found no change in the Sf 12 to 20 and
Sf 20 to 100 lipoprotein fractions of the blood
(see discussion under Cholesterol) in men or
women after estrogenic therapy. Even if the
observations on chickens are transposable to
humans, it is doubtful that many men will choose
the eunuchoid state induced by estrogenic ther-
apy in the hope of avoiding a coronary occlusion.

Use in Poultry. — Implantation of pellets of
diethylstilbestrol in the neck of chickens provides
a simple, non-surgical procedure to produce
capons with a greater market weight in a shorter
feeding time (see in Part III for further in-
formation).

Former Uses. — The concept that daily adminis-
tration of estrogenic substance during pregnancy
will decrease the incidence of late complications
of pregnancy, such as pre-eclampsia, prematurity,
etc., by virtue of stimulating placental production
of progesterone and other essential steroids has
not been substantiated in "blind" control studies
with diethylstilbestrol or a placebo in a total
of 1199 cases (Dieckmann et al., Am. J. Obst.
Gyn., 1953, 66, 1062); Ferguson, ibid., 65, 592).
Prior to the advent of antibiotic therapy, diethyl-
stilbestrol was standard treatment for gonorrheal
vulvovaginitis in children (Russ et al., J. Clin.
Endocrinol, 1942, 2, 383).

Toxicology. — In some of the early clinical
trials of diethylstilbestrol a high incidence of
nausea, vomiting and headache was reported
(Finch, J.A.M.A., 1942, 119, 5). The simultane-
ous administration of ascorbic acid and the vita-
min B complex decreased the incidence of nausea
and vomiting (Karnaky, Surg. Gynec. Obst.,
1950, 91, 617). Side effects observed in 178
patients receiving diethylstilbestrol in large
doses, for inoperable cancer, included anorexia,
abdominal pain, diarrhea, lethargy, paresthesia,
various skin eruptions, dizziness, headache, nipple
and areolar pigmentation, breast engorgement
and tenderness, uterine bleeding, amenorrhea,
dysuria, dependent edema and congestive heart

Part I

Diethylstilbestrol Injection 443

failure (Kennedy and Nathanson, J.A.M.A.,
1953, 152, 1135). Subsequent experience has
shown it to be tolerated in clinically effective
doses by the majority of persons. Large doses
in animals caused fatty degeneration and necrosis
of the liver (MacBryde et al., J.A.M.A., 1942,
118, 1278, and others). In wide therapeutic use
in the human it has not proved to be hepatotoxic
(see J. AM. A., 1942, 119, 632). The very few
cases of serious toxicity reported have been re-
viewed by Elias and Schwimmer {Am. J. Med.
Sc, 1945, 209, 602); these included cases of
exfoliative dermatitis and angioneurotic edema,
and one of hepatitis.

A bizarre case of gynecomastia and nipple
pigmentation in a 4-year-old child exposed to
diethylstilbestrol dust while playing near his
mother, who operated a tableting machine, has
been reported (Prouty, Pediatrics, 1952, 9, 55);
it seems possible that similar effect could be
produced by contact in the home with estrogen-
containing cosmetic creams. A case of congestive
heart failure in a man with carcinoma of the pros-
tate, who was receiving diethylstilbestrol, was
reported by Weyrauch and Rosenberg (Stanford
M. Bull., 1951, 9, 245). Sudden appearance of
a lepromatous eruption during prolonged therapy
with diethylstilbestrol in a person unsuspected of
having leprosy is recorded (Symmers, Internat.
J. Leprosy, 1951, 19, 37).

Several cases of bilateral carcinoma of the
male breast, some with metastases, have been
reported during intensive therapy with diethyl-
stilbestrol (Corbett and Abrans, /. Urol., 1950,
64, 377; McClure and Higgins, J. A.M. A., 1951,
146, 7, and others). Although these instances are
infrequent, this is a calculated risk in intensive
therapy. A case of grade I adenocarcinoma of a
myomatous uterus, in a woman of 60 years who
had taken 1 mg. of diethylstilbestrol daily for
12 years, is on record (Novak, Am. J. Obst. Gyn.,
1951, 62, 688).

Dose. — The usual dose of diethylstilbestrol
is 0.5 mg. (approximately %2o grain) daily by
mouth, with a range of 0.25 to 1 mg., in man-
agement of menopausal symptoms. For this pur-
pose the maximum safe dose is usually 1 mg.,
but up to 15 mg. or more is used for palliative
effect in patients with cancer. In the menopause
untoward effects are minimized if treatment is
commenced with a small dose of 0.1 mg. by
mouth daily and increased if needed until the
symptoms are controlled; the majority of pa-
tients respond to less than 0.5 mg. daily. The
dose should be decreased as soon as relief is
obtained and discontinued as soon as possible;
it may be started again if needed. Intramuscular
doses of 0.25 to 1 mg., in oil, two or three times
a week are adequate in the menopause. Freed
(/. Clin. Endocrinol., 1946, 7, 420) administered
2.5 or 5 mg. in aqueous suspension, parenterally,
every 2 weeks; marked reduction in toxic
symptoms was observed. For senile vaginitis the
same doses are employed; 0.5 mg. is used in the
form of vaginal suppositories or ointment. For
gonorrheal vaginitis in children, suppositories of
0.1 mg. are used every night until the vaginal
smears show no gonococci and for two weeks

thereafter; orally, the dose is adjusted according
to age in sufficient amount to cause vaginal
cornincation. For the inhibition of lactation, 5
mg. is given orally or intramuscularly from one
to three times daily for two to four days and
may be repeated if symptoms recur. For carci-
noma of the prostate, the initial dose is 3 mg.
daily by mouth or 5 mg. twice weekly intra-
muscularly followed by 1 mg. daily orally or
2 to 4 mg. twice weekly intramuscularly; criteria
for adequate dosage are the level of blood serum
acid phosphatase and the presence of mild sensi-
tivity of the nipples. For functional uterine
bleeding, large doses are employed, such as
5 mg. three to five times daily orally or intra-
muscularly until bleeding ceases; some have ad-
vocated administering 2 mg. of diethylstilbestrol
daily for 15 days, after which progesterone is
given; when bleeding starts this cycle is repeated.
For threatened abortion, 100 mg. has been given
every 15 minutes intramuscularly until cramps
cease, followed by 200 mg. daily, in divided doses
by mouth, for 7 days, then in gradually decreas-
ing doses until the end of the third month of
gestation. For habitual abortion 5 mg. daily is
given when pregnancy is diagnosed and increased
to 15 mg. daily, which is continued through the
15th week of gestation and then decreased to
10 mg. and eventually 5 mg. daily, at weekly
intervals, and finally discontinued. In mumps,
2 mg. daily is used to prevent and 5 mg. daily to
treat orchitis.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DIETHYLSTILBESTROL INJECTION.
N.F. (LP.)

[Injectio Diethylstilbestrolis]

"Diethylstilbestrol Injection is a sterile solu-
tion of diethylstilbestrol in oil or in other suitable
solvent. It contains not less than 90 per cent
and not more than 110 per cent of the labeled
amount of C18H20O2." N.F. The LP. specifies
the same rubric; the definition indicates that the
solution is sterilized, in its final containers, by
heating at 150° for 2 hours.

LP. Injection of Diethylstilboestrol ; Injectio Diethyl-
stilboestroli. Sip. Inyeccion de Dietilestilbestrol.

Assay. — The diethylstilbestrol, being phenolic,
is extracted from an ether solution of the injec-
tion by shaking with portions of sodium hydrox-
ide T.S. and then transferred to peroxide-free
ether by extraction with this solvent after acidi-
fication of the alkaline solution. The ether is
evaporated and the residue dissolved in a hydro-
alcoholic solution. An aliquot of this solution,
representing 0.2 mg. of diethylstilbestrol, is
treated with vanadyl sulfate solution, the inter-
action resulting in a pink color being developed,
the intensity of which is measured at 520 m\i and
quantitatively evaluated by comparison with the
intensity of color produced when reference stand-
ard diethylstilbestrol is treated similarly. N.F.

Storage. — Preserve "in single-dose or mul-
tiple-dose containers, preferably of Type I glass."
N.F.

444 Diethylstilbestrol Injection

Part I

Usual Sizes. — 1 ml. containing 0.5, 1, 2, 5,
and 25 mg. (approximately Vi:>u. lm, Vso, ¥12,
and ->8 grain) ; also multiple dose containers of
corresponding strengths.

DIETHYLSTILBESTROL TABLETS.
U.S.P. (B.P.) (LP.)

[Tabellae Diethylstil'oestrolis]

"Diethylstilbestrol Tablets contain not less
than 90 per cent and not more than 110 per cent
of the labeled amount of C1SH20O2." US.P. The
corresponding limits of the B.P. are 89.0 to
110.0 per cent; the limits of the LP. are the
same as those of the U.S.P.

B.P. Tablets of Stilboestrol ; Tabellae Stilbcestrolis.
I. P. Tablets of Diethylstilboestrol ; Compressi Diethyl-
stilboestroli. Sp. Tabletas de Dietilestilbestrol.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Usual Sizes. — 0.1, 0.25, 0.5, 1, 5, and 25 mg.
(approximately Kwo, k-so, Vno, Veo, W2, and H
grain).

DIGITALIS. U.S.P. (B.P, LP.)

Foxglove, [Digitalis]

"Digitalis is the dried leaf of Digitalis pur-
purea Linne (Fam. Scrophulariacece). The po-
tency of Digitalis is such that, when assayed as
directed, 0.1 Gm. is equivalent to not less than
1 U.S.P. Digitalis Unit. One U.S.P. Digitalis
Unit represents the potency of 100 mg. of U.S.P.
Digitalis Reference Standard. Note. — When Digi-
talis is prescribed, Powdered Digitalis is to be
dispensed." U.S.P.

The B.P. and LP. name for the same drug is
Digitalis Leaf; both require it to be rapidly
dried at about 60° as soon as possible after
collection. The B.P. does not assay the leaf; the
LP. requires it to contain not less than 10 Inter-
national Units in 1 Gm.

B.P., LP. Digitalis Leaf; Digitalis Folium. Fairy Cap,
Fingers, Thimbles or Bells; Lady's Glove. Folia Digitalis.
Fr. Digitale; Feuilles de digitale. Ger. Fingerhutblatter;
Digitalisblatter; Fingerhutkraut. /(. Digitale. Sp. Hoja de
digital ; Digital; Dedalera.

The common foxglove, Digitalis purpurea, is a
biennial herb, native to Europe, but now widely
cultivated in many parts of the world. It has
become naturalized in several sections of the
United States, particularly in Washington, Ore-
gon and New York and has more recently been
found growing as a weed in southern New-
foundland.

The underground portion of the plant consists
of a fibrous root system which, during the first
year, sends forth a rosette of long stalked,
ovate to ovate-lanceolate, radical leaves. During
the second summer, a single, erect, downy and
leafy stem arises from the center of a leaf rosette
to a height of 1 to 1.5 meters and terminates in
an elongated raceme of large, purple, tubular-
campanulate flowers. The lower leaves are ovate
to ovate-lanceolate, pointed, up to 12 inches in
length and 3 in breadth, and possess winged
petioles; the upper are alternate, sparse, and
lanceolate; both are irregularly creante to den-

tate, and have wrinkled pubescent surfaces, of
which the upper is a fine deep green, the under
paler and more downy. The flowers are numerous,
and attached to the upper part of the stem by
short pedicels, in such a manner as generally to
hang down upon one side. At the base of each
pedicel is a bract, which is sessile, ovate, and
pointed. The calyx is divided into five segments,
of which the uppermost is narrower than the
others. The corolla is gamopetalous, tubular
bell-form, swelling on the lower side, irregularly
divided at the margin into short obtuse lobes, and
in shape and size not unlike the end of the
finger of a glove, a circumstance which has sug-
gested most of the names by which the plant is
designated in different languages. Its mouth is
guarded by long soft hairs. Externally, it is in
general of a bright purple; internally, it is sprin-
kled with dark spots upon a white ground. There
are four didynamous stamens whose filaments
are white, curved, and surmounted by large yel-
low anthers. The style is simple, and supports a
bifid stigma. The seeds are numerous, very small,
grayish-brown, and contained in a pyramidal two-
celled capsule.

A number of varieties of Digitalis purpurea
have occurred in cultivation, the leaves of which
have been commonly collected, with those of the
pure species, as a source of the drug of com-
merce. The var. gloxinceflora Hort. has longer
racemes with larger and more spotted flowers;
the var. alba Hort. possesses white flowers; the
var. campanulata Hort. is a large form whose
upper flowers are united into a large bell-shaped
bloom; the var. monstrosa Hort. is a double
peloric form. All of the species of the genus
Digitalis seem to have similar effects upon the
system.

Foxglove grows wild in the temperate parts of
Europe, where it flowers in the middle of summer.
In this country it is cultivated both for orna-
mental and for medicinal use. (For methods of
cultivation in the United States and Canada see
Miller, Am. J. Pharm., 1913, p. 297; Emerv,
Can. Pharm. /., 1927, 61, 124).

Digitalis leaves are gathered from first year
plants and from second year plants at the com-
mencement of flowering.

The seeds contain more of the active principle
than the leaves, are less likely to suffer in drying,
and keep better, but are, nevertheless, little used,
because of their relatively higher cost. From them
is manufactured Digitalin {German), described in
Ntf.R., 1946 (see Part II).

Before World War II the great bulk of the
digitalis used in the United States came from
Europe, especially Germany. Sufficient digitalis
was grown in America during 1942 to 1946 from
naturalized plants to supply domestic needs. At
present digitalis is again largely imported from
Europe.

Unofficial Species. — The leaves of the D.
thapsi L. have appeared commercially under the
name of Spanish Digitalis. E. M. Holmes found
in English commerce digitalis imported from
Spain which consisted of the leaves of Digitalis
thapsi, D. mariana and D. purpurea. D. thapsi
Linne has yellowish hairs and is also less decur-

Part I

Digitalis 445

rent into the petiole; D. mariana Boiss. is re-
markable for the hoary, white, dense, hairy
coating of the leaves (especially when young)
while the leaves are all stalked and the bracts are
small and scale-like. A sample of D. thapsi on
physiological assay was found to have activity
about one-half that of genuine digitalis (Pharm.
J., 1917, 98, 351 and 399). Juillet et al. (J. pharm.
c/iim., 1938, 28, 465), however, described a
sample from Spain which they assayed according
to the procedure of the French Codex and found
it to be equal, if not superior, to the leaves of
D. purpurea in activity.

Digitalis orientalis Lamarck is a perennial herb
native to Asia Minor; it has a slender stem,
attains to a height of from \]/z to 3 feet, and
bears alternate, sessile, entire, glabrous, linear-
lanceolate leaves and a terminal raceme of
cream-colored flowers, subtended by lanceolate
bracts. The corolla is finely striped red without
and more regularly so within, excepting on the
lower lip. It possesses short lateral lobes and a
large, flat, spatulate lower lip.

For description of D. lanata see under Digoxin.

The leaves of D. lutea L., a native of south-
ern Europe, have been employed as a substitute
for the official article and are claimed to possess
similar properties. They are oblong tc lanceolate,
glabrous and denticulate. For details on their
properties, see Sparks (/. A. Ph. A., 1927, 16,
203), and DeGraaff {Pharm. Weekblad, 1931,
68, 1098). According to Dewar (Quart. J. P.,
1934, 7, 1) the leaves of D. lutea may be dis-
tinguished from those of D. purpurea by the
following characters: "In surface view the anti-
clinal walls of the epidermises are often thick-
ened at the apices of the angles formed by their
undulations; the paucity of non-glandular tri-
chomes; the number of water pores on the mar-
ginal teeth varies from 1 to 4 pores on each
tooth."

Welti found D. lutea (Arch, internat. pharma-
codyn. therap., 1930, 37, 50) to be about equal
in potency to D. purpurea and like it to depend
for its activity chiefly on the glycoside digitoxin.
This species is being cultivated in Canada. Tab-
lets made from leaves of D. lutea have been sold
under the name of digilutea.

Youngken (/. A. Ph. A., 1919, p. 923) found
leaves of D. sibirica Lindl that were decidedly
more powerful than the official species.

The leaves of D. ambigua Murr., indigenous
to Europe and W. Asia, are ovate-lanceolate with
a closely serrate margin, nearly glabrous above,
pubescent on lower surface and possess 1- to 5-
celled, papillose non-glandular hairs and glandu-
lar hairs with a 1-celled stalk and a 1- to 2-celled
head. Morris (J.A.M.A., 1917, 68, 1005) found
the drug equal in action to D. purpurea. For
details on the morphology of the leaves of D.
ambigua see Maheu and Chartier (Bull. sc. Phar-
macol, 1934, 41, 280 and 347); also Jacobs
(J. A. Ph. A., 1941, 30, 21;.

Van Esveld (Arch. exp. Path. Pharm., 1931,
160, 375) reported on comparative studies of the
potency of 12 species of digitalis.

For a comprehensive description of the mor-
phology and anatomy of the leaves of Digitalis

purpurea and the adulterants of this drug, see
Bohny's article in Bot. Centralbl., 1906, p. 267.
Collin reviewed the pharmacognosy of digitalis
(/. pharm. chim., 1905, p. 56), showing the char-
acteristics of the powder and the detection of the
principal leaf adulterants, such as Verbascum
Thapsus, Inula Conyza, Verbascum phlomoides,
Piper angustijolia Ruiz et Pavon (Artanthe
elongata), and Salvia Sclarea. The chief adulter-
ants for digitalis in more recent years have been
the leaves of mullein species, which may be read-
ily detected as an admixture even in small
quantities, by their candelabra-shaped trichomes
and velvety texture.

Description. — "Unground Digitalis occurs as
more or less crumpled or broken leaves. The leaf
blades are ovate, oblong-ovate to ovate-lanceolate,
mostly 10 to 35 cm. in length and 4 to 11 cm. in
width and contracted into a winged petiole. The
apex is obtuse; the margin irregularly crenate or
serrate; the lower surface densely pubescent, the
upper surface wrinkled and finely hairy. The
venation is conspicuously reticulate, the mid-rib
and principal veins broad and flat, and the lower
veins are continued into the wings of the petiole.
The color of the upper surface is dark green, of
the lower surface grayish from the dense pubes-
cence, the larger veins often purplish. The odor
is slight when dry, peculiar and characteristic
when moistened. The taste is very bitter." U.S.P.
For histology see U.S. P. XV.

"Ground Digitalis is dark green. It consists
chiefly of numerous irregular fragments of epi-
dermis and chlorenchyma; non-glandular hairs
which are frequently curved or crooked, up to
500 m- in length, uniseriate, 2- to 8-celled, some
of the cells collapsed so that the planes of ad-
joining cells may be at right angles, the terminal
cell pointed or rounded; few, small glandular
hairs, usually with a 1- or 2-celled stalk and a 1-
or 2-celled head; fragments of veins and petioles
with annular, reticulate, spiral and simple pitted
vessels and tracheids. Calcium oxalate is absent."
U.S.P.

Standards and Tests. — Water. — The limit
is 6 per cent, when determined by drying at
105° or by distillation with toluene. Foreign
organic matter. — The limit of stems, browned
leaves, flowers or other foreign organic matter
is 2 per cent. Acid-insoluble ash. — The limit is
5 per cent. U.S.P.

Assay. — Many methods of assaying digitalis
and its dosage forms and derivatives have been
proposed; these may be broadly classified as
biological and chemical. An explanatory review
of the more important of them is provided here-
under. As a rule digitalis leaf is prepared in the
form of a tincture prior to assay.

Biological Methods. — Of the more than 40
different methods for biological standardization of
digitalis (see Schwartz, Am. J. Pharm., 1934,
106, 196), those employing the frog or cat as
the test animal were the most widely used until
the U.S. P. XIV adopted a method employing the
pigeon. The first attempt at biological standardi-
zation of digitalis was that of Houghton, in 1898;
he used systolic arrest of the frog's heart as the
criterion for evaluation of the drug. The cat

446 Digitalis

Part I

method was originated by Hatcher, in 1910, and
was based on a determination of the quantity of
digitalis, administered intravenously, required to
cause death of the cat. Various modifications of
the two methods were long used by different in-
vestigators and several were adopted in successive
revisions of the United States Pharmacopeia and
other pharmacopeias. The selection of the animal
to be used as a test subject involves consideration
of many questions such as whether the animal
employed and the physiological action observed
measure quantitatively the effect of digitalis on
humans, the cost and availability of experimental
animals, the complexity of the technical aspects
of the assay, and many others. The problem of
the ultimate standard for expressing and com-
paring the potency of digitalis has been a difficult
one; thus the U.S. P. XI unit turned out to be
considerably more potent than that of the
U.S. P. X. even though they were intended to be
the same, in consequence of which there was a
considerable increase in incidence of digitalis
intoxication in medical practice (see Fahr,
JAMA., 1938, 111, 2268; 1939, 112, 1180).

Frog Method. — Methods of assay using frogs
utilized different periods of time of action of
digitalis before examining the heart to determine
whether it was in systolic standstill; these came
to be designated as the " 1-hour" method of
assav, or the " 18-hour'' method of assay (see
Miller, /. A. Ph. A., 1944, 33, 245). For descrip-
tion of the details of the U.S. P. XI method, using
frogs, see U.S.D., 22nd ed., p. 1125.

Cat Method— The U.S.P. XII followed the
lead of several of the European pharmacopeias
in adopting a cat assay in place of the frog
method which had been officially recognized for
25 years; the U.S.P. XIII assay was the same
as that of the preceding revision. This assay was
based on a determination of the average lethal
dose for cats, in ml. per Kg., of a tincture pre-
pared from the digitalis to be tested and a com-
parison of this with the corresponding dose for
a standard preparation of digitalis. The standard
preparation was made by adding 10 ml. of a
menstruum of 4 volumes of alcohol and 1 volume
of water for each Gm. of Digitalis Reference
Standard used, shaking the mixture during 24
hours at 25°, centrifuging it, and decanting the
liquid phase for use as the standard preparation;
in the test, however, this was diluted with isotonic
sodium chloride solution so as to have the esti-
mated fatal dose per Kg. in 15 ml. of the dilution.
Domestic cats weighing between 2.0 and 4.0 Kg.,
free of gross evidence of disease and not being
either obese, emaciated, lactating, or pregnant,
were used in the test; not less than 6 cats were
necessary for each of the two solutions to be
tested. Food was withheld prior to the test and
the animals were anesthetized lightly with ether;
after immobilization a canula was inserted in a
femoral vein with provision for injecting the
test dilution from a burette caUb rated to 0.1 ml.
The test proper consisted in injecting 1 ml. of
diluted material (the sample to be tested being
diluted in the same manner as the standard
preparation) for each Kg. body weight of cat
at 5-minute intervals until the cat died from

cessation of heart beat. If the average number
of doses required to produce death was less than
13 or more than 19, the experiment was repeated
until the results were within these limits.

The lethal dose for each cat in terms of the
ml. of tincture per Kg. of live body weight was
calculated, and the average lethal dose of the
standard preparation and that of the preparation
under test computed. The standard error of each
average was calculated by taking the difference
between the average and the lethal dose for each
cat; the differences were squared, their sum
taken, this divided by the product of the number
of cats and that number less one, and the square
root of the quotient extracted. If the standard
error of each average was not over 5.7 per cent,
the potency of the preparation to be assayed, in
U.S.P. Digitalis Units, was obtained by dividing
the average for the Standard Preparation by the
average for the preparation to be assayed. If the
standard error of either average exceeded 5.7
per cent, the experiments included in the calcula-
tion of the standard error were repeated until this
error was within the limit.

Digitalis tincture was considered to conform
to the pharmacopoeial requirement if the result
of the assay did not vary more than 20 per cent
from such requirement. US.P. XIII.

Pigeon Method— The U.S.P. XIV introduced
the pigeon method (see Braun and Lusky, Fed.
Proc, 1947, 6, 311) of assaying digitalis, its
dosage forms, and certain of its derivatives, and
the U.S.P. XV has continued to use this method.
The procedure is identical with that described
under the cat method except that pigeons are
used. The potency, in U.S.P. units per ml. of
the assay preparation, is defined as the ratio of the
product of the average number of doses of the
test dilution of the standard preparation and
the number of ml. of the standard preparation in
100 ml. of the test dilution to the corresponding
product for the assay preparation. The confidence
limits of the potency are calculated; if these differ
by more than 0.30 U.S.P. Digitalis Unit between
the upper and lower limits the assay is repeated
until it is within this limit. The potency of digi-
talis is considered satisfactory if the assay indi-
cates not less than 0.85 U.S.P. Digitalis Unit per
0.1 Gm.

The B.P. assays its Prepared Digitalis (corre-
sponding to U.S.P. Powdered Digitalis) bio-
logically but permits use of frogs, cats, guinea-
pigs (see /. A. Ph. A., 1947, 36, 363). or pigeons
as test animals. The LP. directs that digitalis leaf
be assayed by the method required by the law of
the country concerned.

Human Method. — Gold and his associates
(/. Pharmacol., 1941. 73, 212) reported that the
U.S.P. XIII cat method, though superior to the
earlier frog method, gave results which may be
misleading when applied to humans. They de-
veloped a method of assay based on the fact that
the therapeutic action of digitalis in man parallels
the change in the '"RS-T" segment of the electro-
cardiogram {ibid., 1942, 75, 196); using one
sample of digitalis for the preparation of tablets,
capsules and two tinctures they were able to
obtain the remarkable reproducibility represented

Part I

Digitalis 447

by a minimum deviation of less than 10 per cent
in the four assays (Science, 1943, 97, 125, 150).

Chemical Assay. — Many attempts to develop
a chemical assay for digitalis have been made but
none of these has proved to be entirely adequate.
A method reported by Bell and Krantz (/. Phar-
macol., 1945, 83, 213) has shown promise in a
collaborative study (/. A. Ph. A., 1946, 35, 260).
This method, originally proposed by Knudson and
Dresbach (/. Pharmacol., 1923, 20, 205), is a
colorimetric procedure based on the reaction ob-
served by Baljet {Schweiz. Apoth. Zeit., 1918, 56,
71, 89) in which a red-orange color is developed
by the active glycosides of digitalis in the pres-
ence of an alkaline picrate solution. Bell and
Krantz (/. Pharmacol., 1946, 88, 14) also studied
the relative intensities of the color reaction of
the principal D. purpurea and D. lanata glyco-
sides; the intensities of the former paralleled
cardiotonic activity but those of the lanata group
did not. Goldstein (/. A. Ph. A., 1947, 36, 296) re-
ported that while the Bell and Krantz method
may not appear to satisfy all requirements for an
official chemical assay of digitalis the method is
useful in control laboratories that are not equipped
for biological procedures. Swoap (ibid., 1948, 37,
268) used a modification of the Knudson and
Dresbach procedure for over 4 years of assaying
digitalis and its glycosides.

Constituents. — From the leaves of Digitalis
purpurea have been isolated a total of about 1 per
cent of the glycosides digitoxin, gitoxin and gitalin,
all possessing cardiac activity and originally
thought to be the natural glycosides of the plant.
In 1935, however, Stoll showed that digitoxin and
gitoxin each had already lost a molecule of glu-
cose by enzymatic hydrolysis during extraction.
Inactivating the glycosi de-splitting enzymes by
extracting digitalis at low temperatures and in the
presence of neutral salts, Stoll (see The Cardiac
Glycosides, 1937) succeeded in isolating the pre-
cursors of both digitoxin and gitoxin. That of the
former he called purpurea glycoside A and dem-
onstrated it to be a deacetyl derivative of digi-
lanid A or lanatoside A, one of the native glyco-
sides of D. lanata, for which reason it is also desig-
nated deacetyldigilanid A. The precursor of gitoxin
he named purpurea glycoside B, or deacetyl-
digilanid B from its being a deacetyl derivative
of digilanid B or lanatoside B, another of the
natural glycosides of D. lanata. In the ordinary
procedures of extraction these natural glycosides
are hydrolyzed by the enzyme digipurpidase,
splitting off a molecule of glucose and leaving
digitoxin and gitoxin, respectively. It is highly
probable that gitalin is likewise a product of the
hydrolysis of a native glycoside in D. purpurea.

Digitoxin, gitoxin and gitalin may be further
hydrolyzed, leaving aglycones entirely free of
sugar and named, respectively, digit oxigenin,
gitoxigenin, and gitaligenin. The sugar liberated
in each case is the same — the alpha-deoxymono-
saccharide digitoxose, C6H12O4, of which three
molecules are split off from digitoxin and from
gitoxin, but only two from gitalin. While the
aglycones constitute the pharmacologically active
components of the glycosides, the otherwise inac-
tive sugar component enhances the activity, pre-

sumably by modifying water solubility, cell pene-
trability, and persistence of cardiac action. It has
been conclusively demonstrated that the aglycones
are weaker in cardiac action than the glycosides
from which the former are derived.

The aglycones digitoxigenin, gitoxigenin and
gitaligenin, in common with the aglycones of most
other cardiac glycosides, contain a cyclopentano-
perhydrophenanthrene nucleus having methyl
groups at carbon atoms 10 and 13, a hydroxyl
group at 3 and 14, and an unsaturated four-carbon
atom lactone ring at 17 (see Sterids, Part II).
Gitoxigenin differs from digitoxigenin only in hav-
ing a hydroxyl group in place of a hydrogen atom
at carbon atom 16. Gitaligenin can be converted
into gitoxigenin by dehydration, one molecule of
water being eliminated; the former is therefore
referred to as gitoxigenin hydrate.

Digitoxin, C41H64O13, was first described in
1869 by Nativelle as pure crystalline digitalin
(not to be confused with other digitalins) but it
was not thoroughly investigated, either chemically
or pharmacologically, until the work of Cloetta
in 1920 (Arch. exp. Path. Pharm., 1920, 88, 113).
For further discussion of this official substance
see under Digitoxin.

Gitoxin, C41H64O14, isolated as a pure sub-
stance by Krafft (Arch. Pharm., 1912, 250, 126),
and later by Cloetta (Arch. exp. Path. Pharm.,
1926, 112, 261), occurs in white needles melting
between 266° and 269°. It is very slightly soluble
in water, alcohol or chloroform. It has been re-
ferred to, in the literature, as anhydro gitalin,
bigitalin, and pseudodigitoxin.

Gitalin, C35H56O12, occurs as white rosettes,
melting at 245°. It is soluble in alcohol, chloro-
form or acetone. This pure crystalline material
should not be confused with the Amorphous
Gitalin described in Part II.

Rothlin (Schweiz. med. Wchnschr., 1935, 1162)
found that purpurea glycoside B is less than half
as potent on the frog heart as glycoside A but
about equally potent in the cat assay. Digitoxin
is somewhat weaker than glycoside A on the frog's
heart but stronger in the cat assay.

From the seeds of D. purpurea has been iso-
lated a glycoside described under the name
digitalinum verum, sometimes called Schmiede-
berg's digitalin or Kiliani's digitalin. Windaus
found it to have the composition corresponding
to C36H56O14; on hydrolysis it reacts with two
molecules of water yielding a primary aglycone
C23H34O5, probably gitoxigenin, and a molecule
each of the sugars digitalose, C7H14O5, and glu-
cose, C6H12O6. Under the rather severe chemical
treatment necessary to effect this hydrolysis the
primary aglycone loses two molecules of water,
leaving as the final product, dianhydro gitoxigenin.
This digitalin should not be confused with (1)
Nativelle's crystalline digitalin (see above); (2)
German digitalin, a mixture of glycosides from
digitalis seeds; (3) French digitalin (Homolle's
digitalin), a mixture of glycosides from digitalis
leaves, obtained by Homolle's process. German
and French digitalin are described in Part II.

The leaves and seeds of D. purpurea also con-
tain a number of saponins, of which digitonin,
gitonin and tigonin have been isolated and in-

448 Digitalis

Part I

vestigated. On acid hydrolysis the following re-
actions occur: Digitonin produces the aglycone
digitogenin, four molecules of galactose and one
of xylose; gitonin yields gitogenin, three mole-
cules of galactose and one of a pentose; tigonin
splits into tigogenin, two molecules each of glu-
cose and galactose, and an unreported number
of molecules of rhamnose. It is noteworthy that
these sapogenins. as the aglycone fractions of
saponins are called, also contain the cyclopentan-
operhydrophenanthrene nucleus. The saponins
possess no digitalis action.

Deterioration. — It has long been known that
preparations of digitalis may lose their potency.
This is due, at least in part, to hydrolysis of the
glycosides, for it is well established that the
aglycones are much less potent than the glyco-
sides from which they are derived; this hydroly-
sis may be brought about by enzymes which are
contained in the leaves. It is also well established
that some samples of digitalis will keep much
better than others, but despite a large amount of
experimental work we have no definite knowledge
of the conditions which affect this loss of potency.

The rate at which digitalis leaf undergoes a loss
of activity may van- from nothing to 50 per cent
within 6 months when tested by the frog method,
but it should be noted that the cat method of
assay shows generally much less evidence of loss
of potencv than the frog method. Christensen and
Smith (/. A. Ph. A., 1938, 27, 841) found that
there was no consistent difference between her-
metically sealed digitalis leaves and those stored
in open containers nor between those containing
5 per cent and 12 per cent, respectively, of
moisture. It is frequently stated that the tincture
deteriorates more rapidly than the leaf does but
there is no convincing proof of this in the ex-
tensive literature on the subject (see also De-
terioration under Digitalis Tincture). Digitalis
infusion is, however, an extremely unstable prep-
aration. For review of the literature on deteriora-
tion of digitalis see Haag (Am. J. Pharm., 1938,
110, 456).

Action. — Although digitalis appears to have
been used by the inhabitants of Britain as far
back as the tenth century of the Christian Era, it
was introduced into regular medical practice by
William Withering in 1775 (reprinted in Medical
Classics, 1937, 2, 305s). who obtained his knowl-
edge of the value of foxglove in dropsy from an
old woman of Shropshire. Substances with action
and chemical structure similar to the glycosides of
digitalis have been obtained from a large number
of plants and from toad poisons (Chen. Ann. Rev.
Physiol., 1945. 7, 677).

General. — The main systemic effects of digi-
talis and allied substances are manifested on the
cardiovascular system in the increased force and
decreased rate of ventricular contraction. It has
some action on the nervous system. Practically
nothing is known of the basic mechanism whereby
digitalis affects cardiovascular function. In man
and the intact animal the initial effect of digitalis
is a decrease in venous pressure (right auricular
pressure) which is followed by the several effects
of digitalis to be discussed, but the mechanism of
this reduction in venous pressure remains to be

satisfactorily elucidated (McMichael and Sharpey-
Schafer, Quart. J. Med., 1944, 13, 123). Cardiac
muscle is much more sensitive to digitalis than are
the other muscles of the body. Heart muscle con-
centrates 37 times as much digitalis glycoside as
do the brain, skeletal muscle, skin, skeleton, lungs
and blood, there being no qualitative or quantita-
tive difference from one glvcoside to another
(Stoll, J. -Lancet, 1951, 71, 195). How the agly-
cones, which are evidently released from the
glycosides in the cell protoplasm, cause such re-
markable changes in muscular contraction is a
mystery.

Ventricular Force. — The most important ac-
tion of digitalis is upon the muscle of the heart.
It increases the force of svstolic contraction
(Cattell and Gold. /. Pharmacol., 1938, 62, 116).
Most of the changes in cardiovascular function
caused by digitalis are an outgrowth of this direct
action. Other effects are secondary and not indis-
pensable. For many years digitalis was looked
upon as influencing the heart mainly through the
slowing of cardiac rate. This was due to the fact
that digitalis was thought to be specific in the
treatment of auricular fibrillation in which condi-
tion it often dramatically slows the ventricular
rate. The slowing in rate was believed to be the
basis for the relief of symptoms. For this reason
the primary action of digitalis on the heart muscle
was minimized and the drug was not used for
heart failure with normal rhythm but rather re-
served for arrhythmias with rapid heart rate.
Through years of investigative work it has been
established that the chief use of digitalis is in
congestive heart failure and that its beneficial ac-
tion is not primarily due to a slowing of the rate
but to its direct action to increase the force of
the myocardial contraction (Gold and Cattell,
Arch. hit. Med., 1940, 65, 263). When digitalis
increases the force of contraction in the failing
heart the ventricle empties more completely. In
this manner the venous pressure is lowered, if it
had been elevated by congestive heart failure, be-
cause the heart is rendered capable of caring for
an increased venous return of blood. Not only is
the force of systole increased, but the length of
systole is shortened, thus giving the heart more
time to rest between contractions and more time
for the ventricle to fill with venous blood. Digi-
talis also apparently increases the mechanical effi-
ciency of the heart muscle (Erickson and Fahr.
Am. Heart J., 1945. 29, 348). Experiments have
shown that after digitalis, the heart muscle is able
to perform a given amount of work with less con-
sumption of oxvgen (Peters and Visscher. Am.
Heart J., 1936. 11, 273).

However, considering the primary fall in ven-
ous pressure which is induced by digitalis (Stewart
et al., Arch. Int. Med., 1938. 62, 547 and 569),
regardless of whether cardiac output is increased
following the drug, as in patients with congestive
heart failure, or decreased, as in persons with
normal, compensated hearts. Katz et al. (J. Phar-
macol, 1938, 62, 1; Am. Heart J., 1938. 16, 149)
claimed that digitalis acts peripherally on the cir-
culation rather than on the contractile power of
the myocardium. The report of Dock and Tainter
(/. Clin. Inv., 1930, 8, 467) that pooling of blood

Part I

Digitalis 449

in the liver of dogs explained the drop in venous
pressure was not confirmed in the human by
P. Wood (Brit. Heart J., 1940, 2, 132) and this
change in venous pressure occurs too rapidly to
be a result of the decrease in blood volume which
follows digitalization (W. B. Wood and Janeway,
Arch. Int. Med., 1933, 62, 151). The decrease in
venous pressure associated with an increase in
cardiac output and a decrease in heart size in
cases of congestive heart failure and similar
changes, except for a decrease in cardiac output
in normal hearts, follows Starling's law of the
heart (McMichael and Sharpey-Schafer, loc. cit.).

Ventricular Rate. — The strengthened cardiac
systole caused by digitalis markedly affects other
aspects of cardiovascular function. Therapeutic
doses of digitalis slow the rapid heart rate in
clinical heart failure. The most likely manner in
which digitalis causes this is through reflex vagal
effect as a result of restoration of compensation
of cardiovascular function. Tachycardia in heart
failure is usually considered a compensatory re-
sponse to maintain the circulation. As digitalis
improves the circulation and relieves the failure
through its myocardial action, the cause of the
tachycardia is corrected and the heart rate is de-
creased. The therapeutic effects are not due to
any direct digitalis-induced vagal slowing. Gold
et al. (J. Pharmacol., 1939, 67, 224) demonstrated
that the initial slowing produced by a digitalizing
dose may be abolished by atropine but that the
ventricular rate is not altered by atropine, emo-
tion or exertion when the full effect of digitalis
has been established. Congestive failure is often
markedly improved without evidence of cardiac
slowing. When the heart rate is decreased by
digitalis it is mainly in patients who have a tachy-
cardia accompanying the heart failure. Even in
auricular fibrillation, where digitalis exerts its
most prominent slowing of ventricular rate, the
drug usually doesn't slow the ventricle unless heart
failure exists. These conclusions are strengthened
by the fact that digitalis when given in full doses
to persons without cardiac failure causes insig-
nificant changes in the heart rate. If therapeutic
doses of digitalis affect the sino-auricular node
directly or through vagal stimulation, this action
is not prominent. Toxic doses of digitalis, how-
ever, do slow the heart rate. This effect is partly
due to a vagal effect, but in larger part to a direct
action on the pacemaker and the conduction tissue
of the heart.

Conduction. — Therapeutic doses of digitalis
do slow the conduction between the auricles and
the ventricles in normal as well as decompensated
hearts and this is reflected in an increased "P-R"
interval in the electrocardiogram. This is mainly
due to a direct action on the muscle of the con-
duction bundle of the heart. When cardiac muscle
contracts more strongly, the refractory period is
increased and hence there is a delay in the rate of
conduction. In instances of normal sinus rhythm,
the rate is not particularly affected because,
despite the delay in conduction of the impulse,
the auricular contractions are neither weak nor
numerous so that all of these impulses are trans-
mitted to excite the ventricle. However, with
toxic doses, degrees of auriculoventricular block

may occur so that the auricular impulses are in-
terfered with resulting in partial heart block or
complete auriculoventricular dissociation.

In auricular fibrillation, where there are many
impulses traveling over the bundle of His to ex-
cite the ventricle to contract frequently and
irregularly, the rate of ventricular contraction is
definitely slowed by therapeutic doses of digitalis.
This is due in part to the direct action of digitalis
on the bundle of His whereby the refractory
period is increased so that the number of impulses
capable of passing over this conduction bundle is
appreciably reduced. This effect is also due in part
to a vagal factor which is largely reflex in nature
and due to restoration of myocardial compensa-
tion. But more important, it is probably due to
the direct action of digitalis on the ventricular
muscle itself because the chief factor in determin-
ing whether digitalis will decrease the ventricular
rate in auricular fibrillation is the presence or
absence of cardiac failure. The direct action of
digitalis on the decompensated myocardium is to
strengthen the force of its contraction, which
increases the refractory period of the muscle. The
ventricle is thus rendered less excitable to auricu-
lar impulses which do pass through the conducting
tissue from the auricle. Also as the myocardium
becomes better nourished, it becomes less irritable
and it will not respond to stimuli which were
capable of causing contractions when the muscle
was in an anoxic state (see Cushny, J. Pharmacol.,
1918, 11, 103).

Cardiac Size. — Full doses of digitalis decrease
the diastolic size of the heart. This is thought to
be true for normal hearts as well as for those
dilated in failure. In normal hearts cardiac ouput
is diminished, due to the fact that the heart is
decreased below its optimal size by direct cardio-
tonic action of the drug (Stewart et al., Arch.
Int. Med., 1938, 62, 547 and 569). Schemm
(Postgrad. Med., 1950, 7, 385) claims that the
data of recent years do not agree that digitalis
impairs function of the normal heart, when given
in therapeutic doses. In failing hearts, however,
cardiac output is increased. This is due to the fact
that the dilated, inefficient ventricle is reduced
to a more normal and efficient one and the systolic
ejection of blood is more forceful and complete
(see Stewart and Cohn, /. Clin. Inv., 1932, 11,
917).

Blood Pressure. — This is affected by thera-
peutic doses of digitalis only through its action on
the heart and not by any significant effect on the
blood vessels or the vasomotor center. Low pres-
sures due to decompensation are elevated toward
normal as digitalis improves cardiac function.

Electrocardiogram. — With usual therapeutic
doses, a change of the normally upright "T" wave
is seen; it becomes diminished in amplitude, flat
or actually inverted. The "RS-T" segment be-
comes depressed. These changes may simulate
those associated with myocardial damage due to
disease of the coronary arteries (Stewart and
Watson, Am. Heart J., 1938, 15, 604). With
larger doses the "PR" interval becomes prolonged
(up to 0.25 second) and the "QT" interval be-
comes shorter.

Kidney Function. — When Withering intro-

450 Digitalis

Part I

duced digitalis he considered that its principal
value was as a diuretic but all investigators agree
that it has little or no influence on the quantity of
urine in normal men or animals. The diuresis
which occurs in cases of congestive heart failure
is secondary to the relief of the heart failure. With
improvement in the general circulation, edema
fluid is mobilized, renal blood flow is improved
and diuresis results. Digitalis passes into edema
fluid (Schnitker and Levine, Arch. Int. Med.,
1937, 60, 240 J. In patients with heart failure and
edema who have not responded rapidly to digitalis
therapy, the rapid mobilization and excretion of
the edema fluid, due to exhibition of diuretic or
other factors, may result in the manifestations of
digitalis intoxication. On the contrary, assays of
ascitic, pleural or edema fluid of fully digitalized
patients with the embryo duck-heart preparation,
by St. George et al. '(/• Clin. Inv., 1953, 32,
1222), disclosed no digitoxin action in 4 of 8
fluids and only 2, 3, 5 and 20 meg. per liter in the
others. Any significant redigitalization from ab-
sorption of such fluid into the circulation seems
impossible and the symptoms of such action,
which are not denied, are attributed to a depres-
sion of intracellular potassium as a result of the
diuresis which can sensitize the heart to digitalis
action (Lown et al., Am. Heart J., 1953, 45, 589).

Coagulation. — Digitalis has recently been
shown to increase the coagulability of the blood
and to antagonize the anticoagulant action of
heparin in the body (de Takats et al., J. A.M. A.,
1944, 125, 840; Massie et al., Arch. Int. Med.,
1944, 74, 172). This may increase any tendency
to thrombosis and embolism.

Calcium Effect. — Loewi (see Blumenfeld and
Loewi, /. Pharmacol., 1945, 83, 96) called atten-
tion to the similarities between the effects of digi-
talis and calcium upon the heart and suggested
that the chief action of digitalis is to sensitize
the cardiac muscle to calcium. Fischer (Arch. exp.
Path. Pharm., 1928, 130, 194). however, reported
that while there is a synergism between digitalis
and calcium, their effects are not identical; fur-
thermore. Xyiri and DuBois (/. Pharmacol., 1930,
39, 99 J have shown that calcium action can be
overcome by washing the heart with sodium or
potassium salt solutions but that the digitalis
effect cannot be washed out (see also under Cal-
cium Gluconate). Oral administration of calcium
salts is safe during digitalis therapy but parenteral
use is inadvisable (Smith, Winkler and Hoff. Arch.
Int. Med., 1939, 64, 322). Digitalis should be
given with caution to patients who are receiving
parathyroid extract or large doses of vitamin D
as well as to individuals with hyperparathyroidism.

Absorption. — The cardioactive material in
powdered digitalis is absorbed well, although in-
completely, from the small intestine even though
patients with heart failure commonly have a con-
gested mucous membrane (Dille and Whatmore.
J. Pharmacol., 1942, 75, 350). The effect of a
single dose appears within 2 hours and is complete
after 6 hours (Pardee. J.A.M.A., 1920, 75, 1258).
Therefore the interval between doses should be
6 hours or more, particularly when large doses
are prescribed. With the exception of digitoxin.
most of the digitalis glycosides are incompletely

absorbed as evidenced by the much larger oral
than intravenous dose which is required with
many preparations. The unabsorbed portion seems
to be destroyed in the intestine because it cannot
be recovered from the feces. Digitalis is well ab-
sorbed from the rectum and may be employed in
the same doses as by mouth. After a cleansing
enema, it may be administered in the form of the
tincture diluted with 7 parts of water or as pow-
dered digitalis in suppository form. The rectal
route avoids, to some extent at least, passage
through a congested liver (Heubner and Fuchs,
Arch. exp. Path. Pharm., 1933, 171, 102). With-
out considerable purification, subcutaneous or in-
tramuscular administration is irritating and the
rate and degree of absorption is unpredictable.
The active principles are absorbed through the
skin and poultices were formerly in use. After
intravenous administration the digitalis effect ap-
pears on the heart within 2 to 5 minutes and the
full effect is reached in a few hours (see under
Digitoxin).

Degradation and Excretion. — Very little is
known about the distribution and fate of the
digitalis glycosides in the body. Digitoxin and the
lanatosides combine with the serum proteins
whereas strophanthin and ouabain do not (Farah.
/. Pharmacol., 1945, 83, 143). A small percentage
of the dose is fixed in the heart and only slowly
released or destroyed. Of the glycosides, digitoxin
seems to remain the longest and hence is the most
likely to be concerned in cumulative poisoning.
It is excreted slowly and mostly in inactive forms
in the urine, bile and feces (Weese, Titer. Geg.,
1939, 80, 250). Little is known of the rate and
nature of degradation in the tissues. However,
this rate is important in the determination of the
maintenance dosage. By means of electrocardio-
grams, Bromer and Blumgart (JAM A., 1929,
92, 204) estimated a daily loss of 150 mg. of
powdered digitalis. U.S. P. X: this confirmed a
previous estimate bv cruder methods made by
Pardee (J.A.M.A., 1919, 73, 1822). Patients vary
greatlv in the rate of loss of digitalis effect; Gold
and DeGraff (JAMA., 1930. 95, 1237) showed
that the rate of loss was actually a percentage of
the amount of digitalis in the body — i.e., when
administration is commenced, the rate of excre-
tion and degradation is slow but increases as more
digitalis is absorbed. The figure of 100 mg. (ap-
proximately \y2 grains) of powdered digitalis,
however, is a useful approximation for therapeutic
purposes of the daily loss.

Toxicology. — Herrmann et al. (J. A.M. A.,
1944. 126, 760) reported that digitalis poisoning
had been more frequent in recent years. They
ascribed this to the more generally active and
stable commercial preparations now available, the
inadequate publicity given to the increased
potency of the U.S. P. XI digitalis unit, the failure
of the physician to ascertain the previous use of
digitalis preparations by the patient, confusion
concerning the activity of the highly potent glyco-
side preparations now available, and the differ-
ences between the oral and parenteral dose of
many preparations. Anorexia, nausea and vomit-
ing are among the earliest effects of digitalis
overdosage. These effects have been shown to be

Part I

Digitalis 451

central in origin (Hatcher and Weiss, Arch. Int.
Med., 1922, 29, 690), but when large doses are
given by mouth there is a local emetic action
(Gold et al, J. Pharmacol., 1944, 82, 187). Ab-
dominal discomfort or pain and diarrhea may also
occur.

Alterations in cardiac rate and rhythm occur-
ring in digitalis poisoning may simulate almost
any known type of arrhythmia seen clinically.
Extrasystoles are probably the most frequent
effect. They are caused by the increased irritabil-
ity of the myocardium produced by excessive
amounts of the drug. Often the extrasystole recurs
after each regular systole — coupling or pulsus
bigeminus. The ventricular rate may be increased
due to numerous extrasystoles or it may be slowed
either through a direct action on the pacemaker
or on the auriculoventricular conduction system.
Prolongation of conduction may occur and result
in dropped beats or even complete heart block
(auriculoventricular dissociation). Digitalis has
been fraudulently used to cause simulation of
heart disease. An electrocardiogram may be nec-
essary in the clinical management of the patient
to aid in the differentiation of arrhythmia due to
digitalis poisoning from that due to heart disease.
Older patients and particularly those with disease
of the coronary arteries and impaired myocardial
blood supply are more susceptible to these un-
toward effects of digitalis. Sinus arrhythmia may
occur early as a minor toxic effect. Paroxysmal
auricular or ventricular tachycardia are particu-
larly ominous and demand immediate cessation
of the drug. Auricular fibrillation can be caused
by large doses of digitalis. Ventricular fibrilla-
tion is the commonest cause of death from digi-
talis poisoning.

Headache, fatigue, malaise and drowsiness may
occur early. Vision is often blurred; objects may
appear yellow or green due to disturbances in
color vision (Am. J. Ophth., 1945, 28, 373 and
639). Diplopia may likewise occur (Ross, ibid.,
1950, 33, 1438). Batterman and Gutner (Am.
Heart J., 1948, 36, 582) described neuralgia in
association with other symptoms as a manifesta-
tion of digitalis glycoside toxicity. Six cases of
delirium were reported by King (Ann. Int. Med.,
1950, 33, 1360); circulatory changes were not
responsible. Diuresis following use of digitalis in
congestive failure reduces coagulation time of the
blood, apparently through increased concentra-
tion of thromboplastin in the circulating blood
(Pere, Acta med. Scandinav., 1950, 139, supp.
251). Eosinophilia, urticaria and other skin rashes
(Romano and Geiger, Am. Heart J., 1936, 11,
742) and allergy to digitalis (Cohen and Brodsky,
/. Allergy, 1940, 12, 69) are very infrequent.
Myocardial hemorrhages, necrosis and fibrosis
and similar changes in the brain have been pro-
duced in animals by large doses of digitalis, but
such lesions have not been observed in humans
(J. A.M. A., 1945, 127, 93; Dearing et al., Circu-
lation, 1950, 1, 394).

Digitalis-induced arrhythmias may be associ-
ated with increased myocardial sensitivity from
alterations in intracellular potassium distribution,
occurring either in malnutrition and gastrointesti-
nal disorders or following vigorous mercurial

diuresis (Lown et al., Proc. S. Exp. Biol. Med.,
1951, 76, 797; Cohen, New Eng. J. Med., 1952,
246, 254). The serum potassium level may be
unaffected. Treatment consists of immediate with-
drawal of digitalis, administration of potassium
salts in dosage of 2 to 10 Gm. daily by mouth or
cautiously by vein, if renal function is normal.
Ventricular arrhythmias refractory to potassium
may be terminated by intravenous injection of
magnesium sulfate, the dosage being 10 to 20 ml.
of a 15 to 25 per cent solution. Procainamide
hydrochloride (q.v.) is of particular value when
renal function is impaired and potassium adminis-
tration contraindicated, both in the ventricular
and auricular arrhythmias of recent origin.

Therapeutic Uses. — Congestive Heart Fail-
ure.— By far the most important use of digitalis
is in congestive heart failure regardless of the
cause. This is true whether the failure is pre-
dominantly right or left ventricular or both, de-
spite the rhythm or rate and for all types of heart
disease. The presence of arrhythmia may modify
the response to digitalis but this does not alter the
fact that digitalis is indicated in heart failure. The
best results are obtained in failure due to hyper-
tensive or arteriosclerotic heart disease or chronic
valvular heart disease.

Myocardial Infarction. — Digitalis is not in-
dicated in cases of acute coronary occlusion be-
cause it increases the tendency to ventricular
tachycardia or fibrillation unless congestive heart
failure is present, in which case the congestive fail-
ure is the greater danger and the risk of serious
ventricular arrhythmia must be accepted. Schemm
(Postgrad. Med., 1950, 7, 385) maintained that
advisability of freer use of digitalis in myocardial
infarction is suggested by the fact that two-thirds
of the patients who survive go into congestive
failure. In a group of 50 patients with proven
myocardial infarction and no obvious complica-
tions, administration of digitalis in therapeutic
amounts induced no more ventricular ectopic
rhythms or instances of sudden death than oc-
curred in a similar control group, according to
Askey (J.A.M.A., 1951, 146, 1008). He recom-
mended use of digitalis in myocardial infarction
when early signs and symptoms of congestive
failure appear.

Myocarditis. — In heart failure complicating
rheumatic carditis the results are not so promi-
nent. Many pediatricians seldom prescribe digi-
talis for this condition and it is important to
realize that the drug should not be pushed in such
cases when evident therapeutic effects are not
obtained. Heart failure secondary to syphilis,
myxedema, hyperthyroidism and thiamine de-
ficiency also yield poorly to digitalis. It is evident
that these cases require more specific manage-
ment. In rheumatic myocardiits, corticotropin
(q.v.) is useful. Digitalis is also not effective in
heart failure or peripheral circulatory collapse
due to infectious or toxic causes such as diph-
theria. There is no justification for the use of
digitalis in pneumonia or in angina pectoris unless
heart failure is present; digitalis actually decreases
cardiac output under these circumstances (Stew-
art and Cohn, /. Clin. Inv., 1932, 11, 917).

Arrhythmias. — Digitalis is indicated in auricu-

452 Digitalis

Part I

lar fibrillation if tachycardia is present; a resting
ventricular (apical) rate of about 70 per minute
is the aim of therapy. Congestive heart failure,
however, is the most common cause of auricular
fibrillation and it is in these cases that digitalis
produces its most dramatic results. It is indicated
in cases of auricular flutter with heart failure and
the flutter may change to fibrillation and thence
to normal sinus rhythm. In some cases of par-
oxysmal auricular tachycardia digitalis may ter-
minate the attack, although quinidine is in more
general use for this purpose. Lewis (Med. Clin.
North America, 1945, 29, 524) reported that
digitalis is a cheaper and simpler remedy than
quinidine for the prevention of attacks of par-
oxysmal auricular tachycardia; for this purpose
it is important to distinguish between auricular
and ventricular tachycardia. Digitalis is also used
for the prevention of attacks of paroxysmal
auricular flutter or fibrillation. Heart failure asso-
ciated with all degrees of auriculoventricular
block has been successfully treated with digitalis
(Blumgart and Altschule, Am. J. Med. Sc, 1939,
198, 455). Christian (J. A.M. A., 1933, 100, 789)
included among the indications the prevention
of heart failure in individuals who have heart dis-
ease but are still compensated and Erickson and
Fahr (Am. Heart J., 1945, 29, 348) presented
evidence of the value of digitalis for such patients.
Stewart (Ann. Int. Med., 1946. 24, 80) has re-
viewed therapeutic practices in heart disease and
Hanenson et al. (Med. Clin. North America, 1953,
37, 643) have integrated the factors of activity,
digitalis, diet, diuretics and other measures in the
management of congestive heart failure.

In children, accurate dosage information has
not been available. Using digitoxin, which is
readily absorbed from the gastrointestinal tract
and thereby provides almost all of the glycoside
action produced by powdered digitalis. Nadas
et al. (New England J. Med., 1953, 248, 98)
studied 41 children with congestive heart failure.
All had right-sided and about half of them left-
sided heart failure; most of the cases had con-
genital heart disease; only 2 had rheumatic heart
disease. The initial digitalizing dose of digitoxin
administered during 24 to 36 hours for children
under 2 years of age was 20 to 30 micrograms per
pound of body weight and over 2 years of age
it was 10 to 20 micrograms per pound. The daily
maintenance dose was one-tenth of the initial
digitalizing dose. For comparison, the average
digitalizing dose of digitoxin for the adult is 10
micrograms per pound or, in terms of powdered
digitalis. 10 milligrams per pound. Instead of
ventricular extrasystoles. toxicity was more fre-
quently manifested in children with disturbances
in auriculo-ventricular conduction and auricular
arrhythmias. Using the electrocardiographic cri-
teria of Gold (see under Assay), Mathes et al.
(J.A.M.A., 1952, 150, 191) found that children
required 50 per cent more digitoxin per pound of
body weight than do adults.

In elderly patients, Raisbeck (Geriatrics, 1952,
7, 12) cited lessened resilience and adaptability,
the limited range of therapeutic effectiveness of
digitalis, and the increased chance of untoward
and toxic reactions. Because of diminished ab-

sorption from the gastrointestinal tract the glyco-
sides are preferred. In the aged a more gradual
readjustment of circulatory dynamics is advan-
tageous, very rapid digitalization rarely being
desirable.

If the indications are carefully observed, there
are few contraindications to digitalis therapy
(Lewis, loc. cit.) except toxic response to digi-
talis or idiosyncrasy, ventricular tachycardia, beri
beri heart disease and some individuals with the
hypersensitive carotid sinus syndrome. |v)

Dose. — Unfortunately, confusion and miscon-
ception continue with regard to the use of digi-
talis. Provided with a reasonable knowledge of the
pharmacological action of digitalis and of heart
disease, its use is not difficult. Consideration of
dosage includes the amount needed to obtain
therapeutic effects in a patient not previously
digitalized and the amount needed to maintain
these effects. It is important to bear in mind
individual differences in susceptibility and the
need for determining the dose in each patient,
according to the response. The patient must be
watched carefully for therapeutic and toxic effects.

Initial. — The total average dose for inducing
full therapeutic effect within 36 to 48 hours in an
adult who has not received digitalis within 10
days is about 1.5 Gm. (approximately 22 grains)
of the powdered (standardized) leaf or 15 ml.
(approximately 4 fluidrachms) of the official tinc-
ture. This total dose may be divided into 4 or
more equal parts and administered orally every
4 to 6 hours (Eggleston, J.A.M.A., 1920, 74,
733). In cases of urgency, one-half or preferably
one-third of this total dose may be given at once
and the remainder in two portions after intervals
of 4 to 6 hours. For rapid digitalization the
glycosides are preferable. As a rough guide the
total dose may be calculated on the basis of 100
mg. (approximately \Yz grains) — i.e., 1 U.S. P.
unit — of the powdered leaf for each 4.5 Kg.
(approximately 10 pounds) of the individual's
normal body weight ; weight due to edema should
not be included for this calculation. This is only
an estimate and the patient must be watched
carefully and the dose regulated according to the
effect produced. Children may require more than
this calculated dose to produce a full therapeutic
effect but this formula may be used as an esti-
mate. On the other hand, old people, particularly
those with recent myocardial infarcts and arterio-
sclerotic heart disease often do not tolerate this
full calculated dose and it is the practice of many
physicians to use only two-thirds of the calculated
dose (about 1.2 Gm., approximately 18 grains,
of powdered digitalis) as an approximation of the
dose required by such cases. Where there is no
need for urgency, the patient may be digitalized
slowly by giving 100 mg. (approximately 1^2
grains) — i.e., 1 U.S. P. unit — of powdered leaf
three times daily until therapeutic effects are evi-
dent— approximately 4 to 7 days for the average
adult.

Maintenance. — The maintenance dose varies
from patient to patient. Recent work has shown
that the patient excretes not a fixed amount of
the drug each day, but rather a certain fraction
of the amount present in the body. Hence, the

Part I

Digitalis Tablets 453

amount required varies with each case and de-
pends upon the level of digitalis action which is
desired. The level which produces optimal thera-
peutic effects may be less than the maximum
tolerated amount. For most adult patients the
maintenance dose of Powdered Digitalis is 100 mg.
(approximately \]/z grains) or 1 ml. (approxi-
mately IS minims) of the Digitalis Tincture, i.e.,
1 U.S. P. unit, once daily. For children the mainte-
nance dose is from 30 to 50 mg. (approximately
Yz to Y^ grains) daily. Some patients require
more and some less; this is determined by the
physician according to their response to treat-
ment. The U.S. P. gives the range of the mainte-
nance dose as 100 to 200 mg. daily. Unless the
cause of the heart failure is correctible, as by
thyroidectomy in cases of hyperthyroidism, the
maintenance dose of digitalis must usually be
continued throughout the remainder of the pa-
tient's life (Rogen, Brit. M. J., 1943, 1, 694).

Note. — This form of digitalis, since it has no
maximum potency requirement, is to be used only
for preparing powdered digitalis or other prep-
arations of digitalis. When digitalis is prescribed,
the pharmacist must dispense powdered digitalis
(see the following monograph).

Storage. — Preserve "in containers that pro-
tect it from absorbing moisture. Digitalis labeled
to indicate that it is to be used only in the manu-
facture of glycosides is exempt from the storage
and water requirements." U.S.P.

POWDERED DIGITALIS.
U.S.P. (B.P.) (LP.)

[Digitalis Pulverata]

"Powdered Digitalis is digitalis dried at a tem-
perature not exceeding 60°, reduced to a fine or
very fine powder, and adjusted, if necessary, to
conform to the official potency by admixture with
sufficient lactose, starch, or exhausted marc of
digitalis, or with a powdered digitalis having either
a lower or a higher potency. The potency of
Powdered Digitalis is such that, when assayed as
directed, 100 mg. shall be equivalent to 1 U.S.P.
Digitalis Unit." U.S.P.

"Note. — When Digitalis is prescribed, Powdered Digitalis
is to be dispensed." U.S.P.

The B.P. official title for this standardized
dosage form of digitalis is Prepared Digitalis; its
potency is required to be 10 Units per Gm. (the
units employed in the U.S.P., B.P., and I. P. defi-
nitions are considered to be identical). It may be
prepared by mixing a digitalis powder of higher
potency with one of lower potency, or by mixing
the former with exhausted digitalis marc, with
powdered lucerne, or with powdered grass. The
LP. describes Standardized Powdered Digitalis
Leaf in its monograph on Digitalis Leaf; it is
required to contain 10 International Units per
Gm. and may be prepared by mixing a digitalis
powder of higher potency with one of lower
potency, or by mixing the former with exhausted
digitalis marc or with rice starch.

B.P. Prepared Digitalis; Digitalis Praeparata. LP.
Standardized Powdered Digitalis Leaf; Pulvis Digitalis
Folii Standardisatus. Fr. Poudre. de digitale. Sp. Digital
Pulverizada.

Description. — "Powdered Digitalis conforms
to the description for Ground Digitalis under
Digitalis." U.S.P.

Powdered digitalis is permitted to contain not
more than 5 per cent of water by the U.S.P. and
LP., but the B.P. allows up to 8 per cent. The
U.S.P. states that the potency of powdered digi-
talis may be considered satisfactory if the result
of the assay indicates not less than 0.85 U.S.P.
Digitalis Unit and not more than 1.20 U.S.P.
Digitalis Units per 0.1 Gm.

Uses. — Powdered digitalis, in the form of cap-
sules or tablets, has been the most widely pre-
scribed form of digitalis in the United States. It
provides an effective, stable and standardized
dosage form of digitalis, being more reliable than
either the infusion or the tincture. For its uses
see under Digitalis.

The usual digitalizing dose (see discussion
under Digitalis) for an adult of about 70 Kg.
weight (approximately 150 pounds) is about 1.5
Gm. (approximately 22 grains), by mouth, di-
vided over 24 to 48 hours; the range of dose is
1 to 2 Gm., with a maximum safe single dose (or
a total in 24 hours) of 2 Gm. The usual daily dose
for maintaining digitalization is 100 mg. (approxi-
mately 1^2 grains), by mouth, with a range of
100 to 200 mg. and a maximum of 200 mg. These
doses must be adjusted to the requirements of
each patient through careful and close observation
by the physician.

Storage. — Preserve "in tight, light-resistant
containers. A suitable cartridge or device contain-
ing a non-liquefying, inert, dehydrating substance
may be used in the container to maintain low
humidity." U.S.P.

DIGITALIS CAPSULES. U.S.P.

[Capsulae Digitalis]

"Digitalis Capsules contain the labeled amount
of powdered digitalis." U.S.P.

Sp. Capsulas de Digital.

For uses and dose see under Digitalis and
Powdered Digitalis.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Usual Sizes. — 60 and 100 mg. (approximately
1 and \Yi grains).

DIGITALIS TABLETS.
U.S.P. (B.P.) (LP.)

[Tabellae Digitalis]

"Digitalis Tablets contain the labeled amount
of powdered digitalis." U.S.P. The corresponding
B.P. preparation is official as Tablets of Prepared
Digitalis, the activity in each tablet of average
weight being required to be not less than 95.0 per
cent and not more than 105.0 per cent of the pre-
scribed or stated amount of prepared digitalis.
The LP. Tablets of Digitalis are required to have
an average potency of not less than 85.0 per cent
and not more than 120.0 per cent of the pre-
scribed or stated number of International Units
of activity.

B.P. Tablets of Prepared Digitalis; Tabellae Digitalis
Praeparatae. LP. Tablets of Digitalis; Compressi Digitalis.

454 Digitalis Tablets

Part I

For uses and dose see under Digitalis and
Powdered Digitalis.

Storage. — Preserve "in tight containers."
U.S.P.

Usual Sizes. — 60 and 100 mg. (approximately
1 and \Yz grains).

DIGITALIS INJECTION. N.F.

[Injectio Digitalis]

"Digitalis Injection is a sterile solution in water
for injection of a mixture of glycosides or thera-
peutically desirable and cardioactive constituents
of digitalis. Its potency is to be indicated on the
label in terms of U.S. P. Digitalis Units.

"Digitalis Injection may contain not more than
10 per cent of alcohol as a preservative.

"Caution. — For the purposes of standardization,
Digitalis Injection is assayed by the U.S. P. bio-
logical method and its potency is expressed in
terms of U.S. P. Digitalis Units. Preparations of
this type are intended for parenteral administra-
tion and when injected may show an effect much
greater than that of an equivalent number of
U.S. P. Digitalis Units when administered orally
in the form of digitalis leaf or digitalis leaf prepa-
rations. The dosage, therefore, should be that
recommended in the labeling." N.F.

Uses. — This injection has enjoyed wide popu-
larity as a therapeutically useful dosage form of
digitalis but the apparently unavoidable uncer-
tainty concerning the composition, potency and
action of the several available digitalis injections
has lessened their use. The general availability of
injections of the individual glycosides or certain
definite mixtures of glycosides of digitalis has
further contributed to the decline in the use of
digitalis injection.

Fatalities have resulted from the confusion re-
garding the potency of different products of the
type of digitalis injection. It was hardly practical
for the clinician to be familiar with all of the
available preparations in this class, especially
since identical therapeutic response could not be
assumed for preparations having identical potency
in U.S. P. Digitalis Units based on the official
assay (see caution statement in the official defini-
tion above). There is enough difference in the
action of the individual glycosides of digitalis,
particularly with respect to cumulative tendency,
that it is in general unwise for the physician to
shift from the use of one digitalis injection to
another solely on the basis of a consideration of
their relative potencies as determined by bioassay.

In 1953 New and Nonoficial Remedies discon-
tinued description and acceptance of proprietary
digitalis injections. In 1952 two such injections
were described in X.X.R. : Solution Digalen In-
jectable (Hoffmann-LaRoche), representing 1
U.S. P. Digitalis Unit in 2 ml., and Solution Digi-
jolin (Ciba), also representing 1 U.S. P. Digitalis
Unit in 2 ml. These and other products are cur-
rently available.

Oral administration of digitalis meets the re-
quirements of the vast majority of patients and
indiscriminate use of digitalis preparations paren-
terally is to be discouraged. Indications and
dosage schedule of digitalis injection are in
general similar to those of orally administered

digitalis (see under Digitalis) but it must be
remembered that when given parenterally the
dose is significantly less than is required by
mouth because of less complete and slower ab-
sorption of active principles from the intestinal
tract. For the reasons indicated the dose of a
particular digitalis injection should be that recom-
mended on the label.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." N.F.

Usual Sizes. — 1 U.S. P. Unit in 1 ml. or in
2 ml.

DIGITALIS TINCTURE.
N.F. (B.P., LP.)

[Tinctura Digitalis]

"The potency of Digitalis Tincture shall be
such that, when assayed as directed, 1 ml. of the
Tincture shall be equivalent to 1 U.S. P. Digi-
talis Unit." N.F. The B.P. requires 1 Unit of
activity in 1 ml., while the LP. requires 1
International Unit in 1 ml. or in 1 Gm., the coun-
try concerned deciding which of these concen-
trations will be adopted in that country'.

B.P., I. P. Tincture of Digitalis. Tincture of Foxglove.
Fr. Teinture de digitale. Ger. Fingerhuttinktur. It.
Tintura di digitale. Sp. Tintura de digital.

Prepare a tincture from 100 Gm. of digitalis,
in fine powder, by Process P, as modified for
assayed tinctures, using as a menstruum a mix-
ture of 4 volumes of alcohol and 1 volume of
water to make about 1000 ml. conforming to the
specified potency. N.F.

The B.P. Tincture of Digitalis is prepared by
percolating either unstandardized leaf or pow-
dered leaf with 70 per cent alcohol; in the for-
mer instance the tincture is assayed biologically,
in the latter no assay is required. An alternative
process is macerating powdered (standardized)
digitalis during two days, straining the mixture
with light expression of the marc, and clarifying
the product by subsidence or filtration; an assay
is not required.

The LP. tincture is prepared by percolating
digitalis leaf with 70 per cent alcohol; the per-
colate is assayed and diluted to produce a tinc-
ture of the required degree of activity.

Assay. — The tincture is assayed biologically,
by the method summarized and explained under
Digitalis. The potency of the tincture is satis-
factory if the result of the assay is not less
than 0.85 U.S. P. Digitalis Unit and not more
than 1.20 U.S.P. Digitalis Units. N.F.

Alcohol Content. — From 70 to 75 per cent,
by volume, of C2H5OH. N.F.

Deterioration. — It is commonly stated that
digitalis tincture is more likely to deteriorate
than is the properly preserved leaf. The rapidity
with which various samples of tincture lose their
potency, assuming that lack of precision of assays
is not in large measure responsible for some of
the apparent differences, is subject to inexplicable
variation. Of two tinctures made by the same
method and preserved under identical condi-
tions, one may show an apparent loss of 20
per cent of its potency within six months while
the other shows no loss at all. Neither hydrogen-
ion concentration, nor proportion of alcohol, nor

Part I

Digitoxin 455

temperature at which the tincture is stored,
appears to be, within reasonable limits, the sig-
nificant variable (see Emig, /. A. Ph. A., 1932,
21, 1273; Rowe and Scoville, ibid., 1933, 22,
1087). Apparent deterioration when the tincture
is tested on one animal species but not on an-
other (frog and cat) has been reported (Gold
and Cattell, Science, 1941, 93, 197). The obser-
vations of Macht and Krantz {Proc. S. Exp. Biol.
Med., 1926, 23, 240) suggest that ultraviolet
rays may have some connection with loss of
potency. In this connection Feinblatt and Fergu-
son {New Eng. J. Med., 1952, 246, 905) re-
ported that a stabilized digitalis tincture may be
prepared by removing the green color, which
they claim hastens deterioration through absorp-
tion of actinic rays, by adsorption on charcoal,
then dissolving in the decolorized tincture 0.1
per cent of either of the red dyes phenylsafra-
nine or amaranth. Their experiments indicate
that the decolorized solution is more stable than
the naturally colored tincture and that tinctures
which are first decolorized and then colored red
are even more stable; they reported the red tinc-
ture to have at least twice the shelf-life of the
regular tincture.

Uses. — Digitalis tincture probably represents
the activity of digitalis leaf as well as does any
liquid preparation. For its uses see under Digi-
talis.

For general discussion of dose see also under
Digitalis. The average maintenance dose of the
tincture, for adults, is 1 ml. (approximately 15
minims), but this must be adjusted to the re-
quirements of the individual patient and may
vary from 0.3 to 2 ml. (approximately 5 to 30
minims) daily. Each ml. of tincture is equivalent,
in action, to 100 mg. of powdered digitalis, i.e.,
it represents 1 U.S. P. Digitalis Unit.

It is important to remember that, as with
most other tinctures, one minim is equivalent
to about two drops of the tincture released from
a dropper having the usual orifice; since the
orifice may vary a standard dropper or other
volume-measuring device is essential for accurate
measurement of a dose of the tincture by the
patient.

Digital (Sharp & Dohme) is a fat-free digitalis
tincture corresponding in drug strength to the
official tincture; it produces a relatively clear
mixture with water, [v]

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." N.F.

DIGITOXIN. U.S.P. (LP.)

[Digitoxinum]

C,8H3,09

"Digitoxin is a cardiotonic glycoside obtained
from Digitalis purpurea Linne and Digitalis lanata
Ehrh. It contains not less than 90 per cent of
C41H64O13, calculated on the dried basis." U.S.P.
The LP. name for this substance is Digitoxoside,
being defined as one of the heterosides of the leaf
of Digitalis purpurea L. No assay rubric is pro-
vided.

I. P. Digitoxoside; Digitoxosidum. Cardigin {National
Drug); Crystodigin (.Lilly); Digisidin (Winthrop); Digi-
taline Nativelle (Varick); Purodigin (Wyeth). Sp. Digi-
toxina.

In 1869 Nativelle announced the isolation of
a fairly pure crystalline glycoside which came
to be known as digitaline cristalisee {Nativelle),
but which should not be confused with other digi-
talins. Nativelle's substance is believed to have
been largely digitoxin.

Depending on the process of extraction and
the degree of purification, commercial digitoxin
contains more or less gitoxin and possibly small
amounts of other digitalis glycosides. The amount
of gitoxin present in various samples has been
estimated at from 5 to 30 per cent.

As has been pointed out under digitalis {q.v.)
digitoxin is not a native glycoside; its precursor
in the plant is purpurea glycoside A which, by
enzymatic hydrolysis during the extraction proc-
ess, splits off a molecule of glucose and leaves
digitoxin. The latter, however, still contains sugar
and on further hydrolysis splits off three mole-
cules of the alpha-deoxymonosaccharide digitox-
ose, C.6H12O4, and leaves as the aglycone digitoxi-
genin. The aglycone is a cyclopentanoperhydro-
phenanthrene derivative (see Sterids, Part II)
characterized by the presence of methyl groups
at carbon atoms 10 and 13, of hydroxyl groups
at 3 and 14, and an unsaturated four-carbon atom
lactone ring at position 17 (see Cardiac Agly-
cones, under Sterids).

Description. — "Digitoxin is a white or pale
buff, odorless, microcrystalline powder. Digitoxin
is insoluble in water and very slightly soluble in
ether. One Gm. dissolves in about 40 ml. of
chloroform and in about 60 ml. of alcohol."
U.S.P.

Standards and Tests. — Identification. — (1)
A portion of the eluate obtained in the assay is
evaporated. The residue of digitoxin when dis-
solved in 2 ml. of glacial acetic acid containing
0.5 per cent of ferric chloride T.S. produces, when
superimposed on 2 ml. of sulfuric acid, a brown
color at the zone of contact of the two liquids;
on standing, the brown color changes to light
green, then to blue, and finally the entire acetic
acid layer acquires a blue color. (2) Another por-
tion of the eluate is evaporated. The residue of
digitoxin, when treated with ,m-dinitrobenzene
and tetramethylammonium hydroxide solutions,
produces a red-violet color which fades. Loss on
drying. — Not over 1 per cent when dried in vac-
uum at 100° for 2 hours. Residue on ignition. —
The residue from 100 mg. is negligible. Complete-
ness of solution in chloroform. — 100 mg. of digi-
toxin dissolves completely in 5 ml. of chloroform
within 24 hours. Digitonin. — No precipitate forms
within 10 minutes following addition of 2 ml. of
a 1 in 200 solution of cholesterol in alcohol to a

456 Digitoxin

Part I

solution of 10 mg. of digitoxin in 2 ml. of alcohol
contained in a test tube the inner walls of which
are free from scratches. U.S.P.

Assay. — An alcohol solution representing 2
mg. of the digitoxin to be tested is adsorbed on
purified siliceous earth which, after evaporation
of the alcohol, is transferred to a chromatographic
tube containing purified siliceous earth moistened
with a solution of formamide and water as the
immobile phase. Subsequently the digitoxin com-
ponent of the sample is removed from the column
by elution with a mixture of benzene and chloro-
form; certain impurities, notably gitoxin, are not
eluted and remain in the chromatographic column.
After evaporating the solvent from a portion of
the eluate, the residue is dissolved in alcohol and
an alkaline picrate solution is added which pro-
duces with digitoxin an orange color; the inten-
sity of the color is measured at 495 mn and quan-
titatively evaluated by comparison with the color
produced when the same reagent is added to an
alcohol solution oi U.S. P. Digitoxin Reference
Standard. The chromatographic procedure is a
modification of the method reported by Banes and
Carol (/. A. Ph. A., 1953, 42, 674); the color
reaction with alkaline picrate is one proposed
originally by Baljet and quantitatively developed
by Bell and Krantz (/. Pharmacol, 1946, 87,
198). This reaction depends on the presence of
the butenolide ring attached at carbon number 17
of the steroid structure. U.S.P.

A reaction sometimes employed for estimation
of digitoxin is that of Keller and Kiliani. in which
a greenish blue color (dependent on the presence
of the digitoxose moiety of digitalis glycosides)
is produced when a reagent containing sulfuric
acid, acetic acid, and ferric chloride is added to
the glycoside; the quantitative aspects of this re-
action were developed by James et al. (J. A.
Ph. A., 1947, 36, 1).

Anderson and Chen (/. A. Ph. A., 1946, 35,
353) developed the Raymond reaction of m-
dinitrobenzene with digitoxin. in which a blue
color (from the presence of the butenolide ring)
is produced, as the basis for a colorimetric assay
of digitoxin. A colorimetric procedure using so-
dium beta-naphthoquinone-4-sulfonate. which in
alkaline solution forms a purple color with digi-
toxin. has been used to assay preparations of the
glycoside by Warren et al. (ibid., 1948, 37, 186).

Uses. — Digitoxin possesses the action and
uses of digitalis (see under Digitalis) with the
advantages of complete and more rapid absorp-
tion from the gastrointestinal tract, almost com-
plete lack of gastric irritation, the uniformity of
potency characteristic of a pure or almost pure
crystalline substance and a dosage based on
weight rather than a biological assay (Gold et al.,
J. Pharmacol., 1944. 32, 187).

Absorption. — The complete and rapid absorp-
tion of digitoxin from the gastrointestinal tract
and lack of irritation enable the physician to
produce full digitalis effect in 6 to 8 hours after
its ingestion, in contrast to the 24 to 48 hours
required with digitalis powder or tincture. In
fact the full effect on the heart appears as
rapidly after oral as after intravenous adminis-
tration without the dangers inherent in large

intravenous doses of the digitalis glycosides. The
infrequency of gastric irritation makes it possible
to give the full digitalizing dose (about 1.2 mg.)
at one time orally and produce the benefits to
be derived from digitalization within 6 to 8 hours
(Gold et al., J. A.M. A., 1942, 119, 928; con-
firmed by Katz and Wise, Am. Heart J., 1945, 30,
125). This is in sharp contrast to the incomplete
and variable absorption of other digitalis glyco-
side preparations at present available and the
local irritation which prevents the administration
of the full amount of digitalis powder or tincture
required in a single dose.

Clinical Potency. — Assay of digitoxin on
humans by the electrocardiographic or the ven-
tricular-slowing-in-auricular-fibrillation methods
showed it to be about 1000 times as potent per
unit weight as powdered digitalis, i.e., 1.25 mg.
of digitoxin possessed activity equivalent to 1.25
Gm. of powdered digitalis (Gold et al., loc. cit.,
1944). When assayed on cats 1.25 mg. of digi-
toxin, however, possessed only about 3 U.S.P.
units instead of the 12.5 units represented in the
1.25 Gm. of powdered digitalis (Gold. Connec-
ticut M. J., 1945. 9, 193). This may' illustrate
marked difference in the absorption and utiliza-
tion of these two preparations. Anderson and
Chen (/. A. Ph. A., 1946. 35, 353), however,
reported for 21 samples of digitoxin potencies,
determined by the U.S.P. XII cat method, rang-
ing from 1.86 to 2.37 units per mg.

Single Dose Digitalization. — A single, oral
dose of 1.2 mg. of digitoxin caused nausea within
the first two hours in only 1 per cent of 512
patients and after six hours or more in only 1.8
per cent. A single dose of 2 mg. caused mild
toxicity in almost one-third of 98 patients. The
1.2 mg. dose produced therapeutic results in the
majority of cases; a few, as with other digitalis
preparations, required a larger dose to produce
full digitalization. The cumulation and elimina-
tion of digitoxin is similar to that of digitalis
powder; in fact, it seems that the major action
of digitalis powder is due to its digitoxin content.
Digitoxin appears to be one of the best available
digitalis preparations for most therapeutic pur-
poses (Cattell et al., Cornell Conference on
Therapy, N. Y. State J. Med., 1945, 45, 1676).

Excretion. — The availability of radioactive,
carbon- 14-labeled digitoxin (Geiling et al., Trans.
A. Am. Phys., 1950, 63, 191) has provided a
means of studying in greater detail the tissue
distribution and excretion of this glycoside.
Sjoerdsma and Fischer (Circulation, 1951, 4,
100) washed isolated mammalian hearts of four
species with a Locke-Ringer solution containing
radioactive digitoxin and learned that the most
rapid uptake occurs early and that a considerable
proportion of the digitoxin fixed in heart muscle
is changed to other substances of unknown com-
position. Digitoxin itself is less firmly bound to
the heart muscle than are its metabolites. Findings
of Fischer et al. (ibid., 1952, 5, 496) support
the theory that unchanged digitoxin is responsible
for the cardiotonic effect, and suggest that there
may be an increased metabolism and utilization
in animals with congestive failure. Okita et al.
(ibid., 1953, 7, 161) discovered that after a

Part I

Digoxin 457

single intravenous injection of radioactive digi-
toxin there is very rapid elimination during the
first 24 hours, 60 to 80 per cent of the dose being
excreted through the kidneys; the larger the
amount given, the longer it is retained. In har-
mony with its prolonged clinical action, digitoxin
as such can be detected in the urine for 23 to 50
days after a single dose, the metabolites for
31 to 85 days. Other studies have indicated that
labeled digitoxin can be detected in blood 24
hours after a single dose (Editorial, New Eng.
J. Med., 1952, 247, 74). For other studies see
Okita et al. (J. Pharmacol, 1955, 113, 376). IYJ

Toxicology. — In a critical review of the ad-
vantages and disadvantages of therapy with
digitoxin Diefenbach and Meneely (Yale J. Biol.
Med., 1949, 21, 421) noted that various prepara-
tions of digitoxin apparently differ in potency
and composition within the U.S. P. (XIV) defi-
nition of the drug, and advised clinicians to
become familiar with a single commercial prepa-
ration of the drug and to use it consistently. In
100 patients they found toxic symptoms in 20
per cent; because of slow excretion the toxicity,
when it occurs, is likely to be prolonged. Levin
(Ann. Int. Med., 1948, 29, 822) pointed out that
toxic rhythms are more likely to occur insidi-
ously with digitoxin than with whole digitalis
leaf, as there are few warning signs. A clue to im-
minent toxicity is a rising ventricular rate or
sudden regularization of a totally irregular
rhythm. Gelfand (J.A.M.A., 1951, 147, 1231)
described the occurrence of such visual symptoms
of toxicity as white and yellow vision, scotomata,
flickering lights, snow-covered objects, etc., in
the absence of any other toxic symptoms or signs.
Berger (ibid., 1952, 148, 282) reported a case
of thrombopenic purpura caused by digitoxin.

Whereas earlier U.S. P. definitions for digitoxin
recognized "either pure digitoxin or a mixture of
cardioactive glycosides," the U.S. P. XV standards
restrict the composition of the substance to pro-
vide at least 90 per cent of pure digitoxin. This
should serve to eliminate the variable of uncer-
tainty of action of different lots of digitoxin and,
probably, to lessen the incidence of toxic effects.

While digitoxin injection is available for in-
travenous use of the drug, this route is indicated
only when vomiting or other conditions prevent
oral administration; digitoxin does not act any
more rapidly intravenously than orally and in-
travenous use of digitalis glycosides is always at-
tended by danger. A new solvent for digitoxin
for intramuscular injection, containing polyethyl-
ene glycol 300, benzyl alcohol, ethyl alcohol, water
and glycerin, is stated to produce no undesirable
systemic, and only minimal local, effects (Strauss
et al, Am. Heart J., 1952, 44, 787).

Dose. — The usual digitalizing dose in the
average-sized adult, who has not received digitalis
or related glycosides within the preceding two
weeks, is 1.5 mg. (approximately Yio grain) by
mouth, divided over a period of 24 to 48 hours,
with a range of dose of 1 to 2 mg. The maximum
safe single dose is 1.5 mg., and 2 mg. is seldom
if ever exceeded in 24 hours. The average main-
tenance dose by mouth is 0.1 mg. (approximately

Vwo grain) daily, with a range of 0.1 to 0.2 mg.
and a maximum safe daily dose of 0.2 mg.

Intravenously it is usually both unwise and
unnecessary to give more than 0.5 mg. (approxi-
mately V\2Q grain) at one time, although in
urgent situations this dose may be repeated once
or sometimes twice at intervals of 15 minutes;
injections should be made very slowly. A total
initial dose of 1.2 mg. in 24 hours should seldom
be exceeded. The maintenance dose is 0.1 mg.,
with a range of 0.1 to 0.2 mg., intravenously or,
in a special vehicle (see above), intramuscularly
daily.

In children, the initial digitalizing dose for
those under 2 years of age is 20 to 30 micro-
grams per pound of body weight, divided into
2 or 3 portions over a 24- or 36-hour period, and
administered by mouth; for those between 2 and
12 years it is 10 to 20 micrograms per pound
of body weight, administered similarly. The oral
maintenance dose is one-tenth of the initial digi-
talizing dose daily. Doses by the intravenous or
intramuscular route are the same as by mouth,
but are to be administered with caution.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

DIGITOXIN INJECTION. U.S.P.

[Injectio Digitoxini]

"Digitoxin Injection is a sterile solution of
digitoxin in 5 to 50 per cent alcohol, and may
contain glycerin or other suitable harmless solu-
bilizing agents. It contains not less than 90 per
cent and not more than 110 per cent of the
labeled amount of C41H64O13." U.S.P.

Sp. Inyeccion de Digitoxina.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass, protected from light."
U.S.P.

Usual Sizes. — 0.2 mg. in 1 ml.; 0.4 mg. in
2 ml.

DIGITOXIN TABLETS. U.S.P.

"Digitoxin Tablets contain not less than 90 per
cent and not more than 110 per cent of the
labeled amount of C41H64O13. Note: Avoid the
use of strongly adsorbing substances, such as
bentonite, in the manufacture of Digitoxin Tab-
lets." U.S.P.

Usual Sizes. — 0.1, 0.15, and 0.2 mg.

DIGOXIN. U.S.P., B.P., LP.

[Digoxinum]

"Digoxin is a cardiotonic glycoside obtained

458 Digoxin

Part I

from the leaves of Digitalis lanata Ehrh. (Fam.
Scrophulariacea). U.S.?. The B.P. and I.P. defi-
nitions are practically the same as this. "Cau-
tion.— Digoxin is extremely poisonous." U.S.P.

Sp. Digoxina.

Digitalis lanata Ehrh. is a perennial or bien-
nial herb native to Europe; it is characterized by
having light grayish-green, nearly glabrous, decur-
rent, sessile, olanceolate to lanceolate leaves with
an entire or slightly toothed margin and small
creamy yellow or purple flowers.

From D. lanata leaves, which produce the
characteristic physiological effects of the digi-
talis group and are said to be considerably
stronger, Stoll and co-workers (Helv. Chim.
Acta, 1933, 16, 1049) isolated three natural
glycosides known formerly as digilanid A, digi-
lanid B, and digilanid C, but now referred to as
lanatoside A, lanatoside B, and lantoside C (a
mixture of these is known as Digilanid) . Chemical
investigation has revealed that the first of these
is an acetyl derivative of purpurea glycoside A
(see Constituents under Digitalis), the second
an acetyl derivative of purpurea glycoside B,
but that the third has no counterpart in D. pur-
purea. Enzymatic hydrolysis splits off glucose and
mild alkaline hydrolysis removes the acetyl group
from each of the lanatosides, leaving digitoxin,
gitoxin and digoxin as the residues from lanato-
sides A, B, and C, respectively. It will be recalled
that enzymatic hydrolysis of purpurea glycosides
A and B yields digitoxin and gitoxin, respectively,
a result to be expected from the known relation-
ship of the purpurea glycosides as deacetyl
derivatives of the corresponding lanatosides. Acid
hydrolysis of digitoxin, gitoxin and digoxin splits
off three molecules of digitoxose in each case,
forming digitoxigenin, gitoxigenin, and digoxi-
genin, respectively, as aglycones.

Description. — "Digoxin occurs as colorless
to white crystals or as a white, crystalline pow-
der. It is odorless. It melts indistinctly, and
with decomposition, above 235°. Digoxin is in-
soluble in water, in chloroform, and in ether. It
is freely soluble in pyridine and soluble in dilute
alcohol." U.S.P.

Standards and Tests. — Specific rotation. —
The specific rotation, determined in an anhydrous
pyridine solution containing 1 Gm. of digoxin in
10 ml. of solution, using the mercury 546.1 mu.
fine, is between +13.6° and +14.2°. Identification.
— (1) A solution of 1 mg. of digoxin in 2 ml. of
glacial acetic acid containing 0.5 per cent of
ferric chloride T.S. produces, when superimposed
on 1 ml. of sulfuric acid, a brown ring, free
from red, at the zone of contact; after some time
the acetic acid layer acquires a blue color. (2)
When a solution of digoxin is chromatographed
a grayish green spot is produced, after develop-
ment with trichloroacetic acid, on paper at a
level corresponding to approximately Rf 0.75. Loss
on drying. — Not over 0.5 per cent, when dried
at 105° in vacuum for 1 hour. Residue on igni-
tion.— The residue from 100 mg. is negligible.
U.S.P.

Uses. — Digoxin possesses the actions and uses
of digitalis (see under Digitalis). White (/.

Pharmacol., 1934, 52, 1) found that it produced
the characteristic effects of digitalis; he also
reported that it was better absorbed than digi-
talis tincture. Chen and Anderson (/. A. Ph. A.,
1936, 25, 579; found that when assayed by the
cat method digoxin was practically of the same
potency as digitoxin but that by the frog method
it was about three times as strong. Kwit and
Gold (/. Pharmacol., 1940, 70, 254), in a com-
parative study of digoxin on both animals and
men, reached the conclusion that digoxin assayed
by the frog method was about 440 times as
powerful as a selected digitalis leaf, about 290
times by the cat method, but only 170 times by
oral administration in man. Rothlin (Munch,
med. Wchnschr., 1933, 80, 726) reported that
digoxin is the most cumulative of the glycosides
of D. lanata. (See also under Lanatoside C, and
Digilanid, which latter is a mixture of the three
lanatosides.)

Ventricular Rate. — In a study on the effect
of digoxin on heart rate and cardiac output Kelly
and Bayliss (Lancet, 1949, 257, 1071) ascer-
tained that when digoxin is given in the presence
of heart failure the rise in cardiac output is as
pronounced in patients with sinus rhythm as in
those with auricular fibrillation, that there is no
relation between cardiac slowing and increase in
output, and that relief of venous congestion is
also independent of the degree of slowing. After
its use improved cardiac output is equally prob-
able, regardless of ventricular rate. They con-
cluded that presence or absence of slowing of the
heart rate plays no measurable role in producing
the immediate hemodynamic improvements fol-
lowing digitalization with this drug. Harvey et al.
(Circulation, 1951, 4, 366) demonstrated that
digoxin administered intravenously in full thera-
peutic dosage to patients with enlarged hearts, but
without failure, results in either no change or a
decrease in cardiac output, no change in right
heart pressure, and inconsequential changes in
systemic arterial pressure.

Diuresis. — Farber et al. (Circulation, 1951,
4, 378) noted that intravenous administration
of 1.5 mg. digoxin in 20 to 30 ml. of a 5 per cent
aqueous solution of dextrose during a 10-minute
period caused prompt sodium and water diuresis
in 10 patients with congestive heart failure. Their
observation that following administration of di-
goxin there was an increase in sodium and water
excretion and urine flow in 7 patients with edema
due to nephrosis and hepatic cirrhosis, and in
21 persons without edema, suggested that the
drug may have a direct action on renal tubules.

Absorption and Duration of Action. — Di-
goxin has the advantages, over preparations of
the crude drug, of purity, stability, constant po-
tency, and rapid action. According to Gold et al.
(J. Pharmacol., 1953, 104, 45) it stands high
among the digitalis glycosides with respect to
speed and extent of absorption from the gastro-
intestinal tract, but not quite so high as digi-
toxin with respect to absorption. The ratio of
oral to intravenous dosage for a particular effect
is 1.5 to 1; for digitoxin it is nearly 1:1. Being
more rapidly excreted than digitoxin, it has less
persistent action and the daily maintenance dose

Part I

Digoxin Injection 459

approximates 50 per cent of the digitalizing dose,
as against 15 per cent for digi toxin. While a sin-
gle dose of 1.2 mg. of digoxin produces the same
therapeutic effect as the same amount of digi-
toxin, nausea and vomiting occur in 1 out of 3
persons, as compared with 1 in 50 for digitoxin.
Gold (loc. cit.) found evidence that digoxin pro-
duces vomiting by local gastrointestinal action as
well as by systemic effect (see also Gold et al.,
Am. J. Med., 1952, 13, 124). Following oral
administration, some effect on the heart is
noticeable within one hour and is complete within
6 hours. When given intravenously in auricular
fibrillation there is a prompt effect, the full
effect being obtained in 2 hours. It is claimed
that digoxin is largely eliminated within 48 hours,
no traces remaining after 3 days, thus providing
a large margin of safety. Gold indicates that the
return to control levels does not occur for 7 days.

Toxicology. — Hoffman and Pomerance (Am.
Pract., 1952, 3, 433) found improvement in
some patients in whom administration of digoxin
replaced digitalis leaf or digitoxin, and that there
was a definite decrease in toxic reactions in
comparison with other digitalis preparations. In
their experience digoxin is easier to use because
of its wider dosage range, more rapid dissipation
and lower toxicity. Reasons for the thousands
of cases of digitalis intoxication since the advent
of purified glycosides have been enumerated by
Buff (South. M. J., 1949, 42, 1037), among them
being the tendency to use a single standard dose
for all persons, the insidious onset of toxicity
with minimal irritative symptoms, and the well-
known cumulative effect of the longer-acting
glycosides. In treatment of toxicity he recom-
mends administration of 5 to 10 Gm. of potas-
sium chloride in milk, by intubation if necessary,
with subsequent maintenance doses of 1 Gm.
three times daily; one week after recovery from
poisoning digoxin should be substituted for the
other digitalis preparation, using the smallest
dose of the former than will maintain digitali-
zation. Digoxin has been found to be more effec-
tive and safer than the older and cruder injectable
preparations of digitalis (Herrmann, Ann. Int.
Med., 1939, 13, 122; Fahr, J. A.M. A., 1938, 111,
2268; McMichael and Sharpey-Schafer, Quart.
J. Med., 1944, 13, 123).

Dose. — The usual digitalizing dose of digoxin
by mouth is 1.5 mg. (approximately Ho grain),
followed by 0.25 to 0.75 mg. every 6 hours until
the therapeutic effect is obtained, which is usually
produced with a total dose of 3 mg. in 24 hours
but may require 4 mg. in some cases. The range
of initial dose is 0.5 to 2 mg., and the maximum
safe dose in 24 hours is 4 mg. The usual digitaliz-
ing dose intravenously is initially 1 mg. (approxi-
mately Veo grain), followed by 0.25 to 0.5 mg.
(approximately V250 to M20 grain) every 6 hours
until therapeutic effect is obtained; this is often
produced with a total of 1.5 mg. in 24 hours
but as much as 4 mg. may be required. The range
of intravenous dose initially is 0.5 to 1.5 mg.;
the maximum safe dose in 24 hours should not
exceed 4 mg.

The usual maintenance dose by mouth is 0.5
mg. (approximately M20 grain), with a range of

0.25 to 0.75 mg. ; the maximum safe dose is
0.75 mg. Intravenously the usual maintenance
dose is 0.5 mg., with a range of 0.25 to 0.75 mg.,
and a maximum safe dose in 24 hours of 0.75 mg.

For intravenous use the injection should be
diluted with 10 ml. of sterile, isotonic sodium
chloride solution for injection and be adminis-
tered over a period of 5 to 10 minutes, with care
to avoid extravasation of the solution around
the vein. It should be remembered that digoxin
is more active when it is given intravenously
than when administered orally (v.s.).

Besides the official injection and tablets of
digoxin there is available an oral solution (Bur-
roughs, Wellcome) containing 0.5 mg. of digoxin
per ml.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DIGOXIN INJECTION.
U.S.P. (B.P., LP.)

"Digoxin Injection is a sterile solution of
digoxin in 10 per cent of alcohol, and may contain
other suitable solubilizing agents. It contains not
less than 90 per cent and not more than 110 per
cent of the labeled amount of digoxin." U.S.P.

As Injection of Digoxin both the B.P. and LP.
recognize a preparation made by diluting 1 ml. of
0.05 per cent w/v sterile solution of digoxin in
70 per cent alcohol with 9 ml. of injection of
sodium chloride, immediately before use; the alco-
holic solution is required to contain not less than
0.045 per cent and not more than 0.055 per cent
w/v of digoxin.

B.P., LP., Injection of Digoxin; Injectio Digoxini.

The currently official digoxin injection is pre-
pared in a different vehicle from that employed
in the U.S.P. XIV injection, which was made with
a vehicle of 70 per cent alcohol, and diluted im-
mediately before administration, as in the case of
the B.P. and LP. injection described above; the
high proportion of alcohol was required to main-
tain the stability of digoxin. More recent experi-
ments by the manufacturer of this injection (Bur-
roughs Wellcome) indicate that a stable prepara-
tion is obtained by using a vehicle containing 10
per cent of alcohol and 40 per cent of propylene
glycol; it is claimed that this solution may be
injected without dilution.

Assay. — Injection equivalent to 0.2 mg. of
digoxin is treated with w-dinitrobenzene, in the
presence of sodium hydroxide, which reacts with
the butenolide ring of digoxin to produce a blue
color, the intensity of which is measured at 620
mix and quantitatively evaluated by comparison
with the color produced with 0.2 mg. of U.S.P.
Digoxin Reference Standard similarly treated.
U.S.P. This assay has been criticized by Banes
(/. A. Ph. A., 1954, 43, 355) as being unreliable
because of the difficulty of obtaining reproducible
absorbance measurements and because of inter-
ference by gitoxin, which is a concomitant glyco-
side; when the same test is performed in the
presence of the weaker alkali tetramethylammo-
nium hydroxide the color arising from digoxin is
more stable, and gitoxin interferes to a negligible

460 Digoxin Injection

Part I

extent. The B.P. and LP. determine digoxin by a
colorimetric procedure involving interaction with
sulfuric and acetic acids in the presence of ferric
chloride; a disadvantage of this assay is that other
digitalis glycosides interfere (see Assay under
Digi toxin).

For uses and dose of the injection see under
Digoxin.

Storage. — Preserve "in single-dose containers,
preferablv of Type I glass, protected from light."
U.S.P.

Usual Size. — 0.5 mg. in 2 ml.

DIGOXIN TABLETS.

(B.P.), (LP.)

U.S.P.

"Digoxin Tablets contain not less than 90 per
cent and not more than 110 per cent of the labeled
amount of C41H.64O14." U.S.P. The B.P. and LP.
rubrics are identical with that of the U.S.P.

B.P. Tablets of Digoxin; Tabellae Digoxini. LP. Tab-
lets of Digoxin; Compressi Digoxini.

Usual Size. — 0.25 mg.

DIHYDROCODEINONE
BITARTRATE. N.F. (LP.)

Dihydrocodeinonium Bitartrate

coo-

(CH0H)2. z\ H20
COOH

"Dihydrocodeinone Bitartrate contains not less
than 98 per cent of Ci8H2iN03.C4H606.2^H20."
N.F. The LP. requires not less than 58.7 per cent
and not more than 60.7 per cent of C18H21O3N,
and indicates that the salt contains a variable
amount of water of crystallization.

LP. Hydrocodone Bitartrate ; Hydrocodoni Bitartras.
Dicodid Bitartrate (Bilhiiber-Knoll) . Hycodan Bitartrate
(Endo).

This synthetic alkaloid bears the same chemical
relation to codeine that dihydromorphinone does
to morphine. Dihydrocodeinone is a rearrange-
ment product of codeine; the former differs from
codeine in containing a ketone group in place of
a hydroxyl and in one double bond being hydro-
genated. thus leading to the same empirical for-
mula for both compounds. Dihydrocodeinone may
be prepared by catalytic rearrangement of codeine
or bv hydrolvsis of dihydrothebaine (see /. A.
Ph. A., 1951, 40, 580).

Description. — "Dihydrocodeinone Bitartrate
occurs as fine white crystals or as a fine white
crystalline powder. It is affected by light. One
Gm. of Dihydrocodeinone Bitartrate dissolves in
16 ml. of water. It is slightly soluble in alcohol
and insoluble in ether and in chloroform." N.F.

Standards and Tests. — Identification. — (1)
Dihydrocodeinone base separated from the salt
melts between 194° and 198°. (2) Dihydro-

codeinone oxime prepared from the salt melts
between 261° and 265°, with decomposition. (3)
No color develops on adding ferric chloride T.S.
to a solution of dihydrocodeinone bitartrate in
sulfuric acid (codeine yields a purple color).
(4) Addition of a sulfuric acid solution of sele-
nious acid to a water solution of dihydrocodeinone
bitartrate produces a green color which changes
to blue and then slowly to purple (morphine pro-
duces a blue color which changes to green and
then to brown). (5) The salt responds to tests
for tartrate. Chloride. — Silver nitrate T.S. pro-
duces no opalescence immediately when added to
a solution of dihydrocodeinone bitartrate acidified
with nitric acid. Residue on ignition. — The limit
is 0.1 per cent. N.F. The LP. limits loss on drying
to constant weight at 100° to between 7.5 per cent
and 12.0 per cent.

Assay. — About 150 mg. of dihydrocodeinone
bitartrate is dissolved in water, the alkaloidal base
liberated with ammonia and extracted with several
portions of chloroform. After evaporating the
solvent the residue is dissolved in neutralized alco-
hol, a measured excess of 0.02 N sulfuric acid is
added and the excess of acid is titrated with
0.02 N sodium hydroxide, using methyl red T.S.
as indicator. Each ml. of 0.02 AT sulfuric acid
represents 9.89 mg. of CisILnNCte^HeOe^-
H2O. N.F. The LP. assay is similar in principle
but utilizes 500 mg. of sample and 0.1 A7 volu-
metric solutions.

Uses. — Dihydrocodeinone bitartrate is essen-
tially similar to codeine salts in its actions; when
compared on the basis of equal content of alka-
loidal base the dihydrocodeinone salt is more
active and more prone to cause addiction. It is
useful primarily as an antitussive.

Dihydrocodeinone salts were used extensively
in Europe, and especially in Germany, prior to
their use in this country. For early reports of its
effects see Hecht, Klin. Wchnschr.', 1923. 1, 1069;
Schindler, Munch, med. Wchnschr., 1923, 70, 476;
Roller, ibid., 1924, 71, 648; Schwab and Krebs,
ibid., 1924, 71, 1363. It has proven useful as a
cough sedative in acute respiratory infections,
laryngeal and pulmonary tuberculosis, acute and
chronic bronchitis, and cough associated with
heart disease (Stein and Lowy, Am. Rev. Tuberc,
1946, 53, 345; Curtis and Brouning, Ohio State
M. J., 1946, 42, 500; Rudner, South. M. J., 1947,
40, 521).

Toxicology. — The toxic effects of dihydro-
codeinone are similar to those of codeine. In
therapeutic doses its effect on respiration is mini-
mal; however, it is capable of producing respira-
tory depression similar to that of codeine when
used in large doses. Myers (/. Hygiene, 1940, 40,
228, 533) reported it to be less constipating than
either codeine or morphine. Dihydrocodeinone has
a greater addiction liability than codeine, and is
probably equal to that of morphine; for reports
on addiction liability see Fraser and coworkers
(Fed. Proc, 1950, 9, 273), also Fraser and Isbell
(/. Pharmacol.,^ 1950, 100, 128).

Other Derivatives. — Dihydrocodeinone hy-
drochloride is available commercially (Dicodid
Hydrochloride, Bilhuber-Knoll) and is used simi-
larly. Under the name Acedicon the compound

Part I

Dihydromorphinone Hydrochloride 461

dihydrocodeinone enol acetate has been recom-
mended as an anodyne and cough sedative. Wiki
(Rev. mid. Suisse Rom., 1935, 55, 173), studying
respiratory action on rabbits, found the compound
to be intermediate in effect between heroin and
dionin. Matshulass (Arch. exp. Path. Pharm.,
1936, 183, 13) found it to prolong the local anes-
thetic effect of cocaine. It is used in about the
same dose as dihydrocodeinone bitartrate.

Dose. — The usual dose range of dihydrocode-
inone bitartrate is 5 to 10 mg. (approximately
¥12 to Vc, grain), every 6 to 8 hours, by mouth.
The maximum safe dose is 15 mg. and the total
dose in 24 hours seldom exceeds 60 mg. Children
over 2 years of age may receive 2.5 mg., and
those under 2 years, 1.25 mg.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

DIHYDROCODEINONE
BITARTRATE SYRUP. N.F.

"Dihydrocodeinone Bitartrate Syrup contains
not less than 90 per cent and not more than 110
per cent of the labeled amount of C18H21NO3.-
C4H606.2^H20." NJ.

The syrup may be prepared by dissolving 2.5
Gm. of dihydrocodeinine bitartrate in 50 ml. of
purified water, warming gently, then adding suffi-
cient cherry syrup to make 1000 ml. N.F.

Storage. — Preserve "in well-closed, light-re-
sistant containers." N.F.

DIHYDROCODEINONE
BITARTRATE TABLETS. N.F.

"Dihydrocodeinone Bitartrate Tablets contain
not less than 90 per cent and not more than 110
per cent of the labeled amount of C18H21NO3.-
C4HfiO,.2^H20." N.F.

Usual Size. — 5 mg. (approximately Vvz grain).

DIHYDROMORPHINONE HYDRO-
CHLORIDE. U.S.P. (LP.)

Dihydromorphinonium Chloride

The LP. requires Hydromorphone Hydrochlo-
ride to contain not less than 87.5 per cent and not
more than 89.5 per cent of C17H19O3N. The
U.S.P. has no assay rubric.

LP. Hydromorphone Hydrochloride; Hydromorphoni
Hydrochloridum. Dilaudid Hydrochloride (Bilhuber-
Knoll). Sp. Cloridrato de dihidromorfinona.

Dihydromorphinone is an alkaloid obtained by
hydrogenation of morphine in the presence of a
catalyst such as palladium. While dihydromor-
phinone and morphine have the same empirical
formula, the former has a ketone group in place

of a hydroxyl in morphine, and also is hydro-
genated at a double bond of the morphine
molecule.

Description. — "Dihydromorphinone Hydro-
chloride occurs as a fine, white, odorless, crystal-
line powder. It is affected by light. One Gm. of
Dihydromorphinone Hydrochloride dissolves in
about 3 ml. of water. It is sparingly soluble in
alcohol, and nearly insoluble in ether." U.S.P.

Standards and Tests. — Identification. — (1)
Dihydromorphinone base melts with decomposi-
tion at about 260°. (2) The filtrate separated
from dihydromorphinone base responds to tests
for chloride. (3) Dihydromorphinone oxime melts
with decomposition between 230° and 235°. (4) A
deep blue color is produced at once on adding a
mixture of 5 ml. of potassium ferricyanide T.S.
and 5 drops of ferric chloride T.S. to a solution
of 10 mg. of dihydromorphinone hydrochloride in
1 ml. of water. Specific rotation. — Not less than
— 136° and not more than — 139°, when deter-
mined in a solution containing 200 mg. of dihy-
dromorphinone hydrochloride in each 10 ml. and
calculated on the dried basis. Acidity. — A solution
of 300 mg. requires not more than 0.3 ml. of
0.02 N sodium hydroxide to produce a yellow
color with methyl red T.S. Loss on drying. — Not
over 1.5 per cent, when dried at 105° for 2 hours.
Residue on ignition. — The residue from 200 mg.
is negligible. Sulfate. — No turbidity results on
adding barium chloride T.S. to a solution of di-
hydromorphinone hydrochloride. Ammonium salts.
— No odor of ammonia is perceptible on heating
to boiling a mixture of dihydromorphinone hydro-
chloride and sodium hydroxide T.S. Codeine. —
No blue color results on adding ferric chloride
T.S. to an acid solution of dihydromorphinone
hydrochloride. U.S.P.

Assay. — About 400 mg. of dihydromorphinone
hydrochloride is dissolved in water, the solution
alkalinized with sodium bicarbonate, and the di-
hydromorphinone base extracted with chloroform.
The chloroform solution is evaporated nearly to
dryness, 25 ml. of 0.1 N sulfuric acid is added and,
after heating to volatilize the remaining chloro-
form, the solution is titrated with 0.1 N sodium
hydroxide, using methyl red as indicator. Each
ml. of 0.1 N sulfuric acid represents 28.53 mg. of
C17H19O3N. LP.

Incompatibilities. — Dihydromorphinone hy-
drochloride has the incompatibilities of alkaloids
generally. Perhaps the most important of these is
the incompatibility with alkalies or with sub-
stances producing an alkaline reaction in solution
by which the alkaloidal base is precipitated.

Uses. — The physiological action of dihydro-
morphinone is very similar to that of morphine,
its most important action being a depression of
the pain-perceiving mechanism and of the respira-
tory center. Buchwald and Eadie (J. Pharmacol.,
1941, 71, 197) reported that by intravenous in-
jection it is 3.7 times as toxic for mice as mor-
phine. Stanton (/. Pharmacol., 1936, 56, 252)
from experiments on rats concluded that, in its
tranquilizing power and its depressant action on
respiration, dilaudid is about 10 times as potent
as morphine. Gruber (/. Pharmacol., 1936, 57,
170) found that the actions of morphine and

462 Dihydromorphinone Hydrochloride

Part I

dilaudid upon the intestines are essentially the
same except that the latter is 10 times as powerful.
Seevers and Pfeiffer (/. Pharmacol., 1936, 56,
156) and Wolff et al. (/. Clin. Inv., 1940, 19,
659) compared the action of this with other opium
alkaloids on humans. After subcutaneous adminis-
tration, dihydromorphinone hydrochloride was
somewhat slower in action than morphine sulfate
or codeine phosphate but after intravenous ad-
ministration the rate of action was similar. How-
ever, dihydromorphinone was much more effective
hypodermically than intravenously. With reference
to duration of analgesic action, duration and in-
tensity of subjective depression, euphoria and
untoward side-effects it was less active in doses
of 1 mg. than morphine in doses of 10 mg. The
latter investigators reported than 3 mg. of dihy-
dromorphinone intramuscularly elevated the pain
threshold to radiant heat on the skin by 100 per
cent after 90 minutes; 30 mg. of morphine was
required to produce the same effect on the pain
threshold (see also under Acetanilid). It is about
10 times as analgesic as morphine but the duration
of analgesia is shorter and it is only about 4 times
as somnifacient; hence, pain may be relieved with-
out causing sleep.

Seevers (/. Pharmacol., 1936, 56, 156), from
experiments on monkeys, concluded that dilaudid
was less likely to give rise to addiction and that
the abstinence symptoms of its withdrawal were
less severe than with morphine. On the other hand
Stanton (loc. cit.) sees no difference in the habit-
forming tendencies between the two drugs but
found that tolerance was apparently somewhat
more slowly developed for dilaudid. This latter
fact is emphasized by Stroud (J.A.M.A., 1934,
103, 1421) as a result of clinical experience.
Nausea, vomiting and constipation seemed to be
less annoying than with morphine.

As with other opiates, dihydromorphinone hy-
drochloride causes spasm of the sphincter of Oddi
with increased pressure in the biliary tract of
humans; if bethanechol chloride is then adminis-
tered the pressure is increased even further and
colic and vomiting occur (Curreri and Gale, Ann.
Surg., 1950, 132, 348). In other words, the dose
required to relieve biliary colic is sufficient to
cause definite depression of the central nervous
system. In a comparison of the analgetic action
of Dromoran hydrobromide (5 mg.), meperidine
hydrochloride (75 to 100 mg.), and dihydro-
morphinone hydrochloride (2 mg.) in patients fol-
lowing thoracoplasty or comparable surgical pro-
cedures on the chest, meperidine was least effective
and the Dromoran salt was preferred to dihydro-
morphinone hydrochloride because of longer dura-
tion of action (Curreri et al., J. Thoracic Surg.,
1950, 20, 90).

A methyl derivative of dihydromorphinone hy-
drochloride, known as metopon hydrochloride, has
received extensive clinical evaluation (see in
Part I).

Toxicology. — Dihydromorphinone hydrochlo-
ride is an opium derivative with addicting prop-
erties; it must be handled under the surveillance
of the federal Bureau of Narcotics. Being more
active than morphine, although of shorter dura-
tion of action, dihydromorphinone may be used

in smaller but more frequent doses by addicts;
manifestations of the .withdrawal syndrome ap-
pear more rapidly, reach greater intensity and
subside more quickly than with morphine (Isbell
and White, Am. J. Med., 1953, 14, 561).

Dose. — The usual dose is 2 mg. (approximately
Vsa grain) every 4 hours, as necessary, by mouth or
subcutaneously; the range of dose is 1 to 4 mg.
The maximum safe dose seldom exceeds 4 mg. and
the total dose in 24 hours will rarely exceed 10
mg. A dose of 2.5 mg. in a caco butter suppository
is sometimes employed.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DIHYDROMORPHINONE HYDRO-
CHLORIDE INJECTION. U.S.P. (LP.)

[Injectio Dihydromorphinoni Hydrochloride

"Dihydromorphinone Hydrochloride Injection
is a sterile solution of dihydromorphinone hydro-
chloride in water for injection. It contains not
less than 95 per cent and not more than 105
per cent of the labeled amount of C17H19NO3.-
HC1." U.S.P. The LP. limits are the same; it is
indicated that the solution may be sterilized by
heating in an autoclave or by filtration through
a bacterial filter.

I. P. Injection of Hydromorphone Hydrochloride; In-
jectio Hydromorphoni Hydrochloridi.

The pH of this injection should be between 4
and 5.5, according to the U.S.P., and between
4.0 and 4.5, according to the LP.

Assay. — A portion of the injection, equivalent
to about 60 mg. of dihydromorphinone hydro-
chloride, is alkalinized with sodium bicarbonate
and the liberated base extracted with chloroform.
After washing and filtering the chloroform solu-
tion the solvent is evaporated nearly to dryness
and, after adding 25 ml. of 0.02 N sulfuric acid,
the mixture is heated gently to expel any re-
maining chloroform. The excess acid is titrated
with 0.02 N sodium hydroxide, using methyl red
T.S. as indicator. Each ml. of 0.02 N sulfuric acid
represents 6.436 mg. of C17H19NO3.HCI. U.S.P.
The LP. assay is similar in principle but differs
in details.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass,
protected from light." U.S.P.

Usual Sizes. — 2 and 3 mg. (approximately
V30 and 34o grain) in 1 ml.

DIHYDROMORPHINONE HYDRO-
CHLORIDE TABLETS. U.S.P. (LP.)

[Tabellae Dihydromorphinoni Hydrochloridi]

"Dihydromorphinone Hydrochloride Tablets
contain not less than 90 per cent and not more
than 110 per cent of the labeled amount of
C17H19NO3.HCI." U.S.P. The LP. limits are the
same.

I. P. Tablets of Hydromorphone Hydrochloride; Com-
pressi Hydromorphoni Hydrochloridi.

The assay is based on the reactions employed
in the assay of Dihydromorphinone Hydrochloride
Injection.

Usual Sizes. — Oral tablets containing 2.5

Part I

Dihydrostreptomycin Sulfate 463

mg. (Vzi grain); compounding tablets containing
32 mg. (l/t grain); hypodermic tablets contain-
ing 1, 1.5, 2, 3, 3.5, and 4 mg. (%*, Mo, %2,
Y20, Yi&, %6 grain).

DIHYDROSTREPTOMYCIN
SULFATE. U.S.P. (B.P., I.P.)

"Dihydrostreptomycin Sulfate contains an
amount of (C2iH4iN70i2)2.3H2S04 equivalent to
not less than 65 per cent of dihydrostreptomycin
base (C21H41N7O12), except that if it is crystal-
line it contains the equivalent of not less than
72.5 per cent of base (the antibiotic activity of
650 meg. and 725 meg., respectively, of the base
in each mg.). Dihydrostreptomycin Sulfate con-
forms to the regulations of the federal Food and
Drug Administration concerning certification of
antibiotic drugs. Dihydrostreptomycin Sulfate not
intended for parenteral use is exempt from the
requirements of the tests for Pyrogen, Sterility,
and Content variation." U.S.P.

Under the title Dihydrostreptomycin both the
B.P. and I. P. recognize either Dihydrostreptomy-
cin Hydrochloride, C21H41O12N7.3HCI, or Dihy-
drostreptomycin Sulfate; both salts are required
to contain not less than 600 units (microgram
equivalents of dihydrostreptomycin base) per mg.

Dihydrostreptomycin is an antibiotic base that
is produced by catalytic hydrogenation of strep-
tomycin (Peck et al., J.A.C.S., 1946, 68, 1390).
Chemically it differs from streptomycin only in
that the aldehyde group of the streptose moiety
of the latter is reduced to an alcohol. Dihydro-
streptomycin base readily forms salts with acids,
and has been used medicinally in the form of the
hydrochloride and sulfate.

Description. — "Dihydrostreptomycin Sulfate
is a white or practically white powder. It is
odorless or has not more than a faint odor. It
is hygroscopic, but is stable toward air and light.
Its solutions are acid to nearly neutral to litmus,
and are levorotatory. Dihydrostreptomycin Sul-
fate is freely soluble in water. It is very slightly
soluble in alcohol and practically insoluble in
chloroform." U.S.P.

Standards and Tests. — Identification. — (1)
A solution of about 0.5 mg. of dihydrostrepto-
mycin sulfate in 5 ml. of water is mixed with
1 ml. of 1 in 10 sodium hydroxide solution and
1 ml. of 1 in 2000 solution of alphanaphthol in
diluted alcohol. The mixture is cooled to about
15°, and 3 drops of sodium hypobromite T.S.
are added: a red color is produced. (2) The salt
responds to tests for sulfate. Loss on drying. —
Not over 5 per cent, when dried in vacuum at 60°
for 3 hours. pH. — The pH of a 1 in 5 solution is
between 4.5 and 7.0. Limit of streptomycin. — Not
more than 3.0 per cent of streptomycin base,
except that if the dihydrostreptomycin sulfate is
crystalline it contains not more than 1.0 per cent
of streptomycin. The test is based on the fact that
streptomycin in alkaline solution produces with
ferric chloride a purple color, while dihydrostrep-
tomycin does not. Depressor substances. — The
requirements of the test are met with a test dose
of 1 ml. per Kg. of a solution containing 10 mg.
of dihydrostreptomycin base in each ml. Pyrogen.
— Dihydrostreptomycin sulfate, used in a test

dose of 1.0 ml. per Kg. of a solution containing
10 mg. of the base per ml., meets the require-
ments of the test. Safety. — Dihydrostreptomycin
sulfate, used in a test dose of 0.5 ml. of a solu-
tion containing 2 mg. per ml., meets the require-
ments of the test. Sterility. — The antibiotic is
free of bacteria, molds and yeasts. Content varia-
tion.— The content of dihydrostreptomycin sul-
fate in containers for parenteral administration is
not less than 90 per cent of the labeled content.
U.S.P.

Assay. — Dihydrostreptomycin sulfate is as-
sayed by the official microbial assay (see discus-
sion of Assay, under Streptomycin Sulfate).
U.S.P.

Uses. — Preparation of dihydrostreptomycin
from streptomycin followed shortly after the
first clinical trials of streptomycin were reported.
The investigations of Donovick and Rake (/.
Bad., 1947, 53, 205) indicated that the hy-
drogenated derivative possessed the same anti-
bacterial activity in vitro but was slightly less
toxic than streptomycin. These same investigators
(Am. Rev. Tuberc, 1948, 58, 479) found no
significant difference in the therapeutic effective-
ness of the two preparations in tuberculosis in
mice, while Feldman et al. (ibid., 1948, 58, 494)
made the same observation in the guinea pig.

All clinical experience with dihydrostreptomy-
cin has confirmed that it is essentially equivalent
to streptomycin in antibacterial activity. How-
ever, it is now recognized that dihydrostrepto-
mycin is equally as toxic as streptomycin,
although the toxicity is manifest in a different
way. Whereas streptomycin injures primarily
the vestibular mechanism, dihydrostreptomycin
damages the cochlear branch of the eighth cra-
nial nerve and impaired auditory function may
be the first evidence of toxicity. Frequently, by
the time the nerve has been injured sufficiently
for deafness to occur, the neurologic damage is
irreversible and deafness, which may be partial
or complete, is permanent. Careful and repeated
audiometric studies should be performed when-
ever dihydrostreptomycin is used for more than
a few days.

Dihydrostreptomycin, if used alone, is best re-
served for treatment of patients who are allergic
to streptomycin and have an infection which is
not amenable to some other antibiotic and will
require only a short period of therapy.

The safest procedure in streptomycin or di-
hydrostreptomycin therapy, and now the common
practice, is to apportion the total dosage into
equal parts of streptomycin and of dihydrostrep-
tomycin and to give the two antibiotics together.
Thus, since the two drugs are equally active anti-
bacterially, but since the dose of each component
is only one-half the normal dose for the drug
used alone, an effective antibiotic dosage can be
achieved without undue risk of either agent exert-
ing its specific neurotoxic effect. The mixture of
equal parts of streptomycin and dihydrostrepto-
mycin is called streptoduocin (see under this
title), and is available under the trade-marked
names Combistrep (Pfizer), Distreptocin (Lilly),
Distrycin (Squibb), Duostrep (Sharp and Dohme),
and Multamycin (Bristol).

464 Dihydrostreptomycin Sulfate

Part I

Miller et al. {Arch. Dermal. Syph., 1950, 61,
648) found dihydrostreptomycin ointment, con-
taining 5 milligrams of the antibiotic per gram,
to be an effective agent for the treatment of
pyogenic infections of the skin; vesicular derma-
titis from use of the ointment occurred in only
3.7 per cent of patients treated. The following
ointment base formulations were found to be sat-
isfactory: (1) Carbowax 1540, 36 Gm.; Carbo-
wax 4000, 18 Gm.; polyethylene glycol 200, 46
Gm. (2) Cetyl alcohol, 21 Gm.; glycerin, 21
Gm.; sodium lauryl sulfate, 2 Gm.; propylpara-
ben, 0.02 Gm.; distilled water, to 100 Gm. (3)
Cetyl alcohol, 8 Gm. ; white petrolatum, 20 Gm. ;
light liquid petrolatum, 18 Gm.; propylparaben,
0.02 Gm.; distilled water, to 100 Gm.

For further discussion of the clinical appli-
cations of dihydrostreptomycin in systemic medi-
cation, and of its toxicity, dosage, stability, etc.,
see Streptomycin Sulfate.

Dose. — The usual dose is 500 mg. of the base
daily, given intramuscularly, with a range of 500
mg. to 1 Gm. The maximum safe dose is 6 Gm.
during 24 hours and this dose is used only in
unusual circumstances and for only a few days.
In tuberculosis, an intramuscular dose of 500 mg.
to 1 Gm. once or twice weekly, along with para-
aminosalicylic acid, isoniazid, etc., seems to be
fully effective.

Storage. — Preserve "in tight containers."
U.S.P.

DIHYDROSTREPTOMYCIN SULFATE
INJECTION. U.S.P. (B.P., LP.)

"Dihydrostreptomycin Sulfate Injection is a
sterile solution of dihydrostreptomycin sulfate in
water for injection. It contains an amount of
(C2iH4iN70i2)2.3H2SC<4 equivalent to not less
than 90 per cent of the labeled amount of dihy-
drostreptomycin base (C21H41N7O12). Dihydro-
streptomycin Sulfate Injection conforms to the
regulations of the federal Food and Drug Ad-
ministration concerning certification of antibiotic
drugs." U.S.P.

The B.P. recognizes Injection of Dihydrostrep-
tomycin as a sterile solution of dihydrostrepto-
mycin hydrochloride or dihydrostreptomycin sul-
fate in water for injection, prepared by dissolving
the contents of a sealed container in the requisite
amount of water for injection, using aseptic
technic. The LP. definition of Injection of Dihy-
drostreptomycin is essentially the same.

Description. — "Dihydrostreptomycin Sulfate
Injection is a clear, colorless to yellow, viscous
liquid. It is odorless or has a slight odor." U.S.P.
The pH of the injection is required to be between
5 and 8.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass,
protected from light." U.S.P.

Usual Sizes. — 1 Gm. in 2 ml.; 5 Gm. in
10 ml.

DIHYDROXY ALUMINUM
AMINOACETATE. N.F.

Basic Aluminum Glycinate

H2NCH2COOAl(OH)2

"Dihydroxyaluminum Aminoacetate, dried to
constant weight at 130°, yields not less than 35.5
per cent and not more than 38.5 per cent of
aluminum oxide (AI2O3). Dihydroxyaluminum
Aminoacetate may contain small amounts of
aluminum oxide and of aminoacetic acid." N.F.

Aluminum Dihydoxyaminoacetate. Alglyn (Brayten) ;
Aspogen (Eaton); Alzinox (Hatch); Doraxamin (Smith-
Dorsey); Kobalate (Robins).

Dihydroxyaluminum aminoacetate, a gastric
antacid, was first prepared by Krantz et al.
(/. Pharmacol., 1944, 82, 247) by interaction of
aluminum isopropoxide (obtained by reacting alu-
minum metal with anhydrous isopropyl alcohol)
and aminoacetic acid (see also U. S. Patent 2,480,-
743). The product contains small amounts of alu-
minum hydroxide and aminoacetic acid.

Description. — "Dihydroxyaluminum Amino-
acetate occurs as a white, odorless powder. It has
a faintly sweet taste. Dihydroxyaluminum Amino-
acetate is insoluble in water and in organic sol-
vents. It dissolves in dilute mineral acids and in
solutions of fixed alkalies." N.F.

Standards and Tests. — Identification. — (1)
An aqueous solution prepared with the aid of
hydrochloric acid responds to tests for aluminum.
(2) Addition of phenol and sodium hypochlorite
T.S. to a solution prepared as in (1) produces a
blue color. pH. — A suspension of 1 Gm. in 25 ml.
of water has a pH between 6.5 and 7.5. Loss on
drying. — Not over 14.5 per cent, when dried to
constant weight at 130°. Acid-consuming capacity.
— In 10 minutes acid is neutralized in the propor-
tion of not less than 140 ml. of 0.1 N hydrochloric
acid per Gm. of dihydroxyaluminum aminoacetate.
Acid-neutralizing capacity. — At the end of 10 min-
utes the pH of a mixture of 200 mg. of dihydroxy-
aluminum aminoacetate and 25 ml. of 0.1 N
hydrochloric acid is not above 3.0. Prolonged
neutralization. — Using simulated gastric fluid, at
38°, dihydroxyaluminum aminoacetate under the
conditions of the test produces a rapid rise of pH
to above 3.5, and maintains a pH above 3 for not
less than 2 hours. Mercury. — No orange color is
produced with dithizone under the conditions of
the test. Isopropyl alcohol. — Absence of this sub-
stance is indicated by failure to obtain a test for
acetone with sodium nitroferricyanide T.S. in a
portion of distillate separated after oxidative treat-
ment of dihydroxyaluminum acetate. Nitrogen. —
Not less than 9.9 per cent and not more than 10.6
per cent, determined by the semi-micro Kjeldahl
procedure. N.F.

Assay. — About 1 Gm. of dihydroxyaluminum
aminoacetate is heated with nitric acid and some
sulfuric acid to oxidize the aminoacetic acid. The
residue obtained by this treatment is dissolved in
acid, and the aluminum ion precipitated as alu-
minum hydroxide, which is separated by filtration,
ignited to aluminum oxide, and weighed. N.F.

Uses. — Dihydroxyaluminum aminoacetate is an
orally effective gastric antacid which is claimed to
have the advantage over aluminum hydroxide of
providing both immediate and prolonged neu-
tralization of gastric acidity. Both the amino
group and the two hydroxyl groups of the com-
pound participate in neutralization, with the amino

Part I

Diiodohydroxyquin 465

group apparently reacting more quickly than the
hydroxy Is, which are mainly responsible for the
prolonged neutralizing effect (see Krantz et al.,
loc. cit.). As dihydroxyaluminum aminoacetate
contains less aluminum than the same weight of
aluminum hydroxide, less aluminum chloride,
which is astringent, is produced and less consti-
pating action may result. How significant these
theoretical advantages over aluminum hydroxide
may be in clinical practice is open to question
(N.N.R.).

Dihydroxyaluminum aminoacetate is particu-
larly useful in controlling hyperacidity in the
management of peptic ulcer.

Dose. — Dihydroxyaluminum aminoacetate is
administered orally in a dose of 500 mg. to 1 Gm.
(approximately iy2 to 15 grains), usually after
meals and at bedtime, for control of hyperacidity.
As with other aluminum preparations taken in-
ternally, prolonged use may produce constipation.

Storage. — Preserve "in well-closed contain-
ers." N.F.

DIHYDROXYALUMINUM AMINO-
ACETATE MAGMA. N.F.

"Dihydroxyaluminum Aminoacetate Magma is
a suspension which yields an amount of AI2O3
equal to not less than 28.5 per cent and not more
than 35 per cent of the labeled amount of C2H6-
AINO4. It may be flavored with suitable flavoring
agents, and stabilized by the use of appropriate
suspending agents, and preservatives." N.F.

Description. — "Dihydroxyaluminum Amino-
acetate Magma is a white, viscous suspension,
from which small amounts of water may separate
on standing." N.F.

The preparations currently available (Magma
Alzinox and Gel Doraxamin) contain 100 mg. of
dihydroxyaluminum aminoacetate per ml. of sus-
pension.

Storage. — Preserve "in tight containers and
protect it from freezing." N.F.

DIHYDROXYALUMINUM AMINO-
ACETATE TABLETS. N.F.

"Dihydroxyaluminum Aminoacetate Tablets
yield an amount of AI2O3 equal to not less than
28.5 per cent and not more than 35 per cent of
the labeled amount of C2H.6AINO4." N.F.

Usual Size. — 500 mg. (approximately iy2
grains).

DIIODOHYDROXYQUIN. U.S.P. (B.P.)

Diiodohydroxyquinoline (U.S.P. XIV),
5,7-Diiodo-8-quinolinol

"Diiodohydroxyquin, dried over sulfuric acid
for 4 hours, contains not less than 60.5 per cent
and not more than 64 per cent of iodine, corre-
sponding to not less than 94.5 per cent of C9H5-

I2NO." U.S.P. The B.P. defines Di-iodohydroxy-
quinoline as 8-hydroxy-5:7-di-iodoquinoline and
requires it to contain not less than 61.5 per cent
and not more than 64.0 per cent of I, calculated
with reference to the substance dried over phos-
phorus pentoxide at a pressure not exceeding 5
mm. of mercury for 4 hours.

B.P. Di-iodohydroxyquinoline. Diodoquin (Searle) ;
Yodoxin (Lemke).

This antiprotozoan agent is obtained by the
iodination of 8-hydroxyquinoline.

Description. — "Diiodohydroxyquin occurs as
a colorless or light yellowish to tan, microcrystal-
line powder not readily wetted by water. It is
odorless or has a faint odor, and is stable in air. It
melts with decomposition. Diiodohydroxyquin is
almost insoluble in water, and is sparingly soluble
in alcohol and in ether." U.S.P.

Standards and Tests. — Identification. — Vio-
let vapors of iodine evolve upon warming diiodo-
hydroxyquin with sulfuric acid. Loss on drying. —
Not over 0.5 per cent, when dried over sulfuric
acid for 4 hours. Residue on ignition. — Not over
0.5 per cent. Free iodine and iodide. — No violet
color is imparted to chloroform by an acidified,
saturated aqueous solution of diiodohydroxyquin.
The iodine released by potassium dichromate T.S.
from the same mixture does not exceed that corre-
sponding to 500 parts per million of iodide. U.S.P.
The B.P. specifies, as an identification test, that
the absorbancy of a 1-cm. layer of a 0.0005 per
cent w/v solution in dehydrated alcohol at 258
mn be about 0.425. The loss on drying (see defi-
nition above) is limited to 0.5 per cent.

Assay. — About 200 mg. of dried diiodohy-
droxyquin is analyzed by a slight modification of
the method employed in the assay of 1 odophthalein
Sodium for iodine. Each ml. of 0.05 N silver
nitrate represents 6.346 mg. of iodine. U.S.P.

Uses. — Diiodohydroxyquin is widely used in
the treatment of amebiasis, of Trichomonas vag-
inalis vaginitis, and of infestation with Balantidium
coli. The compound is chemically related to both
chiniofon and iodochlorhydroxyquin ; for infor-
mation concerning the concentration of iodine in
the blood obtained with each of these substances
see under Chiniofon. The distribution of the same
drugs, each labeled with radioactive iodine-131,
in the rabbit has been studied by Haskins et al.,
Am. J. Trop. Med., 1950, 30, 399).

Amebiasis. — Diiodohydroxyquin is the drug of
choice for treatment of intestinal amebiasis
(D'Antoni, ibid., 1943, 23, 237; Kansas City
M. J., 1948, 24, 6). It is more effective than other
amebicides, and also less toxic. Tablets of the
compound can be chewed by children. It rarely
causes diarrhea. Sodeman and Beaver, Am. J . Med.,
1952, 12, 440) reported better results in intestinal
amebiasis with Diodoquin than with chiniofon.
In South Africa Wilmot et al. (J. Trop. Med.
Hyg., 1951, 54, 161) found Diodoquin by mouth
to be about as effective as emetine administered
intramuscularly; immediate disappearance of
parasites in 58 per cent of cases was observed
with Diodoquin. On the basis of their highly
favorable experience with the drugs, Conn and
Feldman (Postgrad. Med., 1951, 9, 137) advo-

466 Diiodohydroxyquin

Part I

cated administration of Diodoquin followed by
carbarsone. Simultaneous use of succinylsulfa-
thiazole and Diodoquin was found to be effective
by El-Ghaffar (/. Roy. Egyptian M. A., 1949, 32,
In amebic abscess of the liver, Zavala and
Hamilton (Ann. Int. Med., 1952. 36, 110) ob-
tained the best results with Diodoquin and chloro-
quine. Liver function tests show no evidence of
liver damage during treatment with Diodoquin or
carbarsone. Use of tetracycline antibiotics is dis-
couraged because of the disturbance of intestinal
flora thev produce (Knight and Tarun, Am. J.
Trop. Med., 1952. 32, 11

Other Uses. — Diodoquin has been found to be
effective in balantidiasis (Shookhoff. ibid., 1951,
31, 442). In Trichomonas vaginalis vaginitis cure
in 88 per cent of patients treated resulted from
use of cleansing acid douches followed by inser-
tion of 1 or 2 vaginal tablets containing 100 mg.
of Diodoquin even- 12 hours for 12 days although
to prevent relapse treatment may be continued
for 4 to 8 weeks.

Toxicology. — Severe dermatitis following use
of diiodohydroxyquin has been reported (David.
J.A.M.A., "1945." 129, 572; see also Leifer and
Steiner. /. Invest. Dermat., 1951, 17, 233). De-
velopment of furunculosis in two patients, and of
chills, fever, rash and erythema in a third, have
also been described (Silverman and Leslie.
JAMA., 1945. 128, 1080).

Dose. — The usual dose is 650 mg. (about 10
grains), by mouth. 3 times daily for 20 days: the
range of dose is 650 mg. to 1 Gm. For children
the dose is 200 mg. for each 7 Kg. (approximately
15 pounds) of body weight, within the dosage
limits just stated. 3 times daily for 20 days. A
vaginal tablet (Floraquin, Searle). containing 100
mg. of diiodohydroxyquin. with lactose, dextrose
and boric acid to promote an acid reaction in the
vagina is used once or twice daily.

Storage. — Preserve "in well-closed contain-
ers." US.P.

DIIODOHYDROXYQUIN TABLETS.
U.S.P.

''Diiodohydroxyquin Tablets contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of C9H5I2XO." U.S.P.

Usual Sizes. — 200 and 650 mg. (approximately
3 and 10 grains).

DILL OIL. B.P.

Oleum Anethi

Dill Oil is the volatile oil distilled from the
dried ripe fruits of Anethum graveolens L. It
contains not less 43.0 per cent w w and not more
than 63.0 per cent w. w of carvone, C10H14O.

Fr. Essence d'aneth. Ger. Dillol.

Dill oil is colorless or of a pale yellow color,
with the odor of the fruit, and has a hot. sweetish,
acrid taste. Its weight per ml., at 20°, is between
0.895 and 0.910 Gm. The optical rotation is from
+ 70° to +80°; the refractive index is from 1.481
to 1.492.

The assay for carvone is the same as for car-

vone in caraway oil (B.P. method), which utilizes
the reaction with hydroxylamine hydrochloride,
followed by titration of liberated acid with 1 N
potassium hydroxide.

Dill oil contains from 40 to 65 per cent of
carvone, considerable rf-limonene and smaller
amounts of other terpenes; English and Spanish
oils also contain phellandrene which, it is said,
does not occur in oil of German origin.

East Indian dill oil, which is occasionally used
as an adulterant or substitute, comes from a
different plant (Anethum Sowa Roxb.). It
differs from the genuine in containing less car-
vone; a small amount of crystalline residue is
also present which is stated to consist of paraf-
fin. Oil of dill should be kept in a well-closed
container, protected from light and stored in a
cool place.

Dill oil is used as an aromatic carminative,
particularly in the form of either concentrated
dill water or dill water. The dose of dill oil is given
by the B.P. as 0.06 to 0.2 ml. (approximately 1
to 3 minims).

CONCENTRATED DILL WATER. B.P.

Concentrated Dill Water is made by dissolv-
ing 20 ml. of dill oil in 600 ml. of 90 per cent
alcohol, with enough distilled water to make
1000 ml. Powdered talc is added as a filtering
medium; the preparation is occasionally shaken
for a few hours and then filtered. It contains
approximately 54 per cent of alcohol.

Although concentrated dill water may be used
undiluted, as an aromatic carminative, it is
generally employed diluted with 39 volumes of
distilled water to provide essentially the equiva-
lent of dill water prepared by saturating distilled
water with the oil; such a diluted water contains
about 1.3 per cent alcohol.

The B.P. dose of concentrated dill water is
0.3 to 1 ml. (approximately 5 to 15 minims); the
dose of the diluted water is 15 to 30 ml. (approxi-
mately ^ to 1 fluidounce).

DIMENHYDRINATE. U.S.P.

(? ^-C-0-CH2CH2N*(CH3)2

CH3^

''Dimenhydrinate contains not less than 53 per
cent and not more than 55.5 per cent of diphen-
hydramine (C17H21XO ). and not less than 44 per
cent and not more than 47 per cent of 8-chloro-
theophylline (C7H7CIN4Q*)." US. P.

Dramamine (.Searle).

This salt is the product of the interaction of the
antihistaminic base diphenhydramine with the
acidic compound S-chlorotheophvlline. For details
of synthesis see U. S. Patent 2.499,058 (1950).

Description. — "Dimenhydrinate occurs as a
white, crystalline, odorless powder. Dimenhydrin-
ate is slightly soluble in water. It is freely solu-

Part I

Dimenhydrinate 467

ble in alcohol and in chloroform, and sparingly
soluble in ether. Dimenhydrinate melts between
102° and 107°." U.S.P.

Standards and Tests. — Identification. — (1)
Diphenhydramine base is liberated from dimen-
hydrinate and then converted to the hydrochlo-
ride, which is required to respond to identification
tests (1) and (2) under Diphenhydramine Hydro-
chloride. (2) 8-Chlorotheophylline liberated from
dimenhydrinate melts between 300° and 305°,
with decomposition. (3) Chloride, obtained from
8-chlorotheophylline by fusion with sodium per-
oxide, produces a precipitate with silver nitrate;
the precipitate is soluble in ammonia T.S. and is
reprecipitated upon acidification with nitric acid.
Loss on drying. — Not over 0.5 per cent, when
dried in a vacuum over phosphorus pentoxide for
24 hours. Residue on ignition. — Not over 0.3 per
cent. Chloride. — The ammoniacal filtrate from the
precipitation of silver chlorotheophyllinate in the
assay remains clear, or at most shows only a faint
opalescence, on acidification. Bromide and iodide.
—On adding 10 ml. of diluted hydrochloric acid
to a mixture of dimenhydrinate, sodium nitrite,
and chloroform, the chloroform remains colorless.
U.S.P.

Assay. — For diphenhydramine. — About 500
mg. of dried dimenhydrinate is dissolved in water,
and the solution is nearly saturated with sodium
chloride; the diphenhydramine released with am-
monia is extracted with ether, and estimated by
interaction with a measured excess of 0.1 N hydro-
chloric acid and titration with 0.1 N sodium hy-
droxide after evaporating the ether. Each ml. of
0.1 iV hydrochloric acid represents 25.54 mg. of
C17H21NO. For 8-chlorotheophylline. — About 800
mg. of dried dimenhydrinate is dissolved in water
and the acidic constituent precipitated as silver
8-chlorotheophyllinate by adding a measured ex-
cess of 0.1 N silver nitrate in the presence of
ammonia. In an aliquot portion of the filtrate
separated from the mixture the excess silver
nitrate is titrated with 0.1 N ammonium thio-
cyanate. Each ml. of 0.1 N silver nitrate repre-
sents 21.46 mg. of C7H7CIN4O2. U.S.P.

Uses. — This drug is best known for its utility
in the treatment of motion sickness and other
vertiginous and nauseous syndromes, though it
possesses antihistaminic activity attributable to
the diphenhydramine component as evidenced by
protection studies against a mist of histamine.
The spasmolytic action of dimenhydrinate as
measured on the isolated intestinal strip is quite
weak; this may be due to the very slight solu-
bility of the compound. During the evaluation of
dimenhydrinate in the management of allergic
patients, Gay and Carliner (Science, 1949, 109,
359) gave the drug to a pregnant woman with
urticaria and recognized the significance of her
report that the car-sickness from which she had
always suffered was relieved, as well as the urti-
caria. In a carefully controlled study with the
cooperation of the United States Army, Gay and
Carliner (Bull. Johns Hopkins Hosp., 1949, 84,
470) found the drug to be effective, both prophy-
lactically and therapeutically, in the control of
sea-sickness. Strickland and Hahn (Science, 1949,

109, 359) reported a decrease in the incidence
of air-sickness, from 55 per cent in the case of
subjects given a placebo, to 29 per cent in those
given dimenhydrinate. In experimental studies,
White et al. (Fed. Proc, 1950, 9, 325) reported
that 2 mg./kilo of dimenhydrinate protected dogs
from the emesis ordinarily produced by 30 mg./
kilo of apomorphine. Freese et al. (ibid., 21 A)
failed to protect dogs from the emesis produced
by morphine. Tyler (Science, 1949, 110, 170)
questioned the superiority of dimenhydrinate over
0.6 mg. of hyoscine for motion sickness (see also
Tyler and Bard, Physiol. Rev., 1949, 29, 311) as
regards both effectiveness and incidence of un-
toward effects. With the possibility of controlling
this disabling syndrome in both civilians and
military personnel at hand for the first time, in-
tensive investigations were instituted in many
laboratories. In rabbits, forced circling movements
are caused by the intracarotid injection of a sub-
convulsive dose of diisopropyl fluorophosphate,
which is an anticholinesterase drug. Johns and
Himwich (Am. J. Psychiat., 1950, 107, 367)
reported that these movements could be corrected
by intravenous injection of 3.3 mg./kilo of dimen-
hydrinate, 2.6 mg./kilo of diphenhydramine, or
2.2 mg./kilo of promethazine (see discussion of
motion sickness under Diphenhydramine Hydro-
chloride for a review of information which indi-
cates that the diphenhydramine component of
dimenhydrinate is the active portion in prophy-
laxis and treatment of motion sickness, also the
comments of Nickerson, Science, 1950, 111, 312,
and of Mitchell, ibid., 1950, 112, 154). The study
of the effect of dimenhydrinate and other drugs
on labyrinthine function, utilizing the caloric
method of stimulating the peripheral end-organ
of the labyrinth and the galvanic method of stimu-
lating the vestibular nerve, showed that 100 mg.
of dimenhydrinate markedly depressed labyrin-
thine function, judged by its effect on the onset,
duration and character of nystagmus, the amount
of electric current required to produce tilting, and
decrease in subjective vertiginous sensations
(Gutner et al., Arch. Otolaryng., 1951, 53, 308).
In the same study, 50 mg. of diphenhydramine,
0.6 mg. of hyoscine hydrobromide, 100 mg. of
secobarbital, 500 mg. of aminophylline, and 100
mg. of 8-chlorotheophyllinate each was without
effect on labyrinthine function, although sedation
in some instances minimized the sensation of
vertigo. An independent comparison by Boland
and Grinstad (/. Aviation Med., 1951, 22, 137)
demonstrated equal air-sickness protection and
comparable side effects with 0.6 mg. of scopol-
amine hydrobromide or 100 mg. of dimenhydrin-
ate. As concluded in the discussion of motion
sickness under promethazine hydrochloride (q.v.),
statistics vary, and controversy is bitter as to
which drug is most effective and least troublesome
with side effects in the control of motion sick-
ness, but it seems definite that dimenhydrinate,
diphenhydramine, hyoscine, promethazine and
some other anticholinergic drugs are effective
agents (Chinn et al., Am. J. Med., 1952, 12, 433).
Further studies by Gay (Mil. Surg., 1951, 108,
324), Shaw (ibid., 1950, 106, 441), Wright (U. S.

468 Dimenhydrinate

Part I

Armed Forces Med. J., 1950, 1, 570) and others
have amply confirmed the efficacy of dimen-
hydrinate in the prevention and treatment of mo-
tion sickness. Shaw reported that the drug had
no deleterious effect on marksmanship. Wright
advised the use of 2.5 mg. of amphetamine sulfate
with each 100 mg. of dimenhydrinate.

Nausea and vomiting of early pregnancy were
relieved with dimenhydrinate in 31 of 43 women
by Carliner et al. (Science, 1949, 110, 215), an
observation confirmed by Cartwright (West. J.
Surg. Obst. Gyn., 1951, 59, 216), Joas (Munch,
vied. Wchnschr., 1952, 94, 169) and others. In
roentgen illness, Beeler et al. (Proc. Mayo, 1949,
24, 477) reported relief in 65 of 82 patients
given 100 mg. of dimenhydrinate 1 hour before,
and 1^2 and 3 hours after irradiation; DeFeo
et al. (Radiology, 1951, 56, 420) reported efficacy
in 46 of 100 cases and found that 23 of those
benefited required daily administration throughout
the course of radiation. Kerman (Dis. Nerv.
System, 1951, 12v 83) reported prevention of
nausea and vomiting in 51 of 55 cases following
electroshock therapy. Waisbren et al. (J. A.M. A.,

1949, 141, 938) gave it before chlortetracycline
for patients unable to use the antibiotic because
of nausea and vomiting. Gutner et al. (J. Clin.
Inv., 1952, 31, 259) reported that it inhibited
the stimulating action of meperidine or morphine
on the vestibular mechanism. Rubin and Winston
(ibid., 1950, 29, 1261) found that it prevented
the nausea and vomiting caused by motion after
morphine or meperidine. Failing (Attn. West. Med.
Surg., 1952, 6, 293) injected it preoperatively to
prevent the tendency of meperidine to cause
vomiting. Moore et al. (Anesth., 1952, 13, 354)
reduced postoperative vomiting from 22.2 to 11.2
per cent with 50 mg. just before surgery, repeated
after the operation, then every 4 hours for 4 doses,
all intramuscularly. By oral administration, it was
less effective (Rubin and Metz-Rubin, Surg.
Gynec. Obst., 1951, 92, 415). Armer (7. Oral
Surg., 1952, 10, 225) reported it to be useful in
cases receiving intravenous thiopental anesthesia.
Hume and Wilner (Anesth., 1952, 13, 302) gave
it intravenously every 4 hours as long as the pa-
tient remained in the "recovery room" and found
it particularly useful in instances of prolonged
anesthesia.

Vertigo in tuberculous patients receiving strep-
tomycin was prevented or relieved by dimen-
hydrinate (Titche and Nady, Dis. Chest., 1951,
20, 324). Campbell (Laryng., 1949, 141, 938)
used it effectively to prevent the most trouble-
some nausea, vomiting, vertigo and nystagmus
following labyrinthine fenestration operations.
Harbert and Schiff (U. S. Armed Forces Med. J.,

1950, 1, 979) noted that the nystagmus usually
persisted but the uncomfortable symptoms were
relieved. W'ener (J.A.M.A., 1949, 141, 500) testi-
fied to the value of dimenhydrinate in Meniere's
syndrome. The tinnitus and vertigo common in
patients with hypertensive and arteriosclerotic
cardiovascular disease were alleviated with doses
of 25 to 100 mg. of dimenhydrinate four times
daily orally (Goldman et al., Am. Heart J., 1951,
42, 302). Witzeman (Eye, Ear, Nose & Throat
Monthly, 1949, 28, 272) found it most useful in

relieving the vertigo of cases of labyrinthitis
while definitive treatment was carried out. Win-
ston et al. (Ann. Otol. Rhin. Laryng., 1950, 59,
622) observed that dimenhydrinate relieved the
discomfort from turning in the Barany chair but
did not interfere with the diagnostic vestibular
responses. With a recording balloon in the duo-
denum, Abbot et al. (Gastroenterology, 1952, 20,
238) observed that 100 mg. of dimenhydrinate
prevented duodenal spasm as well as vomiting
following caloric vestibular stimulation. Gay
(J.A.M.A., 1951, 145, 712) emphasized that no
patient with labyrinthine vertigo should be sub-
jected to surgery on the vestibular apparatus until
a trial of dimenhydrinate therapy had failed. In
refractory cases of migraine. Brentan (Rocky
Mountain M. J., 1950, 47, 197) found it useful at
the onset of the prodromal symptoms. In 3 cases
of chronic ulcerative colitis, Wilson (South. M. J.,
1951, 44, 797) reported symptomatic relief after
usual medication had been ineffective.

The only common side effect is drowsiness, in
most cases with large doses, as might be expected
from the diphenhydramine component. In many
therapeutic problems sedation is desirable.

Dose. — The usual dose is 50 mg. (about }i
grain) up to 4 times daily by mouth, with a range
of 50 to 100 mg. The maximum safe dose is 100
mg. and the total dose in 24 hours should not ex-
ceed 300 mg. For motion sickness, it should be
commenced prior to embarcation. For rectal ad-
ministration, 50 mg. of powder may be suspended
in 30 ml. of physiological saline solution. For
parenteral use a 5-ml. vial containing 50 mg. of
dimenhydrinate per ml. in a vehicle containing 5
per cent benzyl alcohol, 50 per cent propylene
glycol and water is available. The dose is 50 mg.
intramuscularly. For intravenous use, this dose
should be diluted with 10 ml. of sterile, isotonic
sodium chloride solution for injection. For oral or
rectal administration to children, the dose for 5 to
8 years of age is 12.5 to 25 mg., for 8 to 12 years
it is 25 to 50 mg.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

DIMENHYDRINATE TABLETS.

U.S.P.

"Dimenhydrinate Tablets contain not less than
95 per cent and not more than 105 per cent of the
labeled amount of C17H21NO.C7H7CIN4O2 "
U.S.P.

Usual Size. — 50 mg.

DIMERCAPROL. U.S.P., B.P., LP.

2,3-Dimercaptopropanol, BAL, [Dimercaprol]
CH2SH.CHSH.CH2OH

"Dimercaprol contains not less than 99 per
cent of C3H8OS2." U.S.P. The B.P. and LP. re-
quire not less than 98.5 per cent and not more
than the equivalent of 101.5 per cent of C3H8OS2.

LP. Dimercaprolum. British Anti-Lewisite.

Dimercaprol may be prepared by several proc-
esses, some of which are patented. In a typical
process a solution of sodium hydroxide in meth-

Part I

Dimercaprol 469

anol is saturated with hydrogen sulfide, forming
sodium sulfhydrate, NaSH, which is subsequently
treated with 2,3-dibromo-l-propanol, under pres-
sure and in an atmosphere of carbon dioxide;
following acidification dimercaprol may be ex-
tracted from the reaction mixture with chloro-
form and subsequently purified by distillation.
A small amount of ammonia, an ammonium salt,
or a carboxamide may be added as a stabilizing
agent.

Description. — "Dimercaprol occurs as a col-
orless or almost colorless liquid, with an offensive,
mercaptan-like odor. One Gm. of Dimercaprol
dissolves in about 25 ml. of water. It is soluble
in alcohol, in methanol and in benzyl benzoate.
The specific gravity of Dimercaprol is not less
than 1.238 and not more 1.240. Dimercaprol
boils at about 122° under a pressure of IS mm.
and at about 116° under a pressure of 10 mm."
U.S.P. The B.P. specifies tests to limit iron and
bromine, also a stability test in which dimercaprol
is heated at 140° for 2 hours without losing
more than 9.4 per cent of its content of CsHsOSa.
A test for freedom from abnormal toxicity, based
on a comparison of the effect of intramuscular
injections, in rats, of solutions of the dimercaprol
to be tested and of a pure standard preparation
of the substance, is also specified.

Assay. — A methanol solution of dimercaprol,
representing about 250 mg. of the latter, is ti-
trated with 0.1 N iodine to the production of a
permanent yellow color; a hydrogen atom is
removed from each of the sulfhydryl groups in
this reaction, the sulfur atoms simultaneously
becoming linked to each other. Each ml. of 0.1 N
iodine represents 6.211 mg. of C3H8OS2. U.S.P.
The B.P. assay is identical except that oxygen-
free nitrogen is passed through the sample for
about 10 minutes prior to assaying; this removes
hydrogen sulfide which may be present in the
oil.

Uses. — Dimercaprol is an effective agent for
treatment of poisoning by arsenic, gold, mercury
and perhaps other metals.

Action. — In 1909, Ehrlich advanced the theory,
based on studies by Heffter and his associates
several years earlier, that the toxicity of arsenic
is due to its combination with certain sulfhydryl
compounds which function in normal biologic
oxidation and reduction processes of living cells.
Voegtlin et al. (Pub. Health Rep., 1923, 38,
1882) subsequently demonstrated the detoxifying
effects of sulfhydryl compounds, such as gluta-
thione and cysteine, on arsenic. Peters et al.
(Nature, 1945, 156, 616) advanced the theory
that agents which combine with — SH groups in
tissues interfere with the functioning of the
pyruvate-oxidase system, which functions through
the tissue — SH groups. They demonstrated that
dithiol compounds have a greater affinity for
certain arsenicals, forming relatively nontoxic
compounds, than have either monothiols or the
so-called dithiol proteins of tissues. They pro-
posed that the toxic effects of arsenic in the
system may be overcome by introducing into
the system simple synthetic dithiols which would
successfully compete, for arsenic, with the dithiol
proteins of tissues, leaving the proteins unaffected

and free to function normally in the pyruvate-
oxidase system. The first compound to be thus
used was 2,3-dimercaptopropanol (dimercaprol),
being specifically proposed for use as a decon-
taminating and neutralizing agent against the
arsenical chemical warfare agent known as
Lewisite, for which reason the drug came to be
known as British Anti-Lewisite or BAL. Other
thiol compounds are also effective, but are less
active than BAL (Simpson and Young, Can. J.
Research, E, 1950, 28, 135).

Following intramuscular injection of dimer-
caprol, the maximum concentration is attained
in the blood at 2 hours, this decreasing to less
than half of the maximum at 4 hours; the drug
is entirely excreted or metabolized within 6 to
24 hours. For data on the metabolism of isotope-
labeled dimercaprol see Simpson and Young
(Biochem. J., 1950, 46, 634).

Ercoli and Carminati (Science, 1952, 116,
579) found that dimercaprol inhibited the
antispirochetal action, but not the antibacterial
action, of penicillin, bacitracin, and chloramphe-
nicol, as well as of gold and arsenic compounds,
but that it did not interfere with the action of
chlortetracycline, oxytetracycline or streptomy-
cin. In experimental infections in guinea pigs,
dimercaprol potentiated the action of chloram-
phenicol against Brucella melitensis (Renoux,
Ann. Inst. Pasteur, 1951, 81, 541).

Arsenic Poisoning. — Sulzberger and Baer
(J. A.M. A., 1947, 133, 293) summarized the
important effects of dimercaprol as follows: (1)
In both laboratory animals and human beings
the damage to the skin due to arsenical vesicant
agents of chemical warfare could be prevented
by the preceding application to the skin of dimer-
caprol preparations. (2) In both laboratory ani-
mals and human beings the damage to the skin
produced by arsenical vesicant agents of chemical
warfare could be arrested and probably even
reversed by the local application of dimercaprol
preparations two minutes to two hours after
exposure to the damaging agent. While this bene-
ficial action could be achieved by application of
dimercaprol to the skin, the parenteral adminis-
tration of the drug was much more effective.
(3) The systemic poisoning produced in labora-
tory animals by various arsenical agents, including
oxophenarsine hydrochloride, could be effectively
counteracted by dimercaprol. (4) In vitro ex-
periments on trypanosomes and spermatozoa
which had lost their motility and showed de-
generative changes due to arsenic poisoning
indicated that they regained their motility and
their normal appearance after addition of a
dithiol.

Dermatitis produced by antisyphilitic arsenical
drugs has been successfully treated both by inunc-
tion and by intramuscular administration of
dimercaprol; in the latter procedure either a 5
or 10 per cent solution of dimercaprol in peanut
oil, with 10 or 20 per cent, respectively, of
benzyl benzoate was administered. Eagle (/. Ven.
Dis. Inform., 1946, 27, 114) reported on 88
cases of arsenical dermatitis, 51 of which were
typical cases of exfoliative dermatitis; the average
time for definite improvement in 80 per cent of

470 Dimercaprol

Part I

the exfoliating conditions which responded to
treatment was 3 days, while the average time
for almost complete recovery was 13 days. Of
55 patients with toxic encephalitis arising from
arsenical therapy, of which 40 were either con-
vulsing or in coma at the time of start of dimer-
caprol therapy, 44 recovered completely within
1 to 7 days, while 1 1 died. In 1 1 cases of agranu-
locytosis recovery occurred in 10, death in one,
following treatment with dimercaprol. Of 4 cases
in which massive overdosing with oxophenarsine
hydrochloride occurred, 3 responded promptly,
while 1 died, after dimercaprol therapy. Some of
the failures in the foregoing series received doses
of dimercaprol which are now believed to have
been too small. Wade and Frazer {Lancet, 1953,
1, 269) reported benefit in a case of hepatitis
due to Fowler's solution. A case of subacute
arsenical polyneuritis which was aggravated by
treatment with dimercaprol was reported by
Sands et al. {New Eng. J. Med., 1950, 243, 558).
For Lewisite burns of the eye, 2 drops of a 3
to 5 per cent solution of dimercaprol should be
applied within 5 minutes of exposure.

Gold Poisoning. — Dimercaprol has proven
successful in the management of poisoning dur-
ing use of gold salts in the treatment of arthritis;
the most frequent reaction treated has been der-
matitis. A review of 50 cases reported in the
literature shows that over 90 per cent were
improved (Strauss et al., Ann. Int. Med., 1952,
37, 323). Treatment is most effective when
instituted soon after the onset of symptoms;
after several months dimercaprol has been in-
effective.

Mercury Poisoning. — Gilman et al. {J. Clin.
Investigation, 1946, 25, 549) found dimercaprol
to be effective also in the treatment of 23 cases
of acute poisoning by mercury bichloride, 22 of
the patients recovering. Treatment with intra-
muscular injections of dimercaprol was insti-
tuted as late as 19 hours after ingestion of up
to 20 Gm. of the poison. The initial amount used
for the first injection was 300 mg. (3 ml. of a
10 per cent solution) for 21 patients, and 150 mg.
for the two others (including the one who died).
The 21 patients received from 450 to 750 mg.
during the first 12 hours, and a total of 0.9 to
2.87 Gm. in a period of 3 to 4 days. Preferred
dosage in such cases would appear to be 300 mg.
(corresponding to about 5 mg. per Kg. of body
weight) initially, followed during the first 12
hours by 2 or even 3 further injections of 150 mg.
each. With this therapy instituted within 4 hours
of the ingestion of 1 Gm. or more of mercuric
chloride, Longcope et al. {Ann. Int. Med., 1949,
31, 545) reported survival of all of 41 cases of
poisoning, compared to their previous experience
of 31.4 per cent mortality. In experimental
studies, Fitzsimmons and Kozelka (/. Pharma-
col., 1950, 98, 8) found less mercury in the
kidneys but more in other tissues of monkeys
treated with dimercaprol for mercury poisoning;
a decreased excretion of mercury was found in
the urine. Adam {Brit. J. Pharmacol. Chemother.,
1951. 6, 483) studied the effect of dimercaprol on
the metabolism of radioactive mercuric chloride

in rabbits and confirmed the lesser amount in
the kidneys but in contrast reported an increase
in the rate of urinary excretion of the mercury*.
Dimercaprol inhibits the diuretic action of organo-
mercurial diuretics. A case of acrodynia ("pink
disease") in a child, resulting from subacute
mercury poisoning, responded to dimercaprol
therapy (Fischer and Hodes, /. Pediatr., 1952,
40, 143) confirming the similar report of several
cases by Warkany and Hubbard {Am. J. Dis.
Child., 1951, 81, 335) and others. The child
received 3.4 mg. of dimercaprol per Kg. of body
weight even' 4 hours for 6 days, and every 8
hours for another 10 days. Dimercaprol is useful
in the treatment of sensitization dermatitis due
to mercury compounds.

Other Metals. — In experimental poisoning
in rabbits dimercaprol has been found to be an
effective antidote also for antimony, bismuth,
chromium, and nickel; it is ineffective in treating
rabbits poisoned by lead, thallium, and selenium
(Braun et al., J. Pharmacol., 1946, 87, 119,
August Supplement). Clinical reports on poison-
ing with metals other than those discussed
previously indicate dimercaprol to have utility
in antimony dermatitis (Rittey, Lancet, 1950, 1,
255), in bismuth stomatitis, in chronic chrome
dermatitis (a zinc oxide paste containing 3 per
cent of dimercaprol was used topically by Cole.
Arch. Derm. Syph., 1953, 67, 30), in the objec-
tionable odor of body and breath resulting from
tellurium poisoning, and in thallium poisoning
(Welty and Berrey, J. Pediatr., 1950, 37, 756;
Schild and Schrader, Nervenarzt, 1952, 23, 281).
It has been found ineffective in counteracting
the toxicity of cadmium, iron, polonium (unless
given within 12 hours of exposure), selenium,
and silver. The results in lead poisoning have in
general been indefinite (see Ennis and Harrison.
Pediatrics, 1950, 5, 853; Bastrup-Madsen, Lancet,

1950, 2, 171).

The detoxifying action of dimercaprol against
metals has resulted in its trial in other conditions.
Denny-Brown and Porter {New Eng. J. Med.,

1951, 245, 917) reported that dimercaprol in-
creased copper excretion in cases of hepatolentic-
ular degeneration (Wilson's disease) and im-
proved the neurological symptoms. A decrease in
the bilirubinemia in some cases of acute hepatitis
was observed by Wildhirt {Klin. Wchnschr., 1952,
30, 42). Inhibition of alloxan diabetes in rats
was reported by Sen and Bhattacharya {Science,

1952, 115, 41). In hypertensive patients a de-
crease in blood pressure, rather than the usual
increase (see under Toxicology), was observed
(Schroeder, ibid., 1951. 114, 441). In 23 cases
of infectious neuronitis (Guillain-Barre syn-
drome) von Hagen and Baker {J.A.M.A., 1953.
151, 1465) reported benefit from dimercaprol
therapy. Prompt improvement in a child with
bulbar poliomyelitis during treatment with dimer-
caprol was observed by Eskwith {Am. I. Dis.
Child., 1951, 81, 684).

For further information concerning clinical
uses of dimercaprol see the series of papers in
/. Clin. Inv., 1946, 25, 451 to 567, also Randall
and Seeler, New Eng. J. Med., 1948. 239, 1004,

Part I

Dimethyl Phthalate 471

1040; for pharmacological reports see /. Pharma-
col., 1946, 87, August Supplement, also Larson,
Confinia Neurol., 1950. 10, 108. H

Toxicology. — -Dimercaprol is not an innocu-
ous substance. When administered to humans at
a dose level of 2.5 to 3 mg. per Kg. of body
weight at intervals of 4 hours on two successive
days signs of toxicity are barely noticeable. Doses
of 4 to 5 mg. per Kg., however, may produce
nausea, vomiting, headache, burning sensation of
the lips, mouth, throat and eyes, pain in the
teeth, lacrimation and salivation, muscular aches,
burning and tingling of the extremities, a feeling
of constriction of the throat and chest, and ele-
vation of systolic and diastolic blood pressure.
These effects are at their maximum in 15 to 20
minutes after intramuscular administration; the
symptoms are usually transitory. An established
reaction is alleviated by epinephrine or ephedrine.
A dose of diphenhydramine hydrochloride, 50 mg.,
given half an hour before injection of dimer-
caprol, minimizes the discomfort (Holley. Am. J.
Syph. Gonor. Ven. Dis., 1950, 34, 490). When
applied to the skin dimercaprol causes local ery-
thema and edema; skin sensitization to dimer-
caprol ointment was reported by Jenkins {Ann.
Allergy, 1949, 7, 807). Dimercaprol is extremely
irritating when applied to mucous surfaces, pro-
ducing edema and severe ulcerations of respira-
tory passages and gastric mucosa. The 5 to 10
per cent solutions in oil may be injected, or even
applied to the eye, without producing damage.

Dose. — The usual dose, intramuscularly, is 25
mg. (approximately Y% grain) per 10 Kg. (about
22 pounds) of body weight, repeated four times
at intervals of 4 hours on the first and second
days, twice on the third day and once daily for
the next 5 days. The range of dose is 25 to 50 mg.
per 10 Kg. The maximum safe dose should
ordinarily not exceed 50 mg. per 10 Kg.; more
than 6 doses in 24 hours is seldom employed. For
small children, the doses are given at intervals
of 4 to 8 hours. For mercuric chloride poisoning
the initial dose is 50 mg. per 10 Kg. (v.s.). For
topical application a 1 to 3 per cent concentration
may be used.

Storage. — Preserve "in tight containers in a
cold place." U.S.P.

DIMERCAPROL INJECTION.
U.S.P. (B.P, LP.)

[Injectio Dimercaprolis]

"Dimercaprol Injection is a sterile solution of
dimercaprol in a mixture of benzyl benzoate and
oil. It contains, in each 100 ml., not less than 9
Gm. and not more than 11 Gm. of C3H8OS2."
U.S.P. The B.P. requires a content of dimer-
caprol equivalent to 5 per cent w/v of C3H8OS2
(limits, 4.9 to 5.1). The LP. rubric is identical
with that of the U.S.P.

B.P. Injection of Dimercaprol. Injection of B.A.L.

The B.P. directs the injection to be prepared
by dissolving 5 Gm. of dimercaprol in 9.6 ml. of
benzyl benzoate, adding sufficient arachis oil to
make 100 ml. of solution, then enough 5 N alco-

holic ammonia to produce a pH between 6.8
and 7.0 in the aqueous layer when a portion of
the injection is shaken with an equal volume of
water for 2 minutes. The oily solution thus pre-
pared is mixed with about 200 mg. of decoloriz-
ing charcoal, allowed to stand for not less than
one hour, and filtered. After distributing the
solution in ampuls in which the air has been
replaced by nitrogen, and the ampuls immedi-
ately sealed, the injection is sterilized by heating
at 150° for one hour. The benzyl benzoate is in-
cluded for the purpose of solubilizing the dimer-
caprol.

Description. — "Dimercaprol Injection is a
yellow, viscous solution having a pungent, offen-
sive odor. Its specific gravity is about 0.978."
U.S.P. The B.P. gives the weight per ml. of its
injection, which is half the strength of the U.S.P.
preparation, as between 0.940 and 0.955 Gm.,
at 20°.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass."
U.S.P.

Usual Size. — 450 mg. (approximately 7
grains) in 4.5 ml.

DIMETHYL PHTHALATE. U.S.P., B.P.

Methyl Phthalate, [Dimethylis Phthalas]

,C00CH3

COOCH,

"Dimethyl Phthalate contains not less than 98
per cent of C10H10O4." U.S.P. The B.P. rubric is
the same.

Dimethyl phthalate may be prepared by the
esterifi cation of phthalic acid anhydride and
methyl alcohol under the influence of hydrogen
chloride or concentrated sulfuric acid.

Description. — "Dimethyl Phthalate is a clear,
colorless, or practically colorless, oily liquid hav-
ing a slight aromatic odor. It is stable in air,
but is slowly affected by light. Dimethyl Phthal-
ate is insoluble in water. It is miscible with
alcohol, with ether, and with chloroform. The
specific gravity of Dimethyl Phthalate is not less
than 1.188 and not more than 1.192." U.S.P.

Standards and Tests. — Distilling range. —
Not less than 95 per cent distils between 278°
and 285°. Refractive index. — Between 1.5130
and 1.5170, at 20°. Identification. — A mixture of
resorcinol, sulfuric acid and dimethyl phthalate is
heated over a free flame until sulfur trioxide
fumes begin to evolve; on pouring the cooled
solution into a dilute sodium hydroxide solution
a vivid green fluorescence is produced; the fluo-
rescence disappears on acidifying the solution and
reappears when it is made alkaline. Acidity. —
Not more than 2.8 ml. of 0.02 N sodium hydrox-
ide is required for neutralization of 20 ml. of di-
methyl phthalate, using thymol blue T.S. as indi-
cator (corresponding to not more than 0.02 per
cent phthalic acid). U.S.P.

Assay. — A sample of about 2 Gm. of dimethyl
phthalate is saponified by heating with 0.5 N

472 Dimethyl Phthalate

Part I

alcoholic potassium hydroxide, the excess alkali
being titrated with 0.5 N hydrochloric acid using
thymol blue T.S. as indicator. A residual titra-
tion blank is performed. Each ml. of 0.5 N alkali
required for the saponification represents 48.55
mg. of CioHiuCU. L'.S.P.

Uses. — Dimethyl phthalate has found exten-
sive use as an insect repellent, being very effective
against mosquitoes, mites, ticks, fleas and midges.
For general use it is especially effective when
combined with butopyronoxyl and ethohexadiol
in the proportions represented in the official
Compound Dimethyl Phthalate Solution (see fol-
lowing monograph) but various formulations
containing dimethyl phthalate as the sole active
ingredient, for application to the body and to
clothing, are or have been used.

Toxicology. — Dimethyl phthalate appears to
have no irritant or toxic effects that are severe
enough to make its ordinary use hazardous.
Accidental ingestion of it was followed by a
burning sensation in the mouth, and after 2
hours by coma (Doehring and Albritton, Bull.
U. S. Army M. Dept., 1944, 81, 12); recovery
followed gastric lavage and parenteral adminis-
tration of caffeine and sodium benzoate, and 5
per cent dextrose solution (intravenously).

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

COMPOUND DIMETHYL PHTHAL-
ATE SOLUTION. U.S.P.

622 Mixture

Dissolve 200 Gm. of ethohexadiol and 200 Gm.
of butopyronoxyl in 600 Gm. of dimethyl phthal-
ate and mix thoroughly. L'.S.P.

U.S.P. Insect Repellent.

Uses. — This combination of three new insect
repellents and toxicants, commonly known as
6-2-2 mixture, is the one which laboratory and
field tests have shown to be effective against a
wider range of insect species and on more indi-
viduals than any one of its three active compo-
nents when used alone. Although developed
primarily for use by the United States Army, the
mixture can also be used safely by civilians.
Travis et al. (J. Econ. Entomol., 1946, 39, 627)
found the solution to be actively repellent against
mosquitoes, flies, biting gnats and red bugs
(mites); when properly applied it acts also as a
toxicant to mite larvae or chiggers. killing these
rather than repelling them. Though no substance
which is safe to use provides complete protection
from ticks, a considerable measure of protection
is afforded against the lone star tick, the most
abundant of the species.

When used as a repellent against mosquitoes,
flies and gnats the solution may be applied di-
rectly by placing a few drops in the palms, smear-
ing the liquid evenly and rubbing it on the ex-
posed areas of the skin to produce a protective
oily film. One treatment may last several hours
on some people but not so long on others; when
the insects resume biting another application of
the solution should be made. To prevent insects
biting through clothing and also to afford protec-

tion against chiggers and ticks the solution should
be applied to the clothing with a small hand
sprayer or rubbed on in the same manner that
application is made to the skin. Shirts, stockings
or other garments may be treated by saturating
them with a solution or an emulsion of the
repellent. To produce an emulsion easily and
quickly the official solution may be modified by
dissolving 10 parts by weight of an emulsifier
such as Stearate 61-C-2280 (polyalkylene glycol
stearate, Carbide and Carbon Chemicals Corpora-
tion), Tween 60 (polyoxyethylene sorbitan mono-
stearate. Atlas Powder Company), Tween 80
(polysorbate 80, U.S.P.. or polyoxyethylene sorbi-
tan monooleate), glycol monostearate or glycol
monooleate or other suitable emulsifier or mix-
ture of emulsifiers in 90 parts by weight of com-
pound dimethyl phthalate solution; for use 8
fluidounces of this modified solution is vigorously
agitated with 1 to 1.5 pints of water to form a
creamy emulsion which is then diluted with suffi-
cient water to make one gallon of finished emul-
sion. A gallon is sufficient to dip a set of field
trousers, shirts and socks; after dipping, the
garments are wrung out lightly and allowed to
dry. Clothing thus treated will retain its insect-
repellent property for 2 or 3 days of ordinary
wear; washing or prolonged soaking with water
will remove the active material. For further in-
formation concerning the solution, see Travis.
Morton and Smith's "Use of Insect Repellents
and Toxicants," publication E-698 (Revised,
June 1949), U. S. Department of Agriculture,
Bureau of Entomology and Plant Quarantine.

Because the components of Compound Di-
methyl Phthalate Solution possess solvent ac-
tion on plastics and rayons the solution should
not be allowed to come in contact with articles
made of these substances.

DIMETHYL TUBOCURARINE
IODIDE. N.F.

C40H48I2X2O6

Dimethyl tubocurarine results from methylation
of the two phenolic groups of tubocurarine (see
formula under Tubocurarine Chloride) by inter-
action with methyl iodide.

Metubine Iodide (Lilly).

Description. — "Dimethyl Tubocurarine Iodide
occurs as an odorless, white or pale yellow crys-
talline powder. Dimethyl Tubocurarine Iodide is
slightly soluble in water, in diluted hydrochloric
acid, and in diluted solutions of sodium hydroxide.
It is very slightly soluble in alcohol, and prac-
tically insoluble in benzene, in chloroform, and in
ether." X.F.

Standards and Tests. — Identification. — (1)
On heating to about 257° dimethyl tubocurarine
iodide decomposes with evolution of gas. (2) A
curdy, yellow precipitate of silver iodide, insolu-
ble in ammonia T.S., is produced on adding silver
nitrate T.S. to a solution of dimethyl tubocurarine
iodide containing some nitric acid. (3) A pink
precipitate is produced on adding ammonium
reineckate solution to one of dimethyl tubo-
curarine iodide. (4) A yellow precipitate is pro-

Part I

Dioctyl Sodium Sulfosuccinate 473

duced on adding picric acid solution to one of
dimethyl tubocurarine iodide. Loss on drying. —
Not over 7 per cent, when dried in a vacuum at
75° for 8 hours. Specific rotation. — Not less than
+ 148° and not more than +158°, calculated on
the anhydrous basis, when determined in a solu-
tion in water containing 25 mg. in each 10 ml.
Tubocurarine chloride. — A colorless or very faintly
blue solution is obtained on adding Folin-Ciocalteu
reagent for phenols. N.F.

Uses. — Like tubocurarine chloride, dimethyl
tubocurarine iodide is used to relax skeletal
muscles by action on the myoneural junction.
For a general discussion of agents acting thus see
the monograph on Curarimimetic Agents, in Part
II. By the rabbit head-drop method of testing
dimethyl tubocurarine iodide shows a potency
considerably greater than that of tubocurarine
chloride (Swanson et al., J. Lab. Clin. Med., 1949,
34, 516). The accepted potency of dimethyl tubo-
curarine iodide by biologic assay is 6 times that
of tubocurarine chloride, making 0.025 mg. of
dimethyl tubocurarine iodide equivalent to 0.15
mg. of tubocurarine chloride by such assay, which
latter quantity (of tubocurarine chloride) corre-
sponds to one unit of activity. This several-fold
greater activity of dimethyl tubocurarine iodide
over tubocurarine chloride obtains also for rats
and cats, but the former is less effective than the
latter compound in mice (Collier and Hall, Brit.
M. J., 1950, 1, 1293; Collier et al, Nature, 1948,
161, 817). In humans dimethyl tubocurarine io-
dide is about 3 times as active as tubocurarine
chloride (see Unna et al., J.A.M.A., 1950, 144,
448).

In a report on the effect of intravenous admin-
istration of dimethyl tubocurarine iodide to 225
patients receiving general anesthesia for all types
of surgery Stoelting et al. (Anesth. & Analg.,
1949, 28, 130; 1950, 29, 282) concluded that it
is superior to tubocurarine chloride for producing
muscular relaxation during operation since re-
spiratory depression was seldom encountered and
was of a minor degree when present. The degree
of relaxation is comparable to that obtained with
tubocurarine chloride, but the duration of action
is decidedly prolonged as compared with the latter
drug. No cardiovascular or cerebral effects were
noted and there was no evidence of histamine-like
action or autonomic nervous system involvement.
The drug is effective whether the anesthetic agent
is a barbiturate, cyclopropane, ethyl ether, or
nitrous oxide. It has been considered by some to
be the curarizing agent of choice in anesthesia for
thoracic surgery because of its relative freedom
from histamine-like reactions and also by virtue
of its reliability (Wilson et al., Brit. M. J., 1950,
1, 1296).

Curariform drugs are contraindicated in cases
of respiratory depression, advanced pulmonary
disease and myasthenia gravis (unless as a diag-
nostic test in minute doses).

Dose. — The usual initial dose of dimethyl tubo-
curarine iodide, given intravenously in isotonic
sodium chloride solution over a period of 30 to 60
seconds, is 2 mg.; the size of the dose will de-
pend on the type of general anesthetic employed
and the depth of anesthesia. With cyclopropane

a dose of 2 to 4 mg. is suggested; with ether, 1.5
to 3 mg. ; with nitrous oxide or thiopental so-
dium, 3 to 8 mg. The initial dose may be ex-
pected to provide relaxation for 25 to 90 minutes,
after which supplemental injections of from 0.5
mg. to 1 mg. may be made as required and indi-
cated by the depth of surgical relaxation. Respira-
tory paralysis should be treated promptly by
artificial respiration; neostigmine methylsulfate
in 1:2000 solution should be given in 1 to 2 ml.
doses intravenously to combat respiratory depres-
sion except when this is associated with fall in
blood pressure due to excessive curarization. Atro-
pine sulfate may be given to control the excessive
secretion caused by the neostigmine.

Storage. — Preserve "in tight containers." N.F.

DIMETHYL TUBOCURARINE
IODIDE INJECTION. N.F.

"Dimethyl Tubocurarine Iodide Injection is a
sterile solution of dimethyl tubocurarine iodide
in isotonic sodium chloride solution. Each ml.
exhibits a potency equivalent to not less than 93
per cent and not more than 107 per cent of the
potency stated on the label in milligrams of N.F.
Dimethyl Tubocurarine Iodide Reference Stand-
ard." N.F.

Metubine lolide Solution (Lilly).

The injection is assayed by injecting into the
marginal ear vein of suitably restrained rabbits
sufficient of a dilution of the injection to cause
head-drop; quantitative comparison is made by
similar injection of a solution containing a known
quantity of dimethyl tubocurarine iodide refer-
ence standard. N.F.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass.
Phenol, 0.5 per cent, or some other suitable bac-
teriostatic substance, must be added to the injec-
tion in multiple-dose containers." N.F.

Usual Sizes. — 5 mg. in 10 ml.; 10 mg. in 10
ml.; 40 mg. in 20 ml.; 50 mg. in 50 ml.

DIOCTYL SODIUM SULFOSUCCI-
NATE. U.S.P.

[Dioctylis Sulfosuccinas Sodicum]

COO-CH2-CH-(CH2)3-CH3

CH2
I

CH-S03Nq
I
COO- CH2-CH- (CH2)3-CH3

C2H5

"Dioctyl Sodium Sulfosuccinate contains not
less than 7.00 per cent and not more than 7.25
per cent of S." U.S.P.

Bis(2-ethylhexyl) Sodium Sulfosuccinate. Aerosol OT
(American Cyanamid and Chemical Corp.)

Of the more than 200 esters of sodium sulfosuc-
cinic acid which have been investigated for effec-
tiveness as surface-tension-reducing and wetting
agents the one most useful is the dioctyl — more

474 Dioctyl Sodium Sulfosuccinate

Part I

specifically bis(2-ethylhexyl) — sodium sulfosucci-
nate. This surface-active agent may be prepared
by esterifying maleic anhydride with 2-ethylhexyl
alcohol, then adding sodium bisulfite to the re-
sulting di (2-ethylhexyl) maleate to form di(2-
ethylhexyl) sodium sulfosuccinate. Other esters of
the series may be prepared similarly; for data
concerning them, as well as dioctyl sodium sulfo-
succinate. see Caryl (Ind. Eng. Chem., 1941, 33,
731).

Description. — "Dioctyl Sodium Sulfosucci-
nate occurs as a white, wax-like, plastic solid with
a characteristic odor suggestive of octyl alcohol.
One Gm. of Dioctyl Sodium Sulfosuccinate dis-
solves slowly in approximately 70 ml. of distilled
water. It is freely soluble in alcohol and in glyc-
erin and is verv soluble in petroleum benzin."
U.S.P.

Standards and Tests. — Loss on drying. — Not
over 2.5 per cent when dried for 4 hours at 105°.
Residue on ignition. — Not less than 16 per cent
and not more than 17 per cent. Saponification
value. — Not less than 240 and not more than 253.
U.S.P.

Assay. — About 200 mg. of dioctyl sodium sul-
fosuccinate is mixed with sodium peroxide, potas-
sium chlorate and sucrose, and ignited in a Parr
bomb. The residue is dissolved in hot distilled
water and the sulfate in the solution precipitated
as barium sulfate, which is collected, washed and
ignited to constant weight. Each Gm. of barium
sulfate represents 137.4 mg. of S. U.S.P.

Uses. — Dioctyl sodium sulfosuccinate is a sur-
face-active agent (see under this title in Part II)
of the anionic type and its uses are based on this
property. In 0.1 per cent aqueous solution it re-
duces the surface tension from 72.0 to 28.7 dynes
per centimeter, the maximum reduction obtainable
with the substance. Aqueous solutions are prac-
tically neutral and resist precipitation by even
the hardest waters.

Benaglia et al. (J. Indust. Hyg. Toxicol., 1943,
25, 175) reported the toxicity of dioctyl sodium
sulfosuccinate to be of a very low order when
tested on rats, dogs, rabbits, and monkeys. In
connection with the use of various surface-active
agents in ophthalmic preparations to increase their
penetrant action, Leopold (Arch. Ophth., 1945,
34, 99) found that damage followed use of too
strong solutions of such agents, including dioctyl
sodium sulfosuccinate; conjunctival edema, mu-
coid discharge, and sloughing of cells are charac-
teristic of the effects produced in rabbits' eyes
by strong solutions. In 0.5 per cent solution re-
tardation of regeneration of corneal epithelium
was marked; the effect persisted to some extent
even with 0.1 per cent solutions of various surface-
active agents. Leopold believes that surface-active
agents should not be recommended for repeated
use in eyes with corneal lesions; if they are used
the maximum concentration should be 0.1 per
cent. Patients with intact cornea should be
warned to expect irritation and blepharospasm to
follow application of ophthalmic preparations
containing such agents, and should be examined
at routine intervals to determine whether any
local toxic effects are appearing.

Gershenfeld and Perlstein (Am. J. Pharm.,

1941, 113, 237) and Gershenfeld and Milanick
(Am. J. Pharm., 1941. 113, 306) studied the anti-
septic properties of several surface tension depres-
sants and their effects on the bactericidal efficiency
of several antiseptics. Dioctyl sodium sulfosuc-
cinate enhances the activity of phenol, mercuric
chloride, merthiolate, and hexylresorcinol, but
zephiran and zonite were found to be incompatible
with the surface-active agent. Tobie and Orr (/.
Lab. Clin. Med., 1945, 30, 741) reported that 0.1
per cent of dioctyl sodium sulfosuccinate increases
the phenol coefficient of germicides as follows:
phenol, from 1.0 to 1.8; U.S.P. cresol, from 2.4
to 4.4.

Dioctyl sodium sulfosuccinate may be employed
as a dispersing agent and emulsifying aid in the
formulation of various dermatological prepara-
tions. Excellent soapless shampoos, which produce
a copious lather and have remarkable detergent
power, may be prepared with it ; typical formulas
of lotions and creams, and shampoos suitable for
dry and for oily hair have been published by
Duemling (Arch. Dermat. Syph., 1941, 43, 264).
It is sometimes employed for its solubilizing ac-
tion; for example, clear solutions of cresol in
water may be prepared by its inclusion in the
system.

In addition to the solid material, a 25 per cent
and a 10 per cent solution of dioctyl sodium sulfo-
succinate are commercially available.

Storage. — Preserve "in well-closed containers."
U.S.P.

DIPHENAN. B.P.

Diphenanum
C6H5CH2.C6H4O.CONH2

The B.P. defines Diphenan as />-benzylphenyl
carbamate and requires it to contain' not less
than 99.5 per cent and not more than the equiva-
lent of 101.0 per cent of C14H13O2N, calculated
with reference to the substance dried to constant
weight at 105°.

Diphenan may be prepared, according to the
B.P., by the action of ammonia upon p-benzyl-
phenyl chloroformate.

Butolan (Bayer Products); Oxylan (Burroughs Well-
come) .

Description and Tests. — Diphenan is a
white or very pale cream crystalline powder,
odorless and tasteless. It is almost insoluble in
water; sparingly soluble in alcohol; soluble in
dehydrated alcohol, in chloroform, and in ether.
The melting point is between 147° and 150°.
On warming diphenan with sulfuric acid the
liquid becomes dark brown and carbon dioxide
is evolved. The loss on drying at 105° is not over
0.5 per cent. Limit tests for ammonia and chloride
are provided. Sulfated ash is not above 0.1
per cent.

Assay. — Diphenan is assayed for nitrogen by
the Kjeldahl method. Each ml. of 0.1 X sulfuric
acid represents 22.73 mg. of C14H13NO2.

Uses. — Diphenan is used for the treatment of
oxyuriasis (enterobiasis), commonly known as
pinworm, seatworm or threadworm infestation.
In the small intestine, where the worm eggs are

Part I

Diphenhydramine Hydrochloride 475

hatched, diphenan is extensively hydrolyzed to
form p-benzylphenol, C6H5CH2.C6KUOH, which
even in 1 :4000 dilution is said to produce ex-
treme contraction of the worms, killing them in
about five minutes (Schulemann, Deutsche med.
Wchnschr., 1920, 46, 1050). Diphenan is claimed
to be less toxic to the host than is gentian violet
(MacKeith and Watson, Pract., 1948, 160, 264).
The drug may be given to young children, a popu-
lar method of administering it being to mix a
pulverized tablet with jam; enteric coating is
not required since diphenan will not burn the
mouth or produce nausea or other gastric dis-
tress. Mild diarrhea is sometimes encountered.
Miller and Choquette (Can. Med. Assoc. J.,
1950, 62, 271) found eggs in 31 of 37 children
who had received two courses of treatment with
diphenan; a third course was given to 12 of these
children and though the dose in half of the cases
was as great as 4.5 Gm. daily, eggs were still
found at the conclusion of the treatment.

Dose. — The following dosages are to be given
three times daily, after meals, for a period of
one week: For adults, 500 mg. to 1 Gm. (approxi-
mate lYi to 15 grains) ; for older children, 500 mg.
(approximately 7>4 grains); for children up to 12
years. 250 mg. (approximately 4 grains); for in-
fants, 125 mg. (approximately 2 grains). A saline
laxative as required, followed at the end of the
course of treatment by a senna-type or magne-
sium sulfate purgative is recommended. Enemas
are preferably given each night during the course
of treatment and every second night thereafter
until swabs are negative; these consist of a pre-
liminary bowel wash using one level teaspoonful
of sodium bicarbonate in 8 fluidounces of warm
water, after expulsion a solution of one level
tablespoonful of sodium chloride in 8 fluidounces
of warm water is retained for at least 10 minutes.
A second course of treatment with diphenan is
necessary if perianal swabs taken a week after
completion of the first course show worms or
eggs under the microscope.

Usual Dispensing Form. — In flavored chew-
ing wafers containing 0.5 Gm. diphenan.

DIPHENHYDRAMINE HYDRO-
CHLORIDE. U.S.P., LP.

Diphenhydraminium Chloride, 2-(Benzhydryloxy)-N,N-

dimethylethylamine Hydrochloride, [Diphenhydramines

Hydrochloridum]

o*~

CH2CH2N+(CH3)2

"Diphenhydramine Hydrochloride, dried at
105° for 3 hours, contains not less than 98 per
cent of C17H21NO.HCI." U.S.P. The LP. requires
not less than 98.0 per cent of the same constitu-
ent, calculated with reference to the substance
dried at 105° for 3 hours.

LP. Diphenhydramini Hydrochloridum. Benadryl Hy-
drochloride (Parke, Davis).

According to U. S. Patent 2,421,714 (June 3,

1947) this antihistamine, which is the hydrochlo-
ride of diphenylmethyl ether of P-dimethylami-
noethanol, may be prepared by the interaction of
diphenylmethyl bromide, dimethylaminoethanol
and sodium carbonate at 125° for 5 hours.

Description. — "Diphenhydramine Hydrochlo-
ride occurs as a white, odorless, crystalline pow-
der. It slowly darkens on exposure to light. Its
solution is practically neutral to litmus. One
Gm. of Diphenhydramine Hydrochloride dis-
solves in about 1 ml. of water, in 2 ml. of alcohol,
in 2 ml. of chloroform, and in 50 ml. of acetone.
It is very slightly soluble in benzene and in ether.
Diphenhydramine Hydrochloride melts between
166° and 170°." U.S.P.

Standards and Tests. — Identification. — (1)
A pink-colored precipitate is produced on adding
ammonium reineckate T.S. to a 1 in 100 solution
of diphenhydramine hydrochloride. (2) The pic-
rate of diphenhydramine melts between 128° and
132°. (3) Diphenhydramine hydrochloride re-
sponds to tests for chloride. Loss on drying. — Not
more than 0.5 per cent, when dried at 105° for 3
hours. Residue on ignition. — Not over 0.1 per
cent. U.S.P.

Assay. — About 300 mg. of dried diphenhy-
dramine hydrochloride is dissolved in water; so-
dium chloride and sodium hydroxide are added
and the liberated diphenhydramine base is ex-
tracted with ether. The amine is finally estimated
by residual titration using 0.05 N solutions of
sulfuric acid and sodium hydroxide. Each ml. of
0.05 N acid represents 14.59 mg. of C17H21NO.-
HC1. U.S.P. The LP. assay is the same except for
use of 0.1 N volumetric solutions.

Uses. — Diphenhydramine hydrochloride is
used orally, topically and parenterally in the
symptomatic treatment of urticaria, hay fever,
and other allergic disorders and it is reported
to be useful also in a great variety of disorders
only indirectly if at all related to histamine. Of
the many antihistaminic drugs available, it has
a considerable sedative action, which should be
utilized where sedation is therapeutically useful
but avoided in individuals engaged in hazardous
activities. Newer antihistaminic drugs have added
little except efficacy in a smaller dose, less seda-
tive action, longer duration of therapeutic action
and differences in relative anticholinergic, adre-
nergic or permeability actions which often prove
advantageous in specific therapeutic problems.

Historical. — This was the first antihistaminic
drug available in the United States (see also
general discussion of Antihistaminic Drugs in
Part II). Its action has served as a standard for
comparison in the development of the many
others now available. In 1945, Loew et al. (J.
Pharmacol., 1945, 83, 120) introduced the anti-
histaminic concept with diphenhydramine. Its
efficacy in urticaria was demonstrated by Curtis
and Owens (Arch. Dermat. Syph., 1945, 52,
239) and in hay fever and vasomotor rhinitis by
McElin and Horton (Proc. Mayo, 1945, 20, 417).

Action. — Diphenhydramine and other antihis-
taminic drugs are specific blocking agents which
diminish or abolish the effects of histamine on
smooth muscle and endothelial cells. They in-
hibit the contracting or spasmogenic action of

476 Diphenhydramine Hydrochloride

Part I

histamine on the smooth muscle of the bronchi-
oles, gastrointestinal tract and uterus. They pre-
vent the permeability-increasing action of
histamine on capillary endothelium and the vaso-
dilating action on the capillaries. In therapeuti-
cally effective doses, they do not inhibit the
stimulating action of histamine on gastric secre-
tion. The antiallergic action arises from the
inhibition of the effects of histamine. Therapeu-
tic doses have no significant effect on the blood
pressure, heart or gastrointestinal tract. They pro-
tect the body from the effects of exogenous or
endogenous histamine. Other drugs used in the
management of allergic disorders, such as epi-
nephrine or aminophylline, combat the various
physiological responses to histamine by their own
pharmacologic action, which is opposed to that of
histamine on the particular organ. Antihistaminic
drugs provide symptomatic relief in allergic dis-
orders by protecting the cells from the effects of
free histamine released by the pathological con-
dition (see Loew. Attn. N. Y. Acad. Sc, 1950,
50, 1142). ■

In metabolic studies of diphenhydramine by
Glazko and Dill (/. Biol. Chem., 1949, 179,
403) in the rat and guinea pig, the highest con-
centration of the drug was found, about 1 hour
after oral or parenteral administration, in the
lung (particularly after injection), spleen and
liver. After 6 hours little could be found in the
animal. Only 5 to 15 per cent of a dose can be
found in the urine in 24 hours (McGavack et al.,
J. Allergy, 1948, 19, 251; Hald, Acta Pharmacol,
toxicol, 1949, 3, 296). Studies of the drug
labeled with radioactive carbon- 14 indicated
that degradation products appeared in the urine
in greater amount than the unchanged drug
(Glazko et al, J. Biol. Chem., 1949, 179, 409);
the presence of enzymes in the tissues which
had such degradative action was demonstrated
by Glazko and Dill {ibid., 417). Studies of the
pharmacological actions of large doses in animals
were reported by Winder and Thomas (/. Phar-
macol, 1947, 91, 1).

A drug which will afford protection against
histamine shock will also protect against anapyh-
lactic shock at approximately the same dosage,
according to Feinberg et al (J. Pharmacol, 1950,
99, 95) on the basis of extensive quantitative
studies of 26 products for protection against his-
tamine intravenously, anaphylactic shock, and
histamine aerosol. Diphenhydramine, tripelenna-
mine and pyrilamine were found to be the most
effective of 13 antihistaminic substances tested
by Sternberg et al (J.A.M.A., 1950, 142, 969)
for ability to raise the histamine skin-whealing
threshold in man. Hearin and Mori (/. Invest.
Dermat., 1950, 14, 391) confirmed the efficacy
of diphenhydramine in this procedure. In micro-
scopic studies in animals, Matoltsy and Matoltsy
(/. Pharmacol, 1951, 102, 237) demonstrated
that diphenhydramine inhibited the increased
phagocytosis of carbon particles by the capillary
endothelium caused by histamine or trauma.
Landau et al. (J. Allergy, 1951, 22, 19) studied
the local anesthetic action of many antihistaminic
drugs and concluded that there was no correlation
between spasmolytic and anesthetic action; the

local anesthetic power of diphenhydramine was
about half that of the most potent, i.e., prometha-
zine and antazoline. In pharmacological studies
on blood pressure or the isolated muscle strip.
Eckert and Vartiainen (Acta Pharmacol Toxicol,
1949, 5, 347) observed that tissues were more
sensitive to histamine following a previous inhi-
bition of histamine action with diphenhydramine.
West and Peterson (/. Allergy, 1949, 20, 344)
reported that some of the antihistaminic drugs,
including diphenhydramine, increased the excre-
tion of ascorbic acid by rats but Tepperman
et al (J. Pharmacol, 1951, 101, 144) did not
find any change in the adrenal ascorbic acid
concentration after diphenhydramine nor any
protection against the decreased adrenal ascorbic
acid concentration caused by histamine. Lucia
et al. (J. Lab. Clin. Med., 1953, 41, 574; re-
ported that the addition of diphenhydramine to
whole blood prior to transfusion decreased the
incidence of minor transfusion reactions; they
found that it and pyrilamine inhibited isoaggluti-
nation of the red blood cells. A study of the
effect of this antihistaminic chemical on the
action of anti-human-globulin serum on sensi-
tized human erythrocytes (Coombs' test) was
unsatisfactory with diphenhydramine, which
caused hemolysis, although pyrilamine and tri-
pelennamine seemed to retard the agglutination
in this test. An extensive study of the sedative
action of chemicals structurally related to di-
phenhvdramine was reported by Weidmann and
Petersen (/. Pharmacol, 1953, 108, 201).

Allergic Disorders. — Diphenhydramine is
useful in the symptomatic management of all
allergic conditions. In ambulatory, working pa-
tients, its chief disadvantage is the high incidence
of drowsiness (up to 60 per cent) in clinically
effective doses. Diphenhydramine hydrochloride
has proved to be most effective in acute urticaria
and hay fever. Its oral administration in bronchial
asthma has been disappointing, except in mild
cases (Loveless and Brown, New Eng. J. Med.,
1947, 237, 501). Herxheimer (Brit. M. J., 1949,
2, 201) reported benefit in asthma when used
prophylactically rather than after the seizure has
commenced. Rubitsky et al. (New Eng. J. Med.,
1949, 241, 853) recommend intravenous adminis-
tration of the drug to patients with status
asthmaticus, followed by inhalation of an aerosol
or rectal administration; in further studies (/.
Allergy, 1950, 21, 559) in humans, it was re-
ported that aminophylline or ephedrine potenti-
ated the action of diphenhydramine in protecting
against histamine but not against methacholine.
In contact dermatitis, drug eruptions, atopic
dermatitis and neurodermatitis, diphenhydramine
is useful to stop the itching. There is improve-
ment in the lesion as a result of lessened trauma
and infection from scratching, but the etiological
factor must be sought and eliminated. Effective-
ness of the drug in perennial rhinitis, particularly
in cases complicated by infection of the upper
respiratory tract or by psychosomatic disorders,
is often unsatisfactory. In patients with acute
urticaria, arthralgia and nervousness failing to
respond quickly to antihistaminic therapy by
mouth, Parker (Ann. Allergy, 1950, 8, 765) re-

Part I

Diphenhydramine Hydrochloride 477

ported rapid relief from the intravenous injection
of diphenhydramine and Neo-Calglucon (San-
doz) ; about 2 hours after the injection severe
malaise developed followed by relief of the pru-
ritis, and aching and swelling of the joints.

"Common Cold." — The report of Brewster
(U. S. Nav. M. Bull., 1947, 47, 810) of the thera-
peutic value of diphenhydramine in the ''common
cold" was received with enthusiasm and promoted
vigorously in the lay press with products con-
taining small doses of less active antihistaminic
drugs which did not cause drowsiness, usually
in combination with analgesic drugs. The Council
on Pharmacy and Chemistry of the American
Medical Association (J.A.M.A., 1950, 142, 566)
cautioned against the uncritical acceptance of
this therapeutic claim. Feller et al. (New Eng.
J. Med., 1950, 242, 737) reported the failure
of prophylactic or therapeutic use of several of
the antihistaminic drugs in volunteers inoculated
with nasal secretion from a donor with a "typical
common cold"; Paton et al. (Lancet, 1949, 1,
935) reported a similar failure. However, typical
of the good clinical reports in the relief of symp-
toms is that of Kessler (/. M. Soc. New Jersey,
1950, 47, 29) in which several different anti-
histaminic substances were employed with the
conclusion that Hydryllin (Searle) was recom-
mended because of the low incidence of side
effects. Brewster and Dick (Texas Rep. Biol.
Med., 1949, 7, 69) reported that a concentration
of 0.05 mg. per ml. of diphenhydramine had bac-
teriostatic action for Staphylococcus aureus and
that the blood of individuals taking the drug con-
tained bacteriostatic concentrations. From one
of the more detailed studies of the effect of
antihistaminic drugs in treating the common
cold, by Ziporyn (Me d. Times, 1950, 78, 205),
it might be concluded that diphenhydramine has
definite value for the nasal symptoms but no
effect on the lower respiratory or systemic mani-
festations and that it caused drowsiness in almost
all cases. The superior results obtained when
treatment was commenced within the first 24
hours of symptoms is clear in his group treated
with chlorphenamine.

Motion Sickness. — The demonstration that
dimenhydrinate (q.v.) was an effective prophy-
lactic and therapeutic agent for seasickness led
to intensive study of this problem (see review
by Chinn, Mil. Surg., 1951, 108, 20). It was
demonstrated that the activity in dimenhydrinate
(diphenhydramine-8-chlorotheophyllinate) resides
in the diphenhydramine component both for sea-
sickness (Wright, U. S. Armed Forces M. J.,
1950, 1, 570; Chinn et al., Arch. Int. Med.,
1950, 86, 810) and airsickness (Chinn and
Oberst, Proc. S. Exp. Biol. Med., 1950, 73, 218).
Equivalent inhibition of vomiting due to apomor-
phine in dogs was accomplished by 20 mg./kilo
of diphenhydramine or 40 mg./kilo of dimenhy-
drinate (representing 21.6 mg./kilo of diphen-
hydramine) by mouth while the 8-chlorotheo-
phyllinate portion was ineffective (Chen and
Ensor, /. Pharmacol., 1950, 98, 245). In rabbits,
forced circling movements are caused by the
intracarotid injection of a subconvulsive dose of
diisopropyl fluorophosphate (DFP). Johns and

Himwich (Am. J. Psychiat., 1950, 107, 367)
reported that these movements could be cor-
rected by the intravenous injection of diphenhy-
dramine, 2.6 mg./kilo; dimenhydrinate, 3.3 mg./
kilo; or promethazine, 2.2 mg./kilo. It was con-
cluded that the protective action was on the
central nervous system and was perhaps related
to the atropine-like action of these compounds.
Drugs with lesser antiacetylcholine action were
ineffective, e.g., phenindamine, antazoline, tripelen-
namine, pyrilamine, chlorphenamine. A study
indicating equal value in airsickness for diphen-
hydramine and scopolamine (Chinn et al., J.
Aviation Med., 1950, 21, 424) and also efficacy
for trihexyphenidyl and chlorocyclizine pointed
to the anticholinergic action as essential. The
most effective prophylaxis was a combination of
50 mg. diphenhydramine and 0.65 mg. scopola-
mine which, however, caused dry mouth, blurred
vision and drowsiness. Trial of half the dose, 25
mg. diphenhydramine hydrochloride and 0.33 mg.
scopolamine hydrobromide, was equally effective
in both experimental and actual flight conditions
without significant side effects (Chinn et al., U. S.
Armed Forces M. J., 1951, 2, 401).

Parkinsonism. — Confirmation has appeared
of the reports of Budnitz (New Eng. J. Med.,

1948, 238, 874) and Ryan and Wood (Lancet,

1949, 1, 258) of the therapeutic value in Parkin-
sonism, either postencephalitic, idiopathic or
arteriosclerotic in origin. In extensive compara-
tive studies, Effron and Denker (J.A.M.A.,

1950, 144, 5) reported good results with diphen-
hydramine, scopolamine or trihexyphenidyl
alone, and better results with combinations of
diphenhydramine and scopolamine, or pheninda-
mine and trihexyphenidyl or scopolamine. The
dose of diphenhydramine was commenced at
50 mg. three times daily and gradually increased
to 100 mg. four times daily. Moore (Neurology,

1951, 1, 123) reported that the results with
diphenhydramine alone, in a dose of 50 mg. four
times daily, were inferior to the effect of bella-
donna derivatives; better effect was obtained
with a combination of diphenhydramine with
0.3 to 0.8 mg. of hyoscine hydrobromide 3 or 4
times daily, or with ^ to 1 tablet of Rabellon
(Sharp & Dohme), containing hyoscyamine hy-
drobromide 0.4507 mg., atropine sulfate 0.0372
mg., and scopolamine hydrobromide 0.0119 mg.,
4 times daily. A dose of 30 to 40 mg. of diphen-
hydramine, intramuscularly or intravenously,
eliminated tremor and decreased rigidity for 3
to 6 hours. A dose of 60 mg. produced an un-
desirable excessive relaxation. Edwards et al.
(South. M. J., 1951, 44, 886) reported best
results with a combination of 5 mg. trihexy-
phenidyl, 3 Rabellon tablets and 400 mg. di-
phenhydramine in divided doses daily. Studies
with the electroencephalogram and the electro-
myogram by Gitt et al. (Dis. Nerv. System,
1951, 12, 117), following an intravenous dose
of 30 mg. of diphenhydramine, indicated no effect
in normal individuals except a decrease in the
amplitude of muscular activity, both at rest and
during movement. The site of action was thought
to be supraspinal but subcortical. In a study of
chemical structure and therapeutic action, Gair

478 Diphenhydramine Hydrochloride

Part I

and Ducey (Arch. Int. Med., 1950, 85, 284)
reported the best results with diphenhydramine,
prophenpyridamine and doxylamine. In the
"thalamic syndrome," Barris (Neurology, 1952,
2, 59) reported marked improvement in hyper-
pathia in 5 of 17 cases and decrease in sponta-
neous pain in 6 cases with 400 to 600 mg. of
diphenhydramine daily.

Topical Use. — A 2 per cent cream in a water-
miscible base is available. In neurodermatitis,
atopic eczema and ano-genital pruritus, the results
with topical application are superior to those
with oral administration (Waldriff et al., Arch.
Dermat. Syph., 1950, 61, 361). The local anes-
thetic action is probably as important as the
antihistaminic effect. In miliaria, Schultheis and
Traub (Arch. Dermat. Syph., 1951, 64, 635)
reported that addition of 2 per cent diphenhydra-
mine to the lotion containing 3 per cent salicylic
acid, 4 per cent glycerin, 1 per cent phenol, and
0.25 per cent menthol in 95 per cent ethyl alcohol
improved the results. The application of com-
presses of 2 per cent aqueous solution of diphen-
hydramine to burns and scalds within the first
4 hours relieved the discomfort and minimized
the degree of erythema and blistering (Slack
et al, Brit. M. J., 1951, 2, 360). The increasing
problem of acquired sensitivity to the antihista-
minic creams is presented bv Ellis and Bundick
(J.A.M.A., 1952, 150, 773). Scutt (Lancet, 1953,
1, 498) points out that the antipruritic action
of topical applications of antihistaminic drugs
is most useful for a week or two to prevent the
continual trauma of scratching and permit heal-
ing. However, loss of efficacy is frequent after
use for 3 or 4 weeks and sensitivity often develops
after this period of use.

Intravenous Use. — For rapid relief of exten-
sive urticaria, angioneurotic edema, weeping
contact dermatitis and insect bites, Lipman
(Wisconsin M. J., 1951, 50, 873) gave 10 to
100 mg. in 1 to 100 ml. or more of 5 per cent
dextrose in water or physiological saline solution
slowly intravenously, with good results in most
cases. Kulasavage and McCawley (J.A.M.A.,
1951, 145, 429) used this route of administra-
tion in vomiting uremic patients or for the vomit-
ing following inhalation anesthesia. In place of
quinidine Dick et al. (Am. J. Med., 1951, 11,
625) used a 1 per cent solution in the treatment
of auricular fibrillation.

Miscellaneous. — Beneficial reuslts have been
reported in an amazing variety of conditions, in
some of which the effect may be attributed to its
antihistaminic action but in others the effect
appears to be the result of other pharmacological
actions (see discussion under Antihistaminic
Drugs in Part II). These conditions include:
allergic reactions to insulin (Leavitt and Gasti-
neau, Arch. Int. Med., 1947, 80, 271), to liver
extract injection (Carryer and Koelsche. /. Al-
lergy, 1948, 19, 376), to iodopyracet (Olsson,
Acta Radiologica, 1951, 35, 65), to dimercaprol
in the treatment of arsenic poisoning (Hollev,
Am. J. Syph. Gonor. Ven. Dis., 1950, 34, 490),
to penicillin (but it has little effect on the joint
manifestations of the serum sickness reaction),
the Herxheimer reaction during the treatment

of syphilis with penicillin (Stewart, Arch. Dermat.
Syph., 1949, 60, 427), alleviation of opium with-
drawal symptoms in addicts (Vaisberg, Ann.
Allergy, 1951, 9, 74), the acute lepra reaction
(Box, Hawaii M. J., 1948, 7, 303), masked
collagen diseases such as disseminated lupus ery-
thematosus (Stephens and Holbrook, Arizona
Med., 1949, 6, 21), migraine in children (Michael
and Williams, /. Pediat., 1952, 41, 18;, post-
spinal-puncture headache (Shannon, N. Y. State
J. Med., 1950, 50, 1259), allergic headache
(McElin and Horton, Proc. Mayo, 1945, 20,
417), histaminic cephalgia (Tucker and O'Neill,
Lahey Clin. Bull, 1952, 7, 218), Meniere's syn-
drome, trigeminal neuralgia (Horton and Bren-
nan, J.A.M.A., 1948, 136, 870), nocturnal cramps
in the legs (Naide, J. A.M. A., 1950, 142, 1140).
pruritus vulvae, granular proctitis (Wilson, Med.
J. Australia, 1940, 36, 276), oxyuriasis (Siung.
Brit. M. J., 1950, 1, 822), gastrointestinal allergic
disorders in children (Kugelmass, N. Y. State J.
Med., 1949, 49, 2313), infantile diarrhea (in
combination with sulfamethazine, Neumann,
Brit. M. J., 1949, 2, 132), roentgen illness (Lof-
strom and Nurnberger, Am. J. Roentgen., 1946,
56, 211), nausea and vomiting of early preg-
nancy and also during diethylstilbestrol therapy
(Finch, Am. J. Obst. Gyn., 1949, 58, 591), nau-
sea and vomiting during streptomycin therapy
(Bignall and Crofton, Brit. M. J., 1949, 1, 12),
petit mal epilepsy except that in cases with focal
lesions it produced seizures (Churchill and Gam-
mon. J.A.M.A., 1949, 141, 18), psychotic children
(Effron and Freedman. /. Pediat., 1953, 42, 261),
myotonia atrophica (Russell, Brit. M. J., 1949,
2, 1206), postvaccinal (rabies) encephalitis
(Picker and Kramer, South. M. J., 1949, 42,
127), epidermophytosis of feet and "id" on the
hands (Austin, Ann. Allergy, 1951, 9, 50), der-
matitis herpetiformis (Peterkin, Brit. J. Dermat.,
1951, 63, 1), Reiter's syndrome (Makari, /.
Trop. Med. Hyg., 1950, 53, 39), the edematous
stage of scleroderma (Evans et al., J.A.M.A.,
1953, 151, 896). No benefit was found in acute
rheumatic fever (Medical Research Unit 4,
U. S. Nav. M. Bull., 1948, 48, 380).

Toxicology. — The incidence of untoward
side effects obtained with diphenhydramine is
high, being 46 per cent of 1210 patients reported
by Sachs (Ann. Int. Med., 1948, 29, 135), 61 per
cent of 655 cases reported by Loveless (Am. J.
Med., 1947, 3, 296), and 77 per cent of 52 cases
reported by McGavack et al. (J. Lab. Clin. Med.,
1948, 33, 595). Drowsiness, however, comprises
the great majority of these cases; the effect may
be marked at first but diminishes under continued
use or be counteracted by administering am-
phetamine (Arnold, Arch. Derm. Syph., 1946,
54, 71). In many cases the sedative effect is
desirable, particularly at bedtime. In ambulatory
patients the drowsiness and dizziness, which is
another common untoward effect, create an acci-
dent hazard; Holtkamp et al. (J. Allergy, 1948,
19, 384) called attention to impaired psycho-
motor function resulting from use of the drug.
Other untoward effects include dry mouth, lassi-
tude, excitement, and nausea. No tendency to
addiction has been reported. Asthmatic seizures

Part I

Diphenylhydantoin Sodium 479

have been precipitated in some asthmatics (Black-
man and Hayes, /. Allergy, 1948, 19, 390).
Winter (/. Pharmacol., 1948, 94, 7) observed
prolongation of barbiturate sedation by diphen-
hydramine, while Cherry (Med. J. Australia,
1949, 36, 540) described a withdrawal syndrome
of dizziness which was relieved by taking the
drug again. Hypersensitivity following topical
application occurs rarely, but it may be serious
(Barksdale and Ellis, Virginia Med. Month.,

1949, 76, 278). Diphenhydramine hydrochloride
was the drug employed in two of the cases of
hemolytic anemia which Crumbley (J.A.M.A.,

1950, 143, 726) reported as having followed use
of antihistaminic drugs over long periods of
time.

Toxic doses in animals produce a complex
syndrome of excitant reactions, predominantly
neurogenic in origin, involving the motor, sensory
and autonomic nervous systems (Gruhzit and
Risken, J. Pharmacol., 1947, 89, 227). Manifes-
tations include excitement, irritability, spastic
ataxia, mydriasis, hyperesthesia, convulsions, re-
spiratory and cardiac failure. Barbiturates control
the excitement but do not correct respiratory
and cardiac depression.

Death of a 2-year-old child following accidental
ingestion of 474 mg. of Benadryl has been re-
ported (Davis and Hunt, /. Pediat., 1949, 34,
358). Symptoms included lethargy, coma, shallow
respiration and cyanosis, followed by nervousness,
twitching, convulsions, fever and tachycardia; the
child died in 13 hours. A 3-year-old child who
accidentally swallowed 700-800 mg. of Benadryl
recovered (Duerfeldt, Northwest Med., 1947, 46,
781); symptoms of nervousness and muscular
twitchings occurred within 15 minutes, followed
by convulsions and respiratory collapse. A 2-mg.
dose of dihydromorphinone hydrochloride only
partially controlled convulsions; histamine was
ineffective; asthmatic breathing was relieved by
epinephrine; convulsions were finally controlled
by 30 ml. of a 50 per cent solution of ether in
olive oil, administered rectally. After four days
the ataxia had cleared; no brain damage was
apparent on examinations during the following
month. Wyngaarden and Seevers (J.A.M.A.,

1951, 145, 277) reviewed the reported instances
of poisoning, most of which have been accidental
in children (see also Leeks, Quart. Rev. Pediat.,
1951, 6, 294). Convulsions are common in chil-
dren but depression is more prominent in adults.
Convulsions are of intermittent tonic-clonic type.
Pupils are dilated and fixed. Coma develops, asso-
ciated with apnea, cyanosis and vascular collapse.
Autopsy shows anoxic changes resembling the
findings in heat stroke.

The stomach should be emptied mechanically,
rather than with an emetic which may further
depress the central nervous system. For convul-
sions ether-in-oil or paraldehyde are indicated
rectally. Barbiturates will control the seizures
but they cause increased depression. For coma,
amphetamine, caffeine or ephedrine are indicated.
Oxygen, antibiotics and parenteral fluids are
needed.

Dose. — The usual dose is 25 mg. (approxi-
mately % grain) one to four times daily by

mouth, with a range of 25 to 50 mg. The maxi-
mum safe dose is 50 mg. and the total dose in
24 hours should generally not exceed 200 mg.

For children the dose is 10 to 25 mg.; for
infants, 1 to 2 mg. per kilogram of body weight.
Intravenously, the beginning dose is 10 mg., in
a concentration of 1 to 10 mg. per ml. and
administered at a rate of from 2.5 to 10 mg. per
minute; if there is neither relief nor hypnosis
after two hours a dose of 20 to 30 mg. may be
tried. The same dose may be given intramuscu-
larly. A 2 per cent solution is used as an aerosol
for nasal or oral inhalation in doses of 0.6 to 1
ml. A 2 per cent cream is used topically. Be-
sides the capsules, there is available an elixir
containing 10 mg. of diphenhydramine hydro-
chloride per 4 ml.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DIPHENHYDRAMINE HYDROCHLO-
RIDE CAPSULES. U.S.P.

"Diphenhydramine Hydrochloride Capsules
contain not less than 93 per cent and not more
than 107 per cent of the labeled amount of
C17H21NO.HCI." U.S.P.

Usual Size. — 25 and 50 mg.

DIPHENHYDRAMINE HYDROCHLO-
RIDE ELIXIR. U.S.P.

"Diphenhydramine Hydrochloride Elixir con-
tains, in each 100 ml., not less than 235 mg. and
not more than 265 mg. of C17H21NO.HCI." U.S.P.

Dissolve 2.5 Gm. of diphenhydramine hydro-
chloride in 250 ml. of purified water. Dissolve 0.24
ml. of orange oil, 0.11 ml. of cinnamon oil, 0.08
ml. of clove oil, 0.03 ml. of coriander oil, and 0.03
ml. of anethole in 150 ml. of alcohol. Mix the two
solutions, add 350 ml. of syrup, 1.6 ml. of amar-
anth solution, and enough purified water to make
1000 ml. Mix well; filter if necessary. U.S.P.

Alcohol Content. — From 12 to 15 per cent,
by volume, of C2H5OH. U.S.P.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DIPHENYLHYDANTOIN SODIUM
U.S.P. (B.P.) (LP.)

Phenytoin Sodium, [Diphenylhydantoinum Sodicum]

NaO

"Diphenylhydantoin Sodium, dried at 105° for
4 hours, contains not less than 98.5 per cent of
CioHnN2Na02." U.S.P. The B.P. official title for
the same substance is Phenytoin Sodium, and it
is required to contain not less than 98.0 per cent
and not more than the equivalent of 101.0 per
cent of Ci5Hn02N2Na, calculated with reference
to the substance dried to constant weight at 105°.

Under the title Phenytoin (Phenytoinum) the
LP. recognizes 5:5-diphenylhydantoin, the acid

480 Diphenylhydantoin Sodium

Part I

form of the salt ; it is required to contain not less
than 99.0 per cent of C15H12O2X2.

B.P. Phenytoin Sodium; Phenytoinum Sodium. Sodium
5,5-Diphenylhydantoinate. Dilantin Sodium (Parke, Dai-is):
Alepsin; Epanutin; Eptoin. Sp. Difeniihidantoina Sddica.

Diphenylhydantoin may be prepared by sev-
eral different processes. One of these involves
refluxing of a mixture of ammonium carbonate,
potassium cyanide and benzophenone in alcohol
solution. In another process benzophenone and
ammonium cyanide are reacted to form diphenyl-
aminoacetonitrite; the product is hydrolyzed and
treated with phosgene. This is converted to the
sodium derivative to form the compound official
in the U.S. P. and B.P.; the LP. recognizes
diphenylhydantoin itself.

Description. — "Diphenylhydantoin Sodium
occurs as a white, odorless powder. It is somewhat
hygroscopic and on exposure to air gradually
absorbs carbon dioxide with the liberation of
diphenylhydantoin. Diphenylhydantoin Sodium is
freely soluble in water, the solution usually being
somewhat turbid due to partial hydrolysis and
absorption of carbon dioxide. It is soluble in alco-
hol, but practically insoluble in ether and in chlo-
roform." U.S. P. Diphenylhydantoin (the acid
form official in LP.) is practically insoluble in
water, sparingly soluble in alcohol, and slightly
soluble in ether and in chloroform.

Standards and Tests. — Identification. — (1)
Diphenylhydantoin, liberated from the sodium
compound, melts between 292° and 299°, with
some decomposition. (2) The residue from the
ignition of diphenylhydantoin sodium effervesces
with acids and responds to tests for sodium. Loss
on drying. — Not over 2.5 per cent, when dried at
105° for 4 hours. Heavy metals. — The limit is
20 parts per million. Clarity and color of solution.
— Not more than 4 ml. of 0.1 N sodium hydroxide
is required to dissolve diphenylhydantoin liber-
ated by hydrolysis in a solution of 1 Gm. of the
sodium compound in 20 ml. of recently boiled and
cooled water. U.S.P. The B.P. limits lead to 10
parts per million.

Assay. — About 300 mg. of diphenylhydantoin
sodium, previously dried at 105° for 4 hours, is
dissolved in water, the solution acidified, and the
liberated diphenylhydantoin extracted with abso-
lute ether. After evaporating the solvent the resi-
due is dried at 105° for 4 hours and weighed.
U.S.P.

Incompatibilities. — These are practically the
same as for sodium derivatives of barbiturates.
In particular, aqueous solutions develop a pre-
cipitate of diphenylhydantoin on acidification,
even with carbon dioxide present in air. Adjust-
ment of the pH of aqueous solutions to 11.7 is
reported to effect solution of any precipitate of
diphenylhydantoin.

Uses. — Diphenylhydantoin sodium is used for
prevention of convulsive seizures of the grand
mal type. For a discussion of the general group
of drugs of which this is an example, see Skeletal
Antispasmodic Agents, in Part II.

Action. — This anticonvulsant drug was intro-
duced by Merritt and Putnam (J A.M. A., 1938.
Ill, 1068) following studies on the irritability
of the cerebral motor cortex in which it was

demonstrated that of all the anticonvulsants they
tested none gave as good results as diphenyl-
hydantoin sodium. This observation was confirmed
by Knoefel (J. Pharmacol., 1940, 68, 19), who
found that in cats 5 mg. per Kg. of body weight
(which would correspond to about 300 mg. for a
man) raised the convulsive threshold of the
cerebrum about 50 per cent, the effect lasting
for more than 6 hours; also, that the drug aug-
mented the spinal reflexes and did not prevent
convulsions caused by strychnine or cocaine.
Haury and Drake (ibid., 1940, 68, 36) found that
the same dosage injected intravenously into dogs
caused a sharp fall in blood pressure lasting from
3 to 10 minutes — probably by arterial relaxation
— with fatal doses killing by arrest of respiration.
Kozelka and Hine (ibid., 1943, 77, 175) reported
that man and dog excreted approximately 1.2 per
cent of a dose of diphenylhydantoin unchanged,
with about the same proportions of hydantoic acid
and alpha-aminodiphenylacetic acid also being
eliminated; only about 3.6 per cent of the adminis-
tered drug could be accounted for in these studies.

The hypnotic action of diphenylhydantoin so-
dium is much less than that of phenobarbital.
Indeed, diphenylhydantoin sodium is probably the
best example of a useful anticonvulsant drug
wherein hypnotic and antiepileptic activities are
divorced.

Therapeutic Uses. — Diphenylhydantoin so-
dium has been used extensively in the treatment
of epilepsy, with marked reduction in the number
of seizures in grand mal and psychomotor attacks
(Merritt, Cincinnati M. J., 1946. 27, 279). In
petit mal attacks, however, it has failed, and may
actually increase frequencv of attacks (Lennox,
J.A.M.A., 1945, 129, 1069';. The question of its
mode of action is unsettled. Goodman et al.
(J. Pliarmacol., 1953. 108, 168) pointed out that
the hydantoins excel in inhibiting seizure spread
but are relatively less effective in elevating sei-
zure threshold. Diphenylhydantoin sodium may
abolish seizures with or without changing the
characteristic dysrhythmia of the electroenceph-
alogram. It is common practice to commence
therapy of epileptic patients with small doses of
phenobarbital. which are increased gradually over
a period of 2 weeks; if this provides inadequate
control, diphenylhydantoin sodium is tried
(Davidson, Meeting of the Massachusetts Medi-
cal Society, May 20. 1954). If this fails, both
phenobarbital and diphenylhydantoin sodium are
prescribed in a proportion of 1 part of the former
to 3 parts of the latter. Should this prove inade-
quate mephobarbital is tried in place of pheno-
barbital and Mysoline in place of diphenyl-
hydantoin sodium, but Davidson reported that
about three-fourths of cases can be controlled
well with phenobarbital and diphenylhydantoin
sodium.

It has been noted (Robinson. Am. J. Psychiat.,
1942, 99, 231) that the disposition of the patient
often improves, as does efficiency and behavior.
Freyhan (Arch. Neurol. Psychiat., 1945. 53, 370)
studied the effectiveness of the drug in nonepi-
leptic psychomotor excitement states, and found
some improvement in excited catatonic schizo-
phrenic patients.

Part I

Diphtheria Antitoxin 481

Intractable bronchial asthma was relieved by
diphenylhydantoin sodium (Shulman, New Eng.
J. Med., 1942, 226, 260). Benefit has been re-
ported in some cases of Sydenham's chorea, Park-
insonism and migraine (Shapera, Pittsburgh Med.
Bull., 1940, 29, 732), but Schwartzman and
Grossman (Arch. Pediat., 1943, 60, 194) were
not favorably impressed with it in Sydenham's
chorea.

Excellent reviews of the subject, along with
comparisons of diphenylhydantoin sodium with
other antiepileptic agents, are available in the
publications of Toman and Goodman (Physiol.
Rev., 1948, 28, 412), Kaufman and Isenberg
(Med. Clin. North America, 1952, 36, 1381), and
Frommel et al., Arch. int. pharmacodyn., 1953,
92, 368).

Toxicology. — Toxic manifestations of the
drug are nervousness or sleeplessness, rather than
drowsiness. Among the more frequent untoward
effects is a gingival hyperplasia (Esterberg and
White, J. A. Dent. A., 1945, 32, 16; and others) ;
the incidence is stated to be about 54 per cent
and it is believed that local conditions other than
open bite have little effect in initiating the con-
dition. Stern et al. (J. Dent. Research, 1943, 22,
157) noted that long administration favored de-
velopment of this reaction, and that local irritant
factors aggravated its degree; they were unable
to implicate the nutritional state or dosage, and
recommended conservative periodontal treatment.
There has been much controversy as to the role
played by abnormal excretion of ascorbic acid in
this gingival hyperplasia (Drake and Gruber,
/. Pharmacol., 1941, 72, 383), but no proof exists
that this is the important factor. Staple (Lancet,
1953, 2, 600) claimed that results in experimental
animals suggest that the gingival hyperplasia may
be an exaggerated tissue response to injury in
subjects with deranged adrenocortical function.

Many patients develop nausea and vomiting
from taking the drug; this may often be pre-
vented by administering it after meals or by giv-
ing it with dilute hydrochloric acid to diminish
its alkalinity. Barton and O'Leary (Arch. Dermat.
Syph., 1943, 48, 413) listed the following cutane-
ous eruptions as arising from use of the drug:
erythema morbilliforme and scarlatiniforme, urti-
caria, ecchymoses, purpura, petechias, edema, ex-
foliative dermatitis, and erythema multiforme.

A group of symptoms relating to toxicity in-
volves the central nervous system and includes
tremors, dizziness, ataxia, disturbed vision, diplo-
pia, nystagmus, ptosis, and even psychoses (see
Fetterman. J. A.M. A., 1940, 114, 396; also Finkel-
man and Arieff, ibid., 1942, 118, 1209). The
latter reported also that some patients showed
electrocardiographic changes. A comprehensive
discussion of the toxicity and limitations of com-
pounds of the class including diphenylhydantoin
sodium has been presented by Abbott and Schwab
(New Eng. J. Med., 1950, 242, 943).

Dose. — The usual dose is 100 mg. (about \Yz
grains), administered with at least half a glass of
water and preferably after meals, 1 to 4 times
daily; the range of dose is 100 to 600 mg., with
the maximum dose varying from 300 to 900 mg.
according to the tolerance developed by the pa-

tient. Under 4 years of age the usual dose is 30
mg., with a range of 30 to 60 mg., given up to 4
times daily; it may be mixed with cream to mini-
mize the bitter taste and gastric irritation. Caution
must be exercised in withdrawing phenobarbital
from patients who are given diphenylhydantoin
sodium as a substitute since several days are re-
quired for adequate storage of the latter; an in-
crease in the number of convulsions may ensue in
the interim.

Storage. — Preserve "in tight containers."
U.S.P.

DIPHENYLHYDANTOIN SODIUM
CAPSULES. U.S.P.

[Capsulae Diphenylhydantoini Sodici]

"Diphenylhydantoin Sodium Capsules contain
not less than 93 per cent and not more than 107
per cent of the labeled amount of C15H11N2-
Na02." U.S.P.

Sp. Capsulas de Difenilhidantoina Sodica.

Assay. — The contents of not less than 20
capsules are transferred to a beaker and the
empty capsules digested with alcohol for 30 min-
utes, in another beaker, to dissolve the diphenyl-
hydantoin sodium. The alcoholic solution is
filtered into the first beaker, the liquid evapo-
rated nearly to dryness, and the residue dissolved
in a sodium hydroxide solution. After diluting
the solution to 200 ml. an aliquot representing
about 300 mg. of diphenylhydantoin sodium is
acidified with diluted hydrochloric acid and the
precipitated diphenylhydantoin is extracted with
absolute ether. The solvent is evaporated and
the residue of diphenylhydantoin is dried at 105°
for 4 hours; the weight of the residue, multiplied
by 1.087, represents the weight of C15H11N2-
Na02 in the aliquot taken for assay. U.S.P.

Usual Sizes. — 30 and 100 mg. (approxi-
mately yi and \Yz grains).

DIPHTHERIA ANTITOXIN.
U.S.P., B.P.

[Antitoxinum Diphthericum]

"Diphtheria Antitoxin is a sterile solution of
antitoxic substances obtained from the blood
serum or plasma of a healthy animal, usually the
horse, that has been immunized against diphtheria
toxin. It has a potency of not less than 500 anti-
toxic units per ml., based on the N.I.H. Standard
Diphtheria Antitoxin. It may contain not more
than 0.5 per cent of phenol, or not more than 0.4
per cent of cresol, as a preservative." U.S.P.

The B.P. product is defined as the native serum,
or a preparation from native serum, containing
the antitoxic globulins or their derivatives that
have the specific power of neutralizing the toxin
formed by Corynebacterium diphtheria. Native
liquid sera must have a potency of not less than
500 units per ml., dried native sera a potency of
not less than 5000 units per Gm. Liquid globulin
preparations must have a potency of not less than
1000 units per ml. and dried globulin preparations
not less than 10,000 units per Gm.

Purified Antidiphtheric Serum, Concentrated Diphtheria
Antitoxin, Refined Diphtheria Antitoxin, Antidiphtheric

482 Diphtheria Antitoxin

Part I

Globulins. Serum Antidiphthericura. Fr. Serum antidiph-
terique. Ger. Diphtheric-Serum. It. Siero antidifterico.
Sp. Suero antidifterico; Antitoxina Difterica.

Antitoxins are, as their name implies, sub-
stances that neutralize or counteract toxins.
Though soluble toxins are secreted by certain
members of the animal kingdom (known as 200-
toxins), such as the venoms of snakes, spiders,
scorpions, etc., and soluble toxins are found in
some plants (phytotoxins), the term is most fre-
quently applied to the extracellular toxic products
of bacteria. Pathogenic bacteria may be harm-
ful either because of intracellular poisons (endo-
toxins), or because of extracellular toxins (exo-
toxins). In actual practice, the term antitoxin is
usually reserved for serums which contains sub-
stances capable of neutralizing the exotoxins of
bacteria, while the terms antiendotoxin or antibac-
terial serum are used to designate serums capable
of neutralizing endotoxins. Serums capable of
neutralizing zootoxins are usually described as
antivenins.

Antitoxins are obtained from the blood serum
of animals which have been immunized against
the extracellular toxins of bacteria. These anti-
toxins are specific, i.e., they neutralize only the
particular toxins which were employed to produce
them.

Diphtheria Antitoxin prepared from an animal
other than the horse was first officially recognized
by the U.S. P. XII. Any healthy animal can be
used, but the outside label of the container must
indicate "the genus of animal employed when
other than the horse." The B.P. implies that sev-
eral animal sources may be employed in the
preparation of Diphtheria Antitoxin. A Diph-
theria Antitoxin, Bovine, is marketed as an alter-
native to equine diphtheria antitoxin for treat-
ment of those giving evidence or a history of
sensitiveness to horse serum. This cattle serum
contains less antitoxin units per ml. and accord-
ingly larger volumes are required for injection.

The definition given in the British Pharma-
copoeia permits the use of either whole antitoxic
serum, the purified and concentrated antitoxin or
antitoxic globulins in solution, or the dried ma-
terial from either of these antitoxic preparations.
In the U.S. P., however, the only form recognized
is the concentrated and purified antitoxin dis-
solved in physiological salt solution. The purifica-
tion of the antitoxin is based upon the fact that
the antitoxic material is associated with the group
of blood proteins known as globulins — specifically
the pseudo globulins.

Preparation. — In 1892 Emil von Behring
showed that the blood of animals immunized
against diphtheria toxin would protect human
beings against diphtheria. Large-scale manufac-
ture of this, the first, antitoxin began in 1894.

The methods for producing diphtheria anti-
toxin commercially vary only in minor technical
details. For antitoxin production on a large scale
horses have been found to be the most useful ani-
mals. Selected horses are given relatively small
doses of formalin-detoxified diphtheria toxin (see
Diphtheria Toxoid) by subcutaneous or intra-
muscular injection. These doses are progressively

increased every few days until the antitoxic sub-
stance in the blood of the animals has increased
sufficiently so that they will tolerate moderate
doses of diphtheria toxin. The horses are then
given increasing quantities of diphtheria toxin at
intervals over an additional period of one to three
months. The toxin-neutralizing substance in the
blood continues to increase in response to these
injections until a certain maximum is reached.
This maximum may differ quantitatively among
various horses but cannot be increased by subse-
quent injections of diphtheria toxin. In the com-
mercial laboratories preparing diphtheria anti-
toxin, the routines for immunization differ widely
in respect to the size, frequency, and route of in-
jection of the toxoid and toxin doses.

From time to time, during the immunizing proc-
ess, the antitoxin content of the blood is deter-
mined. Generally, today, only horses whose mini-
mum yield is over 500 units per ml. of blood serum
are used for commercial production. The ma-
jority of horses approach a yield of 500 or more
units per ml. of serum within three months, but
much higher yields are not uncommon. Archipoff
reported a horse whose serum yielded 3500 units
per ml.

The horse, having been brought up to a "pro-
duction basis," is bled, and eight or nine liters of
blood are withdrawn. Two or three injections
at four-day intervals are made usually between
bleedings, the first dose on the day following the
bleeding. The bleedings are repeated at intervals
until the antitoxin content of the serum — which
gradually falls because of depletion of the anti-
toxin-forming mechanism of the horse — ap-
proaches the minimal limit (500 units per ml. of
serum) or until the condition of the horse makes
further immunization inadvisable. Treatment (in-
jections with toxin or toxoid) is then discontinued
and the horse is "bled out," that is, the rhaximum
yield of blood is obtained. Occasionally it may be
found advisable to give a horse a rest, discontinu-
ing the bleedings and immunization treatment.
Usually a horse when "bled out" will yield a total
of from 22 to 30 liters of blood.

The bleedings are done in specially constructed
stalls, separated from the stables and other build-
ings, which are as carefully cleansed as the most
modern surgical operating room, and all apparatus
or instruments are thoroughly sterilized. The ani-
mal to be bled is first washed well with soap and
water, the neck is shaved and washed with an anti-
septic solution, and the rest of the body is covered
with a sterile sheet. A sharp-pointed cannula, to
one end of which is attached a sterile rubber tube,
is inserted into the jugular vein. The blood is
allowed to flow through the rubber tube into tall
glass cylinders, called "bleeding jars"; when the
serum is to be purified a sodium citrate solution
is placed in the jars before bleeding into them.
The cylinders of blood, with or without citrate,
are stored at 5° for 48 hours, after which the
serum or plasma has separated from the red celb.
The serum or plasma is aseptically removed from
the cellular portion, preserved with 0.5 per cent
phenol, and stored at 5° until refined. The anti-
toxic serum or plasma which separates from the
blood corpuscles contains a large variety of pro-

Part I

Diphtheria Antitoxin 483

teins as well as lipoids, bile pigments, non-protein
nitrogenous compounds, and inorganic salts.

Purification. — The purification and concen-
tration of the antitoxin is based on the fact that
the antitoxic properties are associated with the
pseudoglobulin fraction of the blood proteins.
This can be separated by fractional precipitation
with ammonium sulfate. After a series of repeated
precipitations, the collected globulins are acidu-
lated with normal acetic acid to a pH of 5.4 and
treated with four volumes of water. After allow-
ing the mixture to settle the supernatant liquid is
siphoned off, filtered through pulp, and sodium
hydroxide solution is added to a pH of 6.8. From
this the pseudoglobulins are precipitated by an
equal volume of saturated solution of ammonium
sulfate. Further purification by isoelectric pre-
cipitation as recommended by Murdick (/. Im-
munol., 1929, 17, 269) is employed by some
workers. The collected precipitate is freed of salt
by pressing and dialysis, and dissolved in a one
per cent sodium chloride solution (usually con-
taining a phenolic or mercurial preservative),
then filtered through pulp and a bacteria-excluding
filter. After testing for sterility, toxicity, and
potency it is distributed in sterile containers and
kept at temperatures not exceeding 10°. Purifica-
tion by selective digestion of the serum proteins
— using pepsin or, less commonly, papain or
trypsin — is being used for the refinement of diph-
theria and other antitoxins. These processes do
not diminish their antitoxic efficacy (see Kekwick
et al., Lancet, 1941, 240, 571, and Petermann and
Pappenheimer, J. Phys. Chem., 1941, 45, 1). Such
preparations are sometimes called despeciate anti-
toxins or modified antitoxins. They seem less
liable to cause serum reactions (Tom and Watson,
Am. J. Dis. Child., 1941, 62, 548) and are now
being used widely.

Stability. — At low temperatures the annual
rate of deterioration of diphtheria and other anti-
toxins does not exceed 10 per cent, but at tem-
peratures between 15 and 20° it may approach 20
per cent per annum. The contents of the finished
marketable diphtheria antitoxin are to possess a
potency of not less than 500 units per ml. When
dried and preserved in vacuo in the refrigerator
practically no deterioration takes place over long
periods of time. Heating to beyond 62° destroys
antitoxin, the rapidity of destruction being greater
the higher the temperature.

Description. — "Diphtheria Antitoxin is a
transparent or slightly opalescent liquid, nearly
colorless, and nearly odorless or having an odor
due to the preservative." U.S.P.

Standards and Tests. — Total solids. — Not
over 20 per cent, when dried to constant weight
at 105°. Other requirements. — The antitoxin com-
plies with the identity, pyrogen, safety, sterility,
and potency tests and other requirements of the
National Institutes of Health. U.S.P.

The National Institutes of Health now require
that all antisera must be tested for freedom from
pyrogenic substances by the injection of 3 ml. per
Kg. intravenously into rabbits. Antisera produc-
ing an average rise in temperature of more than
1.1° C. may not be distributed.

Assay. — The unit of diphtheria antitoxin, as

originally defined by Ehrlich, represents that
amount of antitoxin which will just neutralize 100
minimal lethal doses (M.L.D.) of diphtheria
toxin. (For definition of M.L.D. see Diagnostic
Diphtheria Toxin.) As a matter of practical ad-
vantage, because of the greater stability of diph-
theria antitoxin, the toxin is brought into con-
formity to a standard antitoxin distributed by the
National Institutes of Health. The antitoxic unit,
according to the National Institutes of Health, is
the amount of antitoxin which will exactly neu-
tralize the L+ dose of diphtheria toxin when both
are injected simultaneously, or if allowed to stand
in contact, protected from light, for about thirty
minutes and then injected. (The expression L+,
or "limes death," indicates the smallest quantity
of toxin which when mixed with one unit of anti-
toxin is capable of killing — when injected subcu-
taneously — a 250 Gm. guinea pig at the end of
the fourth day; Lo, or "limes zero or threshold,"
is the largest amount of toxin that, when mixed
with one unit of antitoxin and injected subcu-
taneously into a 250 Gm. guinea pig, will give
rise to no observed reaction.) Theoretically the
Lo dose of diphtheria toxin should contain 100
M.L.D., the L+ dose should contain 101 M.L.D.,
and the difference between the two doses should
be one M.L.D. Practically, however, the differ-
ence is found to be much more. Theoretically the
unit of diphtheria antitoxin should be that amount
of antitoxin which when mixed with an L+ dose
of toxin and injected subcutaneously into a guinea
pig weighing 250 Gm. would preserve the life of
the guinea pig for only four days, i.e., the animal
would die at the end of the fourth day. In com-
mercial practice where a margin of safety is ad-
vantageous the unit of diphtheria antitoxin is
regarded as the smallest amount of antitoxin
which will permanently save the life of a guinea
pig if injected together with an L+ dose of toxin.

In the commercial assay of antitoxin the first
step is to standardize the, toxin against the stand-
ard antitoxin distributed by the Government to
determine the L+ dose ; then varying proportions
of the antitoxin to be tested are mixed with the
L+ dose of this standardized toxin, the mixtures
allowed to stand between 30 and 60 minutes at
room temperature protected from light, and these
mixtures are then injected into guinea pigs of ap-
proximately 250 Gm. From calculations of the
relative proportions of antitoxin and toxin which
will kill and those which do not kill the guinea
pigs, the strength of the unknown may be com-
puted in terms of the standard units of anti-
toxin. While this lethal method is required for
the final standardization of the antitoxin, prelimi-
nary tests are generally made either by the intra-
cutaneous method, in which the degree of local
reaction in the skin of guinea pigs or rabbits pro-
duced by the toxin and antitoxin mixture is used as
the criterion (see Fraser and Wigham, J.A.M.A.,
1924, 83, 1114); the flocculation test, which is
based on the precipitate produced by mixtures of
toxin and antitoxin, is commonly employed.

Uses. — Diphtheria antitoxin is employed as a
specific agent in the treatment of clinical forms
of diphtheria, and for temporary passive pro-
phylaxis of diphtheria. Penicillin is also indicated

484 Diphtheria Antitoxin

Part I

in the acute disease to aid elimination of the
diphtheria organism and prevent secondary in-
fections. The advantages of using a purified and
concentrated antitoxin are the less likelihood of
undesirable allergic reactions and the convenience
of a smaller dosage volume.

Action. — It must be remembered that the
antitoxin neutralizes the free toxin in the body
fluids and to some extent the toxin recently united
with the tissue cells, and will not overcome the
injurious effects of the toxin which is firmly bound
in the body tissues. For this reason it is highly
important that the antitoxin should be used as
early as possible. A stronger affinity exists be-
tween diphtheria toxin and antitoxin than be-
tween diphtheria toxin and body cells, so that
during the early stage before the union of the
latter two components has become firmly fixed,
the toxin may be dissociated to some extent by
the more attractive antitoxin. Virulent diphtheria
bacilli resist phagocytosis, due probably to a local
toxic action of the diphtheria toxin; diphtheria
antitoxin, by neutralizing the toxin as it is
elaborated, facilitates the removal of the bacilli
by phagocytosis.

Treatment of Diphtheria. — Before the in-
troduction of antitoxin the mortality of diph-
theria in various epidemics ranged between 20 and
50 per cent; with proper use of the antitoxin it
should not be more than 2 or 3 per cent. If anti-
toxin is used, in sufficient dose, on the first day
of the disease the mortality should not reach 1 per
cent; if administered on the third day it will be
about 5 or 6 per cent. If administration is delayed
beyond the fifth day the antitoxin is of little avail.
The incidence of diphtheria in adults over 40
years of age seems to be increasing in the United
States. Brainerd and Bruyn (Calif. Med., 1951.
75, 290) reported 273 cases between 1942 and
1950 in the isolation division of the San Francisco
Hospital, with a mortality of almost 20 per cent.
Of 100 cases developing diphtheritic myocarditis.
36 died. Antitoxin is the only specific therapy and
immediate, large single (not divided) doses are
urged.

It has been found that antitoxin injected sub-
cutaneously is but slowly absorbed. Antitoxin
should, therefore, be given intramuscularly (the
gluteal region or the anterior part of the thigh
offer suitable sites) or, in the more severe cases,
intravenously. Most authorities agree that it is
better to give an adequate dose at once rather
than to give many small doses at varying intervals
during the same day. However, the latter pro-
cedure may be necessary when treating patients
who are sensitive to the serum protein of the ani-
mal from which the antitoxin is derived.

Passive Immunity. — Though diphtheria anti-
toxin is most valuable for treatment, it may be
also employed as a temporary preventive. Most
individuals who have been exposed to diphtheria
may be protected from the disease by the admin-
istration subcutaneously of 1000 units of anti-
toxin; 5000 or 10,000 units are preferred by some
physicians. The protection from this does not last
longer than three or four weeks : if it is necessary
to prolong the period of protection, active im-
munization (see under Diphtheria Toxoid) should

be used simultaneously with the first injection of
antitoxin (Fulton et al., Brit. M. J., 1941, 2, 759).
Where a large number of children or individuals
exposed to diphtheria are to be given immediate
temporary protection, it is advisable to first de-
termine by the Schick test (see Diagnostic Diph-
theria Toxin) whether or not they possess a
natural immunity. All those who are Schick posi-
tive, and therefore in danger of contracting the
disease, may be given the prophylactic dose of
diphtheria antitoxin. In Great Britain and Europe
there have occurred, in recent times, outbreaks of
a malignant diphtheria which shows a mortality
of from 50 to 70 per cent even after large doses of
antitoxin were administered early intravenously.
These infections are ascribed to the so-called
B. diphtheria gravis, which produces an extracel-
lular toxin that either rapidly fixes with the tis-
sues, or possesses a low avidity for diphtheria
antitoxin. See Cooper et al. (Proc. Roy. Soc.
Med., 1936. 29, 1029) and MacLeod {Bad. Rev.,
1943, 7, 1) for complete details on malignant
diphtheria. Avirulent strains of diphtheria are not
infrequent in healthy throats and Hewitt {Lancet,
1952, 2, 272) observed that either diphtheria
bacteriophage or staphylococcus bacteriophage is
capable of producing bacterial mutants certain of
which could be virulent to some contacts of these
carriers.

Serum Reactions. — Although the use of con-
centrated, digested, and purified antitoxic prod-
ucts has caused a considerable decrease in the
frequency of severe serum reactions, these still
may occur in about 1 in 20,000 injections.

Serum reactions may be classified into three
general categories: (a) Serum sickness, (b) accel-
erated reactions, {c) immediate reactions. Serum
sickness may occur in about 10 per cent of indi-
viduals who have had no previous injection of
animal serum. It may develop in five to ten days
and is characterized by a rise in temperature fol-
lowed by an urticarial eruption accompanied fre-
quently by joint pains and lymphadenitis. It may
last from one to five days and is more unpleasant
than serious. Accelerated reactions are similar to
serum sickness in manifestations but most fre-
quently occur in patients who have had previous
injections of animal serum. These differ from
primary serum sickness since they develop in two
to five days and tend to produce more intense
symptoms. Immediate reactions (frequently called
anaphylactic reactions) occur only in individuals
who are highly sensitized to the serum that is
administered. In these patients extremely small
quantities of serum may cause an immediate reac-
tion of critical severity. Immediate reactions vary
in intensity but are usually characterized by
flushing, followed by dyspnea, cyanosis, swelling
of the lips and eyelids. Generalized urticaria or
sneezing may occur and the temperature may rise
abruptly to high levels (106° to 108° F.). Evi-
dences of profound shock are seen and death may
occur in a few minutes (Lamson. J. A.M. A., 1929,
93, 1775). Immediate reactions require prompt
and decisive treatment. One ml. of a 1 :1000 solu-
tion of epinephrine should be injected immedi-
ately and atropine may be given in addition.
Symptoms of the delayed or accelerated type of

Part I

Diphtheria Toxin, Diagnostic 485

reaction can be controlled with corticotropin or
cortisone (Shulman et al., Bull. Johns Hopkins
Hosp., 1953, 92, 196); the antihistaminic drugs
have some symptomatic and possibly prophylactic
value. Acute anaphylaxis is a catastrophe calling
for heroic measures, as the patient may not sur-
vive long enough for exhibition of these drugs.

Patients who have not had a serum reaction
following the first injection will probably not
react to subsequent injections given at short in-
tervals during the duration of the disease. How-
ever, if serum injections are given several months
apart the sensitivity of the patient must be deter-
mined once more.

Prevention. — An attempt should always be
made to determine whether a patient has a past
history of having received serum injections or has
had any evidence of allergic conditions such as
asthma, hay fever, eczema, urticaria, or food
allergy. If it is suspected that sensitivity to horse
serum may exist, this should be tested for by the
intradermal injection of 0.02 ml. of a 1:10 dilu-
tion of the antitoxin or normal horse serum in
isotonic salt solution. A positive reaction is evi-
denced by the development of an urticarial wheal
within 30 minutes. The ophthalmic test is also used
to determine sensitivity to foreign protein. This
is performed by instilling one drop of a 1 : 10 dilu-
tion of the serum into the conjunctival sac. If
sensitivity is present, conjunctival redness, swell-
ing, itching, and increased lachrymation will de-
velop within 15 minutes. The ophthalmic test is of
little value in young children as they may wash
out the serum by crying. Many workers perform
tests for sensitivity on all individuals who are to
receive intravenous serum therapy regardless of
their previous history.

Where the reaction is negative or if it is not
possible to perform the test and the history of
sensitivity is negative, it is relatively safe to pro-
ceed with the administration of the antitoxin.

If the patient is hypersensitive to horse serum
and it is necessary to administer an antitoxin, the
best thing to do is to use a serum prepared from
cattle {Diphtheria antitoxin, bovine), if this is
available; it must be remembered, however, that
while allergy to cattle is uncommon it is not un-
known and the same precautions must be observed
in its use as with horse serums. If bovine serum
is not obtainable, attempts may be made to de-
sensitize the patient by injecting subcutaneously,
at half-hour intervals, small doses of the antitoxin,
beginning with 0.005 to 0.025 ml. and gradually
increasing. The initial subcutaneous dose may be
doubled every half-hour according to the severity
of the skin reaction to the previous dose until a
dose of 1 ml. is reached. Then 0.1 ml., well
diluted with saline solution, is given slowly intra-
venously. If tolerated without severe reaction, this
dose is doubled in 30 minutes and again every 20
to 30 minutes until the desired therapeutic dose
of the antitoxin is given. If any dose causes a
marked reaction, the same dose, rather than twice
the dose, is repeated in half an hour. Most pa-
tients can be desensitized in this manner but some
react so severely that antitoxin therapy is im-
possible. The simultaneous use of an antihis-
taminic drug often minimizes the reaction to the

injections. Epinephrine must be immediately
available during such a course of desensitizing
injections.

Dose. — The dose of diphtheria antitoxin for
treatment depends largely upon the severity of
the case and its stage of development when seen
rather than the size or the age of the patient. It
may vary from as low as 20,000 units in mild
cases to 200,000 units in severe cases. The U.S. P.
gives the usual dose as 20,000 units, with a range
of 10,000 to 80,000 units. In mild and moderate
cases the injection is administered slowly intra-
muscularly. In laryngeal and severe cases intra-
venous, or part intramuscular and part intravenous
injections, are given. In malignant cases intra-
venous administration is practiced. As a prophy-
lactic, after exposure to infection, the customary
dose is 1000 units although 5000 and 10,000 units
have been used.

Penicillin, 300,000 units daily intramuscularly,
is also indicated for about 10 days in treating
diphtheria.

Because of the fact that antitoxin deteriorates,
even under the most favorable conditions com-
mercially possible, it is important that the "ex-
piration date" of the package should always be
noted before injection. (It is important to re-
member that the expiration date applies only to
antitoxin kept at a temperature below 10° C.
[50° F.] and that deterioration at higher tem-
peratures is rapid.) However, there will likely be
some curative value after the expiration date
and if no fresh antitoxin be available an expired
sample is better than none.

Labeling. — "The package label bears the name
Diphtheria Antitoxin; the potency in antitoxic
units; the genus of animal employed when other
than the horse; the lot number and the expira-
tion date, which is not more than 1 year after the
date of manufacture or date of issue with a 20
per cent excess of potency, 2 years with a 30 per
cent excess, 3 years with a 40 per cent excess, or
4 years with a 50 per cent excess, and the manu-
facturer's name, license number, and address."
U.S.P.

Storage. — Preserve "at a temperature between
2° and 10°, preferably at the lower limit. It must
be dispensed in the unopened glass container in
which it was placed by the manufacturer." U.S.P.

Usual Sizes.— 1000, 5000, 10,000, 20,000, and
40,000 units.

DIAGNOSTIC DIPHTHERIA TOXIN.

U.S.P. (B.P.)

Schick Test Toxin, Diphtheria Toxin for the Schick
Test, [Toxinum Diphthericum Diagnosticum]

"Diagnostic Diphtheria Toxin is a sterile solu-
tion of the toxic products of growth of the diph-
theria bacillus (Corynebacterium diphtherice) . It
contains a preservative approved by the National
Institutes of Health." U.S.P.

B.P. Schick Test Toxin.

Diagnostic diphtheria toxin is used as a reagent
to determine susceptibility to diphtheria. It is
produced as a filtrate of a suitably toxigenic cul-
ture of Corynebacterium diphtherice, and is di-

486 Diphtheria Toxin, Diagnostic

Part I

luted so that 0.1 ml. contains the test dose. In
the B.P., the test dose is contained in 0.2 ml. The
diluent used may be either a sterile isotonic solu-
tion of sodium chloride or a stabilizing solution
containing buffer salts, or normal human serum
albumin (Edsall and Wymann, Am. J. Pub Health,
1944, 34, 365). These substances are used to pre-
serve the toxicity of the toxin, which tends to
decrease on storage in diluted form. Diagnostic
diphtheria toxin may also be supplied undiluted
along with a suitable vial of sterile diluting fluid
of a volume sufficient for making the required
toxin dilution.

In 1883, Klebs described the presence of bacilli
in the pseudo-membranes from the throats of
cases of diphtheria. One year later, Loffler ob-
tained pure cultures of these organisms. They
have therefore been known also as Klebs-Loffler
bacilli, but today are classified in the genus
Corynebacterium. In 1888, Roux and Yersin
proved that the diphtheria bacillus produces a
soluble poison which they called toxin. It is this
toxin (which can be freed from the bacteria and
is therefore known as exotoxin) that is the chief
noxious agent in diphtheria and must be combated
in that disease.

Production. — Diphtheria toxin is produced by
incubating a pure culture of Corynebacterium
diphtherial, using a strain known to yield a potent
toxin, in a suitable culture medium, free from
horse meat, for about a week in flat-bottomed
containers which yield a shallow layer of medium
with a large surface, thus affording better aeration
and consequently more rapid formation of toxin.
After filtration, tests for sterility and potency are
conducted.

Diphtheria toxin is destroyed, or greatly modi-
fied, by heating to 60° for one-half hour, but
when dried it may withstand 70°. Light and
oxidants destroy it rapidly. It is apparently a non-
crystallizable protein and is precipitated by am-
monium sulfate, alcohol, or nucleic acid. The
degree of toxicity or potency is expressed in terms
of the M.L.D., or minimum lethal dose (also
called M.F.D., minimum fatal dose), which is
the smallest amount of diphtheria toxin that,
when injected subcutaneously, will kill, in 96
hours, a guinea pig weighing 250 Gm. (For defini-
tion of other terms applied to diphtheria toxin see
under Diphtheria Antitoxin.)

Diphtheria toxin which is to be used in the
preparation of diagnostic diphtheria toxin should
be of very high potency so that upon dilution
it will contain a minimum quantity of the non-
specific proteins responsible for pseudoreactions.
However, no minimum potency is required by
the U.S.P.

Description. — Diagnostic Diphtheria Toxin is
a transparent liquid containing one-fiftieth of the
minimum lethal dose of diphtheria toxin in 0.1 ml.
It may be supplied as diluted toxin ready for ad-
ministration mixed with a suitable stabilizing
diluent or as undiluted toxin accompanied by a
vial of diluent suitable for preparing a toxin of
the required strength at the time of administra-
tion. The minimum lethal dose of Diagnostic
Diphtheria Toxin is defined as the smallest amount
of toxin which, administered subcutaneously to a

250- to 275-Gm. guinea pig, will cause the death
of the animal within 96 hours after administra-
tion. Diagnostic Diphtheria Toxin must be free
from harmful substances detectable by animal
inoculation.

Assay. — "Inject, subcutaneously, not fewer
than 5 healthy guinea pigs each weighing between
225 and 275 Gm. with 5 ml. of Diagnostic Diph-
theria Toxin (containing 0.02 minimum lethal
dose per 0.1 ml.). No animal survives and not
fewer than three-fourths of the deaths occur be-
tween 72 and 96 hours after administration."
U.S.P. The B.P. specifies both of the following
tests: (1) Inject into the skin of a normal guinea
pig one test dose mixed with Mssoth of one unit
or less of diphtheria antitoxin which should cause
a local reaction but when mixed with ^soth of a
unit or more of antitoxin it should cause no reac-
tion. (2) The second test is that ^sth of the test
dose causes a reaction, in the skin of the guinea
pig, of the kind known as a "positive Schick re-
action"; smaller quantities cause smaller local
reactions.

Uses. — The Schick Test is used to determine
whether persons have in their blood sufficient
diphtheria antitoxin to render them immune to
the disease. The test is performed by injecting
intracutaneous!}' 0.1 ml. of the test toxin (con-
taining Vm M.L.D.), usually in the flexor surface
of the forearm. A positive reaction — which indi-
cates susceptibility to diphtheria — usually appears
in from 24 to 48 hours and reaches its height in
from two to four days ; it is a circumscribed area
of redness and swelling around the site of injec-
tion from one-third to one-half inch in diameter.
It remains from one to two weeks and is followed
by slight scaling which leaves a brownish pig-
mented area. Occasionally, the reaction does not
appear until the third or fourth day. It is advis-
able to make a similar injection on the other arm
with the same quantity of toxin which has been
inactivated by heating (see Schick Control) as a
control for the reason that areas of redness may
be due to the effects of other proteins rather than
the toxin. This heated toxin is usually referred
to as a Schick Test Control. It has become quite
general practice to apply the Schick test to the
left arm and the Schick Test Control to the right
arm. In doubtful cases it is well to make observa-
tions of the reactions five or six days after the
inoculation as the pseudoreactions fade more
quickly that the positive and the contrasts be-
tween the controlled test and the toxin reaction
are usually obvious at this time.

The reliability of the Schick Test is very high.
O'Brien {Lancet, 1929, 1, 149) reported only 18
cases of diphtheria developing in more than
20.000 Schick-negative individuals and these cases
were very mild. In a routine survey of 2528 army
recruits ranging in age from 17 to 22 years, 40
per cent were Schick positive (Liao, Am. J.
Hygiene, 1954, 59, 262); the incidence of posi-
tive tests was higher in recruits coming from the
northern part of the United States or from cities,
in which areas the morbidity rate of diphtheria
is lower. Untoward reactions are extremely rare;
those that do occur are mostly due to sensitivity
to certain peptones which have been used as

Part I

Diphtheria Toxoid 487

buffers in the diluting solution (see Parish, Lancet,
1936, 2, 310).

The usual test dose of the U.S. P. preparation is
0.1 ml.; of the British preparation 0.2 ml.

Labeling. — "The package label bears the
name Diphtheria Toxin for Schick Test; the lot
number; the expiration date, which is not more
than 1 year after the date of manufacture or date
of issue; and the manufacturer's name, license
number and address." U.S.P.

Storage. — Preserve "at a temperature between
2° and 10°, preferably at the lower limit. Dis-
pense it in the unopened container in which it was
placed by the manufacturer." U.S.P.

The B.P. states that if the toxin is prepared by
dilution with solution of sodium chloride alone it
is very unstable, losing its potency in a few days
even when refrigerated; if diluted with a solution
containing sodium borate, boric acid, and sodium
chloride, and stored at a temperature not exceed-
ing 25°, it retains its potency for at least 2
months.

Usual Sizes. — 1, 5, and 10 ml.

INACTIVATED DIAGNOSTIC
DIPHTHERIA TOXIN. U.S.P. (B.P.)

Schick Control

"Inactivated Diagnostic Diphtheria Toxin is a
portion of a manufactured lot of diagnostic diph-
theria toxin which has been inactivated by heating
between 70° and 85° for 5 minutes and which
may be used simultaneously with the diagnostic
diphtheria toxin of the same lot to assist in dif-
ferentiating in doubtful reactions." U.S.P.

B.P. Schick Control.

Uses. — Schick control is intended to be used
as a control inoculation in the Schick test to ex-
clude reactions due to nonspecific substances.
When diagnostic diphtheria toxin is injected into
the skin any reaction which follows may be due
either to susceptibility to diphtheria toxin or to
sensitivity to other proteins present in the in-
jected toxin. As the toxin is inactivated by heat-
ing, an injection of diagnostic toxin thus treated,
used as a control, will serve to indicate the nature
of any reaction that is observed. Persons with a
positive response to this control solution should
not be given immunizing injections of toxoid;
very small doses, gradually increased, may be
tried under close observation.

The usual dose is 0.1 ml., intracutaneously.

Labeling. — "The package label bears the name
Schick Test Control; the lot number and the ex-
piration date, which is not more than 1 year after
date of manufacture or date of issue; and the
manufacturer's name, license number, and ad-
dress." U.S.P.

Storage. — Preserve "at a temperature between
2° and 10°, preferably at the lower limit. Dispense
it in the unopened container in which it was placed
by the manufacturer." U.S.P.

DIPHTHERIA TOXOID. U.S.P. (B.P.)

Anatoxin-Ramon, Diphtheria Anatoxin,
[Toxoidum Diphthericum]

"Diphtheria Toxoid is a sterile solution of
formaldehyde-treated products of growth of the

diphtheria bacillus (Corynebacterium diphtheria).
It contains not more than 0.02 per cent of residual
free formaldehyde." U.S.P.

Under the general title Diphtheria Prophylactic
the B.P. recognizes diphtheria toxin or material
derived therefrom, the specific toxicity of which
has been either reduced to a low level or com-
pletely removed by action of chemical substances
and to which diphtheria antitoxin may or may
not have been added. Four forms of Diphtheria
Prophylactic are recognized: (1) Fortnol Toxoid,
or Anatoxin, a clear, faintly yellow or colorless
liquid, being diphtheria toxin treated with solution
of formaldehyde until the specific toxicity has
been completely removed, or liquid purified prep-
arations thereof; this corresponds to U.S.P. Diph-
theria Toxoid. (2) Alum Precipitated Toxoid.
which corresponds to U.S.P. Alum Precipitated
Diphtheria Toxoid and is described in the follow-
ing monograph. (3) Purified Toxoid, Aluminum
Phosphate, for which there is no U.S.P. or N.F.
counterpart but which is described in the mono-
graph on Aluminum Hydroxide Adsorbed Diph-
theria Toxoid. (4) Toxoid- Antitoxin Floccules, a
fine suspension of white particles in a colorless
liquid, prepared by adding to diphtheria toxin,
the specific toxicity of which has been either com-
pletely removed or reduced to a low value by the
action of solution of formaldehyde, a quantity of
diphtheria antitoxin equivalent to about 80 per
cent of the toxoid so produced, separating the
floccules and washing and suspending them in
injection of sodium chloride, for which the U.S.P.
or N.F. has no counterpart.

B.P. Diphtheria Prophylactic. Detoxicated Diphtheria
Toxin. Fr. Anatoxine diphterique. Sp. Toxoide Difterico.

The passive immunity produced by injection of
an antitoxin is of relatively short duration; the
active immunity caused by the toxin is much
more permanent. Accordingly, some years ago
bacteriologists began to search for methods of
rendering diphtheria toxin safe for immunizing
purposes. The first effort was to mix it with
enough antitoxin to partially neutralize its harm-
ful effects. These toxin-antitoxin mixtures were
formerly widely used but are now rarely em-
ployed. Later, toxin was modified to toxoid by
treatment with various chemicals.

Diphtheria toxin upon long standing will lose
its toxicity although retaining its power for neu-
tralizing antitoxin; there appears to be no rela-
tionship between the pathogenic power of a toxin
and its ability to neutralize its specific antitoxin
or to stimulate the production of antitoxic sub-
stances. Ehrlich theorized that the toxin molecule
consists of two portions: (1) the toxophore group,
which is easily destroyed by chemicals, and which
is the carrier of the toxic qualities; (2) the much
more stable haptophore group is non-toxic but can
neutralize antitoxin and act as an antigen to incite
the body cells to produce specific antitoxin. Based
on these observations various methods have been
employed to prepare non-poisonous modifications
of diphtheria toxin which are known as diphtheria
toxoid or anatoxin.

Diphtheria toxin to be used for the preparation
of diphtheria toxoid is required by National Insti-

488 Diphtheria Toxoid

Part I

tutes of Health regulations to be free of allergenic
derivatives of horse protein and must contain
neither Witte nor Berna peptones. These sub-
stances are excluded because of the frequency
with which they have been implicated in allergic
reactions resulting from the injection of toxoids
in which they were present. In addition, the toxin
must have an L+ dose of not more than 0.2 ml.
and an M.L.D. of not more than 0.0025 ml. Suit-
able diphtheria toxin is detoxified by the addition
of formaldehyde and incubation, at a temperature
usually between 37° and 43°, for several weeks.
During this incubation period the formaldehyde
combines with the proteins of the toxin; the
amount of free formaldehyde should not exceed
0.02 per cent at the end of the detoxification
period. Proof of detoxification is obtained by in-
jecting 5 ml. of the toxoid subcutaneously into
each of at least 4 guinea pigs weighing 300 to 400
Gm. If, throughout thirty days, no animal shows
evidence of diphtheria poisoning, the toxoid is
considered to be nontoxic. Since phenolic pre-
servatives tend to destroy the potency of diph-
theria toxoids, their use is prohibited. Mercurial
preservatives are usually used. Toxicity, sterility,
and potency tests are made on the final product.
Toxoids are free of any serum protein which
toxin-antitoxin mixture contains because of the
presence of the antitoxin in the latter. It must be
noted, however, that somatic proteins from the
diphtheria bacillus and the culture medium are
present. These may cause occasional allergic reac-
tions, especially in older children and adults.
Toxoid has largely displaced the toxin-antitoxin
mixture for immunization as fewer injections are
needed, and the immunity is developed more
quicklv and more certainly (see Fitzgerald. Am.
J. Pub. Health, 1932, 22, 25). Moreover, diph-
theria toxoid is stable in its antigenic power, is
completely detoxified, and not easily affected by
temperature changes. The expiration date is two
years after date of manufacture or date of issue.

Description. — "Diphtheria Toxoid is a clear,
brownish yellow, or slightly turbid liquid having
a faint, broth-like odor or an odor of formalde-
hyde." U.S.P.

Standards and Tests. — Toxicity. — No local
or general symptoms of diphtheria toxin poison-
ing appear within 30 days following subcutaneous
injection into not fewer than 4 healthy guinea
pigs, each weighing between 300 and 400 Gm..
with a volume of diphtheria toxoid that is at least
5 times the intended human immunizing dose but
not less than 2 ml. Antigenic value. — Not less
than 80 per cent of the animals survive for at
least 10 days when not fewer than 10 healthy
guinea pigs, each weighing between 270 and 320
Gm.. receive subcutaneously not more than one-
sixth the volume of diphtheria toxoid intended
as the total human immunizing dose and then
not more than 6 weeks later, not less than 10
minimum lethal doses of diphtheria test toxin.
Other requirements. — The toxoid complies with
the identity, safety, sterility, and potency tests
and other requirements of the National Institutes
of Health, including the release of each lot indi-
vidually before its distribution. U.S.P.

The Lf Unit. — In evalulating the potency of

diphtheria toxins (or toxoids), the Lf unit, refer-
ring to specific flocculation equivalent (limit floc-
culation) is frequently used. An Lf unit is that
amount of toxin (or toxoid) which gives the most
rapid flocculation with one standard unit of anti-
toxin when mixed and incubated in vitro. The
flocculation test is based on the observation of
Ramon (Compt. rend. soc. biol., 1922, 86, 661)
that a mixture of optimal proportions of toxin
(or toxoid) and antitoxin produces floccules of
antigen-antibody.

Uses. — Diphtheria toxoid is used for prophy-
lactic immunization against diphtheria but the
aluminum-modified forms seem to be preferred.
The active immunity it confers may last for sev-
eral years, in sharp contrast to the temporary
protection afforded by the passive immunity from
the antitoxin. Farago {Lancet, 1940, 239, 68)
found the Schick test to be negative five years
after immunization with refined toxoid in more
than 85 per cent of the cases. Yolk and Bunney
{Am. J. Pub. Health, 1942, 32, 690) compared
the response of children without basic immunity
to injections of plain diphtheria toxoid and alum
precipitated diphtheria toxoid. They found that
the response to three doses of diphtheria toxoid
was somewhat inferior to two doses of the alum
precipitated diphtheria toxoid but better than one
dose of alum precipitated diphtheria toxoid. Ordi-
narily, the immunizing doses are given subcu-
taneously although intracutaneous injection has
been claimed to cause fewer unpleasant reactions
and to be equally efficient {Blatt et al., Am. J.
Dis. Child., 1941. 62, 757). It has become cus-
tomary to immunize children beginning at the
second to sixth month of life, although under
three years of age the so-called "triple antigen-'
(diphtheria and tetanus toxoids and pertussis
vaccine combined, alum precipitated or. aluminum
hydroxide adsorbed) is more commonly used.
After 12 years of age at least and perhaps after
3 years of age, local and even systemic reactions
are frequent with diphtheria toxoid or the alu-
minum modified forms (see under Diphtheria and
Tetanus Toxoids, Alum Precipitated). Schick
tests (see Diagnostic Diphtheria Toxin) are usu-
ally carried out one or two months after the last
immunization dose. If a positive Schick test is
still seen, further doses of diphtheria toxoid may
be given. After the initial immunization with diph-
theria toxoid, diphtheria immunity may persist
at a satisfactory level for considerable periods of
time as indicated above. However, during the
threat of an epidemic or when immunity has been
demonstrated to have decreased by the reversion
of the individual to a Schick-positive status, im-
munity may be enhanced by the administration
of a single "booster" dose of diphtheria toxoid.
This practice is frequently employed in children
about to enter school if they have had previous
immunization at an early age.

Oral ingestion of diphtheria toxoid daily for
5 days is not sufficiently effective to justify its use
unless in previously immunized adults who react
severelv to small doses parenterallv (Greenberg
et al., Can. J. Pub. Health, 1954, 45, 103).

Dose. — Diphtheria toxoid is usually given in
three subcutaneous doses of 1 ml. or 0.5 ml.

Part I

Diphtheria Toxoid, Alum Precipitated 489

(whichever is specified on the label) at intervals
of approximately three to four weeks between
injections. "Booster" doses are given as a single
injection of the same volume. Since adults may
experience exaggerated local and systemic reac-
tions because of sensitivity to the somatic pro-
tein of the diphtheria bacillus, the routine pro-
cedure in a child is contraindicated. If diphtheria
toxoid is used an initial intradermal test injection
of 0.1 ml. of a 1 to 20 dilution of the toxoid is
given. The size of subsequent doses should be
judged on the basis of the reaction following this
initial dose. The interval between doses, however,
is the same. In cases of undue sensitivity toxin-
antitoxin mixture, obtained from goats, has been
given. Hypodermic injection of 1:1000 epineph-
rine hydrochloride solution may be advisable to
control untoward allergic symptoms. (See also
Tetanus and Diphtheria Toxoids Combined, Pre-
cipitated, Adsorbed {for Adidt Use), on page 492).

Labeling. — "The package label bears the name
Diphtheria Toxoid; the lot number and the ex-
piration date, which is not more than 2 years
after date of manufacture or date of issue; the
manufacturer's name, license number, and ad-
dress; and the statement, 'Keep at 2° to 10° C.
(35.6° to 50° F.)\" U.S.P.

Usual Sizes. — 1.5, 7.5, and 15 ml.

ALUM PRECIPITATED DIPH-
THERIA TOXOID. U.S.P. (B.P.)

[Toxoidum Diphthericum Alumen Praecipitatum]

"Alum Precipitated Diphtheria Toxoid is a
sterile suspension of diphtheria toxoid precipi-
tated by alum from a formaldehyde-treated solu-
tion of the products of growth of the diphtheria
bacillus (Corynebacterium diphtherial). It con-
tains a non-phenolic antibacterial agent and not
more than 15 mg. of alum in the volume stated
in the labeling to constitute one immunizing dose."
U.S.P.

Under the general title Diphtheria Prophylactic
(see preceding monograph) the B.P. recognizes
four forms, of which the one designated Alum
Precipitated Toxoid corresponds to the U.S.P.
preparation described in this monograph. It is
defined as a suspension of white or slightly yellow
particles in an almost colorless liquid, prepared
by adding alum to formol toxoid in the propor-
tion necessary to produce a suitable precipitate,
separating the precipitate, washing it, and sus-
pending it in injection of sodium chloride.

It has been observed that addition of alum to
diphtheria toxoid results in precipitation of the
toxoid while leaving in solution many of the cul-
ture medium components occurring in plain diph-
theria toxoid. By collecting the precipitate, then
washing it with sodium chloride solution, a con-
siderable degree of purification of the original
toxoid is effected. Furthermore, the alum-precipi-
tated toxoid is somewhat more active as an im-
munizing agent than is the regular diphtheria
toxoid.

Preparation. — Alum precipitated diphtheria
toxoid may be prepared only from plain toxoid
which meets all of the minimum requirements for
the latter except that it need not equal the anti-

genic value required for the product. Potassium
alum is added to the toxoid to effect precipita-
tion; the quantity of alum used will depend upon
the composition of the toxoid and is usually
equivalent to 1.5 to 2 per cent in final concentra-
tion. The diphtheria toxoid, as well as certain
other culture medium constituents, thereby pre-
cipitate and presently settle at the bottom of the
container. The supernatant liquid, containing the
excess of alum and soluble culture medium con-
stituents, is drawn off and replaced with isotonic
sodium chloride solution. This washing process
may be repeated several times; the precipitated
toxoid is finally suspended in the proper volume
of isotonic sodium chloride solution, adjusted to
a pH of 7.5 to 8.5. Alkaline buffers tend to coun-
teract the acidity of the alum precipitate and
maintain the precipitate in a form that may be
readily dispersed by agitation. Alum precipitated
toxoid is available in concentrations such that
the human dose is contained in 0.5 ml. or 1 ml.
The toxoid usually contains a mercurial preserva-
tive; phenolic preservatives are not permitted
because of their destructive effect on the anti-
genicity of the toxoid.

Description. — "Alum Precipitated Diphtheria
Toxoid is a turbid, white, slightly gray or slightly
pink suspension." U.S.P.

Standards and Tests. — Antigenic value. —
When not more than one-half the recommended
total human immunizing dose of the toxoid is
administered subcutaneously to not fewer than 4
guinea pigs, each weighing between 450 and 550
Gm., at least 2 units of antitoxin per ml. of pooled
blood serum is produced in the pigs within 3 to
4 weeks. Other requirements. — The toxoid com-
plies with the identity, safety, sterility, and po-
tency tests and other requirements of the National
Institutes of Health, including the release of each
lot individually before its distribution. U.S.P.

Uses. — Alum precipitated diphtheria toxoid is
the most effective substance available for pro-
phylactic active immunization against diphtheria.
For infants and young children "triple antigen"
(Diphtheria and Tetanus Toxoids and Pertussis
Vaccine Combined, Alum Precipitated or Alu-
minum Hydroxide Adsorbed) is preferred for
convenience. In an extensive and careful study
reported by Volk and Bunney (Am. J. Pub.
Health, 1942, 32, 690) it was found that 96 per
cent of children had at least 0.01 unit of diph-
theria antitoxin 4 months after immunization
when two doses were given 3 weeks apart. Only
67 per cent were found to have this antitoxin
level after 3 doses of the plain diphtheria toxoid.
These observations have been confirmed by many
other investigations. Basic immunity persists for
3 to 4 years after successful immunization. The
better response which is obtained with alum pre-
cipitated diphtheria toxoid is probably attributable
to the physical nature of the antigen. In this
product the antigen is in a relatively insoluble
form as an alum precipitate ; when it is injected it
tends to remain localized and is disseminated into
the general circulation at a slower rate and over a
somewhat longer period of time than is the fluid
toxoid. This produces a more prolonged stimula-
tion of the antitoxin-producing mechanism of the

490 Diphtheria Toxoid, Alum Precipitated

Part I

body and results in the development of higher
antitoxic levels in a larger proportion of im-
munized children.

Reactions. — Because of the comparative in-
solubility of alum precipitated antigens they are
more prone to produce local reactions than are
other preparations of the antigen. A local reaction
is almost always caused by the injection of alum
precipitated antigens but in the large majority of
children this consists of nothing more than the
formation of a small subcutaneous nodule which,
after a few days, is painless and is slowly ab-
sorbed. Occasionally erythema is seen at the site
of injection and the arm may be painful for sev-
eral days after the administration of the toxoid.
Very rarely the subcutaneous nodule will become
fluctuant, subsequently open through the skin,
and discharge pus. Bacteriological cultures of this
pus are sterile and these lesions are called "sterile
abscesses," "alum abscesses" or "alum cysts."
The formation of sterile abscesses was noted by
Yolk and Bunney in only two of 1614 injections
of alum precipitated diphtheria toxoid.

Beyond 12 years of age local reactions are fre-
quent and often severe. Adults seem to be allergic
to the proteins contained in diphtheria toxoid,
and therefore the immunization of adults should
be undertaken with extreme care. Because of the
slow absorption of alum precipitated diphtheria
toxoid, the local reaction tends to be exaggerated.
Systemic reactions from the alum precipitated
toxoid are the same as they are with diphtheria
toxoid. Immunization of adults, however, must
not be neglected because the incidence of diph-
theria is increasing in adults although it is very
low in children. Edsall (Am. J. Pub. Health, 1952,
42, 393) points out that an injection of toxoid
may put an adult to bed for several days with
fever and a massively swollen, tender and painful
arm which may not return to normal for 2 weeks.
Reactions are 3 to 10 times as frequent in Schick-
negative persons. Hence, the first step is a Schick
test and if it is negative no further prophylaxis is
needed. If it is positive, however, Edsall recom-
mends that the Schick test be repeated since the
antigenic stimulus of the previous intracutaneous
injection of toxin may be sufficient to stimulate
immunity sufficiently for the repeat test to be-
come negative. This reversal may be expected in
25 to 45 per cent of cases and even in those who
remain positive a rise of antitoxin titer in the
blood was observed in 20 to 30 per cent of cases
after the second Schick test. A small booster
dose every 3 or 4 years will maintain adequate
immunity to protect against ordinary exposure
to diphtheria.

If, however, the toxoid must be employed,
an initial dose of 0.1 ml. of undiluted toxoid is
given subcutaneously. If no significant reaction
has occurred in 1 week, a dose of 0.3 ml. may be
given and after a month a dose of 0.5 ml. is
usually safe if there has been no untoward
response to the second dose. Because of these
considerations alum precipitated diphtheria toxoid
is not usually recommended for the immuniza-
tion of adults. See Tetanus and Diphtheria Tox-
oids Combined, Precipitated, Adsorbed (For

Adult Use), described under the dosage statement
on page 492.

Reimmunization. — Alum precipitated diphthe-
ria toxoid is also used for the reimmunization of
children who have received their primary immuni-
zation at an earlier date. It is now well known that
diphtheria antitoxin immunity is not permanent,
and that, as time goes on, the antitoxin content
of the blood tends to diminish. Reimmunization
with diphtheria toxoid (either plain or alum pre-
cipitated) is highly effective, and one dose pro-
duces a satisfactory response in most children.
Volk and Bunney (Am. J. Pub. Health, 1942, 32,
700) found that practically all children had at
least 0.01 unit of diphtheria antitoxin in their
blood 10 days after reimmunization with a single
dose of diphtheria toxoid; the rapidity of this
response is noteworthy. Moderate exposure to the
disease, without producing symptoms of infec-
tion, presumably induces a similar rapid rise in
antitoxin titer in the blood and tissues. For
further discussion of the present status of diph-
theria immunization see Love and Shaul (Med.
Clin. North America, 1950, 34, 1713).

Dose. — Alum precipitated diphtheria toxoid
is given in two doses of 1 ml. (or whatever
smaller dose is indicated on the label) with an
interval of 4 to 6 weeks between doses. This
dosage is used regardless of the age or weight of
the child. Subcutaneous injection is usually recom-
mended, although intramuscular injection has
been recommended as a means of preventing the
occurrence of a sterile abscess. Satisfactory im-
munization may be accomplished by either route
of administration. Immunization of adults should
be undertaken cautiously, using 0.1 ml., and
further dosage judged according to the degree of
reaction obtained.

Labeling. — "The package label bears the
name Alum Precipitated Diphtheria Toxoid; the
lot number and the expiration date, which is not
more than 2 years after date of manufacture or
date of issue; the manufacturer's name, license
number, and address; and the statement, 'Keep
at 2° to 10° C. (35.6° to 50° F.).' " U.S.P.

Usual Sizes. — 1, 5, and 10 ml.

ALUMINUM HYDROXIDE
ADSORBED DIPHTHERIA TOXOID.

U.S.P.

"Aluminum Hydroxide Adsorbed Diphtheria
Toxoid is a sterile suspension of diphtheria toxoid
adsorbed on aluminum hydroxide from a formal-
dehyde-treated solution of the products of growth
of the diphtheria bacillus (Corynebacterium diph-
theria). It contains a non-phenolic antibacterial
agent and not more than 0.85 mg. of aluminum in
the volume stated in the labeling to constitute one
injection." U.S.P.

Roux (Ann. Inst. Past., 1888, 2, 629) was the
first to observe that potassium alum, when added
to toxin culture filtrate, removed the diphtheria
toxin, presumably by adsorption on the precipi-
tate. In 1926, Glenny et al. (J. Path. Bad., 1926,
29, 38) reported on the enhanced antigenic power
of diphtheria toxoid, in horses, when administered

Part I

Diphtheria and Tetanus Toxoids, Alum Precipitated 491

as alum precipitated toxoid, and Glenny and Barr
(ibid., 1931, 34, 118) showed later that by careful
washing of this precipitate much of its irritant
property was removed and it could, therefore, be
used for children. Since then alum precipitated
toxoid has become the reagent of choice for the
immunization of children. Alum precipitated tox-
oid, although considerably more powerful than
fluid toxoid as an immunizing agent, is variable
in its degree of purity, form of the mineral car-
rier, and antigenic properties. In alum precipitated
toxoids the degree of purity is of the order of 300
Lf per mg. of protein nitrogen. By virtue of the
two classes of soluble inorganic compounds pres-
ent in crude toxoid — phosphates and bicarbonates
— the addition of potassium alum results in a
precipitate of aluminum hydroxide and aluminum
phosphate. The more bicarbonate that is present,
the more aluminum hydroxide is formed; simi-
larly, adjustment of pH by addition of alkali or
acid influences the proportion of phosphate to
hydroxide. Aluminum hydroxide being a more
powerful adsorbing agent, the resulting precipi-
tate will be variable in the qualities mentioned
above. To overcome these deficiencies of alum
precipitated toxoid prepared from crude toxoid,
the toxoid may be first refined by ammonium sul-
fate, or alcohol precipitation, and then adsorbed
on pure aluminum hydroxide either by addition of
the toxoid to an aluminum hydroxide gel, with
appropriate dilution, or by the formation of alu-
minum hydroxide in the toxoid solution.

Under existing regulations of the National In-
stitutes of Health no limits are placed on the
purity of toxoid, in terms of Lf per mg. of pro-
tein nitrogen, for aluminum hydroxide adsorbed
toxoids. The work of Holt (Developments in
Diphtheria Prophylaxis, Heineman, London, 1950)
and the experience of the U. S. Army with refined
toxoids, diphtheria toxoid particularly, are bring-
ing about further changes in adsorbed toxoids in
this country. Diphtheria and tetanus toxoid can
now, on a practical basis, be refined so that 1500
Lf per mg. of nitrogen can readily be attained.
As demonstrated by Pappenheimer and Lawrence
(Am. J. Hyg., 1948, 2, 233) it is desirable to
reduce the risk and severity of reactions by re-
ducing the protein content of toxoids to a mini-
mum. Also, as shown by Holt, aluminum phos-
phate appears to be the desirable adsorbing
agent. Aluminum phosphate adsorbed toxoids,
though not yet recognized by U.S. P., are available
commercially. The N.N.R. recognizes Diphtheria
Toxoid, Aluminum Phosphate Adsorbed, while
the B.P. recognizes as a form of Diphtheria Pro-
phylactic (see under Diphtheria Toxoid), a prep-
aration designated Purified Toxoid, Aluminum
Phosphate. The B.P. preparation is required to
have a content of toxoid of not less than 1500 Lf
per mg. of protein nitrogen, with the aluminum
phosphate having adsorbed on it not less than 45
Lf per ml., the fluid portion containing not more
than 20 per cent of the total toxoid used, the pH
being between 5.0 and 7.0, and the content of
AIPO4 being between 10 mg. and 15 mg. per ml.

Description and Requirements. — The
U.S. P. indicates that this preparation conforms to

the description and meets the requirements for
antigenic value and packaging and storage under
Alum Precipitated Diphtheria Toxoid. Require-
ments of the National Institutes of Health must
also be met.

The uses and dose of this preparation are the
same as for the corresponding alum precipitated
product. The labeling data, except for the differ-
ence in name, are also identical for the two
products.

DIPHTHERIA AND TETANUS
TOXOIDS. N.F.

Combined Diphtheria and Tetanus Toxoids

"Diphtheria and Tetanus Toxoids is a clear or
slightly turbid, yellowish or brownish liquid made
by mixing suitable quantities of diphtheria toxoid
and tetanus toxoid, each of which possesses ade-
quate potency to permit combining. The toxoids
shall be mixed in such proportions as to provide
an immunizing dose of each toxoid in the total
dosage prescribed on the label. Diphtheria and
Tetanus Toxoids complies with the official po-
tency test and other requirements of the National
Institutes of Health of the United States Public
Health Service." N.F.

This preparation represents essentially a solu-
tion of diphtheria and tetanus toxoids, rather
than a suspension of them on solid adsorbents, as
is the case with Alum Precipitated Diphtheria and
Tetanus Toxoids or with Aluminum Hydroxide
Adsorbed Diphtheria and Tetanus Toxoids. The
two latter preparations, however, represent a
higher degree of refinement of the active toxoids;
also, they have the advantage of requiring admin-
istration of two doses for immunization, rather
than the three doses required in the case of the
product described in this monograph. For uses of
these preparations see under Alum Precipitated
Diphtheria and Tetanus Toxoids.

The usual dose is 0.5 or 1 ml., whichever is
specified on the label, to be repeated twice at
intervals of 3 to 4 weeks between injections. Ad-
ditional doses may be required to secure a nega-
tive Schick test.

Regulations. — "The outside label must bear
the name Diphtheria and Tetanus Toxoids, the
manufacturer's lot number of the combined tox-
oids, the name, address, and license number of
the manufacturer, and the date beyond which the
Toxoids may not be expected to retain the potency
required by the National Institutes of Health of
the United States Fublic Health Service." N.F.

Storage. — Preserve "at a temperature between
2° and 10°, preferably at the lower limit. It must
be dispensed in the unopened glass container in
which it was placed by the manufacturer." N.F.

ALUM PRECIPITATED DIPHTHERIA
AND TETANUS TOXOIDS. U.S.P.

Diphtheria and Tetanus Toxoids Combined, Alum

Precipitated, [Toxoida Diphtherica et Tetanica

Alumen Prascipitata]

"Alum Precipitated Diphtheria and Tetanus
Toxoids is a sterile suspension prepared by mixing
suitable quantities of alum precipitated diph-
theria toxoid and alum precipitated tetanus

492 Diphtheria and Tetanus Toxoids, Alum Precipitated

Part I

toxoid. The potency and the proportions of the
toxoids are such as to provide an immunizing
dose of each toxoid in the total dosage prescribed
on the label. Alum Precipitated Diphtheria and
Tetanus Toxoids contains a suitable non-phenolic
antibacterial agent approved by the National In-
stitutes of Health, and not more than 15 mg. of
alum in the volume stated in the labeling to con-
stitute one injection." U.S.P.

Alum precipitated diphtheria and tetanus
toxoids is prepared by mixing suitable propor-
tions of alum precipitated diphtheria toxoid and
alum precipitated tetanus toxoid which are both
of sufficient potency that one human immunizing
dose of each toxoid is contained in a volume
of 1 ml. or less. The finished toxoid shall contain
not more than 15 mg. of alum per dose as de-
termined by analysis or in lieu of analysis 20 mg.
of alum per injection may be added if the pre-
cipitate is washed to remove excess alum. It is
also required that the product shall not contain
a phenolic preservative. For detailed discussion
of methods of preparation and potency testing see
Alum Precipitated Diphtheria Toxoid, and Alum
Precipitated Tetanus Toxoid. The combined tox-
oid is required to meet the individual antigenic
value tests specified for the components.

While alum precipitation effects a certain de-
gree of purification of toxoids there is an in-
creasing tendency in manufacture to first purify
the toxoids prior to addition of alum.

Description. — "Alum Precipitated Diphtheria
and Tetanus Toxoids is a turbid, white, slightly
gray or slightly pink suspension." U.S.P.

Uses. — Alum precipitated diphtheria and
tetanus toxoids is used for simultaneous active
immunization against both diphtheria and tetanus.
Diphtheria immunization is generally considered
to have a practical duration of two to four years,
and waning immunity may be detected by the
Schick test (see Diagnostic Diphtheria Toxin).
Immunization with alum precipitated tetanus
toxoid produces antitoxic titers of approximately
0.1 to 0.25 units per ml. of blood within one to
two months after the last dose. Thereafter, the
amount of circulating tetanus antitoxin remains
stationary and then gradually diminishes so that
in six to nine months only a basic immunity
remains. However, once this basic immunity
has been established, it is possible to raise the
antitoxin concentration in the blood to protective
levels very' rapidly by giving a single injection
of tetanus toxoid (Sneath and Kerslake, Can.
Med. Assoc. /.. 1935, 32, 132). It is recom-
mended, therefore, that initial immunization
against tetanus be followed by injection of one
human immunizing dose at yearly intervals and
that a dose of tetanus toxoid be given immedi-
ately after any injury having the possibility of
tetanus infection. If injury occurs less than one
month after completion of primary immuniza-
tion, the patient should be assumed to be non-
immune and a prophylactic dose of tetanus
antitoxin should be given.

Although alum precipitated toxoids are likely
to give more local reactions than plain toxoids,
the reactions caused by alum precipitated diph-
theria and tetanus toxoids are believed to be no

more frequent or severe than those produced by
alum precipitated diphtheria toxoid. Diphtheria
and Tetanus Toxoids Combined, Fluid, which
contains no alum or similar "adjuvant" agent, is
sometimes used in place of the alum precipitated
combination.

Dosage. — Alum precipitated diphtheria and
tetanus toxoids is given in a dose of 0.5 or 1 ml.,
as specified in the labeling of the container, at
intervals of 4 to 6 weeks. Deep subcutaneous
injection, with careful aseptic precautions and
terminal injection of a little air (0.1 to 0.2 ml.)
to clear the needle is usually recommended
(J.A.M.A., 1953, 153, 1067), although intramus-
cular injection is advocated as a means of
preventing occurrence of sterile abscesses; satis-
factory immunization may be accomplished by
either route. It is sometimes necessary to give
additional doses of diphtheria toxoid in order to
secure a negative Shick test. For this purpose
further use may be made of alum precipitated
diphtheria and tetanus toxoids, or diphtheria
toxoid (either plain or alum precipitated) may be
employed. Immunization of adults or children
over 12 years of age with alum precipitated
diphtheria and tetanus toxoids should be under-
taken with caution because of increased fre-
quency of sensitivity reactions to diphtheria tox-
oid in older persons. It is frequently recom-
mended that immunization of adults should be
commenced with a dose of 0.1 ml., with further
dosage determined by the degree of reaction
obtained.

Tetanus and Diphtheria Toxoids Combined
Precipitated, Adsorbed (For Adult Use) is a com-
bination of tetanus and diphtheria toxoids spe-
cially prepared for immunization of adults (see
above). In this preparation the diphtheria toxoid
component is first purified so that 1500 Lf will
be represented by 1 mg. or less of non-dialyzable
nitrogen. Only one-tenth the full human immuniz-
ing dose, not to exceed 2 Lf, of diphtheria toxoid
in the precipitated or adsorbed form, is used in
combination with a full human immunizing dose
of precipitated tetanus toxoid. As has been
demonstrated by the experience of the Armed
Forces, this product will immunize adults against
diphtheria.

Labeling. — "The package label bears the
name Diphtheria and Tetanus Toxoids Combined,
Alum Precipitated; the lot number and the
expiration date, which is not more than 2 years
after date of manufacture or date of issue; the
manufacturer's name, license number, and ad-
dress; and the statement, 'Keep at 2° to 10° C.
(35.6° to 50° F.).'" U.S.P.

Usual Sizes. — 0.5, 1, 2.5, 5, and 10 ml.

ALUMINUM HYDROXIDE

ADSORBED DIPHTHERIA AND

TETANUS TOXOIDS. U.S.P.

Diphtheria and Tetanus Toxoids Combined, Aluminum
Hydroxide Adsorbed

"Aluminum Hydroxide Adsorbed Diphtheria
and Tetanus Toxoids is a sterile suspension pre-
pared by mixing suitable quantities of the alumi-
num hydroxide adsorbed forms of diphtheria and

Part I

Diphtheria and Tetanus Toxoids and Pertussis Vaccine 493

tetanus toxoids. The potency and the proportions
of the toxoids are such as to provide one immu-
nizing dose of each toxoid in the total dosage
prescribed on the label. Aluminum Hydroxide Ad-
sorbed Diphtheria and Tetanus Toxoids contains
a suitable non-phenolic antibacterial agent ap-
proved by the National Institutes of Health, and
not more than 0.85 mg. of aluminum in the vol-
ume stated in the labeling to constitute one injec-
tion." U.S.P.

This preparation is a variant of that recognized
as Alum Precipitated Diphtheria and Tetanus
Toxoids; the reason for using aluminum hydrox-
ide in its preparation is explained under Alumi-
num Hydroxide Adsorbed Diphtheria Toxoid.

The U.S.P. indicates that this preparation con-
forms to the description and meets the require-
ments for antigenic value and packaging and
storage under Alum Precipitated Diphtheria and
Tetanus Toxoids. Requirements of the National
Institutes of Health must also be met.

The uses and dose of this preparation are the
same as for the corresponding alum precipitated
product. The labeling data, except for the differ-
ence in name, are also identical for the two
products.

ALUM PRECIPITATED DIPHTHERIA

AND TETANUS TOXOIDS AND

PERTUSSIS VACCINE COMBINED.

U.S.P.

"Alum Precipitated Diphtheria and Tetanus
Toxoids and Pertussis Vaccine Combined is a
sterile suspension of the precipitate obtained
by treating a mixture of diphtheria toxoid, tetanus
toxoid, and pertussis vaccine with alum, and
combined in such proportion as to yield a mixture
containing an immunizing dose of each in the
total dosage prescribed on the label. It contains
a suitable antibacterial preservative approved by
the National Institutes of Health, and not more
than 15 mg. of alum in the volume stated in the
labeling to constitute one injection." U.S.P.

This preparation, commonly known as triple
antigen, may be prepared in several ways. The
one in most common use is to combine alum
precipitated diphtheria toxoid, alum precipitated
tetanus toxoid, and pertussis vaccine in quantities
that will yield the prescribed dose of each in the
finished product. In this case the separate ingre-
dients are in a three-fold concentrated state, so
that when combined each will be at proper dilu-
tion. Another method of preparation is to combine
the three components in the fluid state and then
precipitate them by adding alum. The method of
choice depends on the manufacturing laboratory.
All methods yield essentially the same product.
Diphtheria and tetanus toxoids combined with
pertussis vaccine is available also as a solution
rather than a suspension. "Adjuvants" other
than alum may sometimes be used, but the con-
tent of such additives may not exceed the
equivalent of 15 mg. of alum in each injection
dose.

Description. — 'Alum Precipitated Diphtheria
and Tetanus Toxoids and Pertussis Vaccine
Combined is a markedly turbid, whitish liquid.

It is nearly odorless or has a faint odor due to
the preservative." U.S.P.

The antigenic value of both toxoids and of
the pertussis component of this preparation is
determined as directed for the separate compo-
nents. The product also complies with the safety,
toxicity, sterility, and potency tests and other
requirements of the National Institutes of Health
of the United States Public Health Service, in-
cluding the release of each lot individually before
its distribution. U.S.P.

Uses. — Alum precipitated diphtheria and
tetanus toxoids and pertussis vaccine combined
is used for simultaneous active immunization
against diphtheria, tetanus, and pertussis. A com-
plete immunization treatment consists of three
hypodermic injections of 0.5 or 1 ml., as specified
on the labeling, 3 or 4 weeks apart. A fourth
dose is recommended by some if the injections
are started before the child is 3 months old.
During the first month of life the active im-
munity produced by the vaccine is less in those
infants whose blood contains a definite antitoxin
titer conferred by the mother (Butler et al.,
Brit. M. J., 1954, 1, 476). Injections are made
intramuscularly or deep into subcutaneous tissue.

Triple antigen is recommended for immuniza-
tion of infants, pre-school children, and school
children up to adolescence. Older children may
be reactive to the diphtheria component and in
this age group Tetanus and Diphtheria Toxoids
Combined (For Adult Use) should be used. Im-
munization should begin not later than the sixth
or seventh month of life, since passive congeni-
tal immunity is lost by this time (45 per cent
of the mortality due to pertussis in England and
Wales during 1950 occurred in infants under 6
months of age, Brit. M. J., 1954, 1, 1322). It is
important that all children be immunized against
diphtheria before the sixth year of life. Use of
combined antigens for immunization of infants
and children is an approved and accepted prophy-
lactic practice (Bunney et al., Am. J. Pub. Health,
1944, 34, 452). Combined antigens have the ad-
vantage of smaller doses, fewer injections, and
savings in time and cost of immunization. In
addition, there is some evidence that the pro-
tection afforded against each disease is greater
when using the combined protection than when
each component is used alone.

Booster doses of alum precipitated diphtheria
and tetanus toxoids and pertussis vaccine com-
bined should be given one year after completion
of immunization, and again at 5 or 6 years of
age (Sauer. J.A.M.A., 1953, 152, 1314). Booster
doses of diphtheria toxoid, tetanus toxoid, or
pertussis vaccine may be given individually as
indicated. This is particularly true at the time
of an injury involving exposure to tetanus in-
fection, when a dose of tetanus toxoid should be
given.

As a rule, reactions are not marked; when
they occur they consist, most frequently, of red-
ness, induration and tenderness. A small nodule
may develop at the point of injection and remain
for several weeks before absorption is complete.
Sterile abscesses rarely develop. Allergic reac-
tions may occur, particularly after repeated doses,

494 Diphtheria and Tetanus Toxoids and Pertussis Vaccine

Part I

or in older children. The fear has been expressed
that injection of antigens or penicillin will pre-
dispose to poliomyelitis or at least increase the
susceptibility of the injected muscle group to
paralysis (Anderson and Slcaar, Pediatrics, 1951,
7, 741), but Brown (/. Pediat., 1953, 43, 175)
found no correlation between paralysis and the
sites of intramuscular injection of penicillin dur-
ing the acute attack of poliomyelitis. Since
vaccine use is an elective procedure it is probably
advisable to give vaccines during the winter, when
poliomyelitis is not prevalent.

Dose. — See opening paragraph under Uses.

Labeling. — "The package label bears the
name Diphtheria and Tetanus Toxoids and Per-
tussis Vaccine Combined, Alum Precipitated; the
lot number and the expiration date, which is
not more than 18 months after date of manu-
facture or date of issue; the manufacturer's
name, license number, and address; and the
statements, 'Keep at 2° to 10° C. (35.6° to
50° F.)' and 'Do not freeze.' " U.S.P.

Usual Sizes.— r0.5, 1.5, 2.5, and 7.5 ml.

ALUMINUM HYDROXIDE AD-
SORBED DIPHTHERIA AND TETA-
NUS TOXOIDS AND PERTUSSIS
VACCINE COMBINED. U.S.P.

"Aluminum Hydroxide Adsorbed Diphtheria
and Tetanus Toxoids and Pertussis Vaccine Com-
bined is a sterile mixture of diphtheria toxoid,
tetanus toxoid, and pertussis vaccine, adsorbed on
aluminum hydroxide. The antigens are combined
in such proportion as to yield a mixture contain-
ing one immunizing dose of each in the total
dosage prescribed on the label. It contains a suit-
able antibacterial agent approved by the National
Institutes of Health, and not more than 0.85 mg.
of aluminum in the volume stated in the labeling
to constitute one injection.'* U.S.P.

The preparation of triple antigen, of which this
product is a form, is discussed under Alum Pre-
cipitated Diphtheria and Tetanus Toxoids and
Pertussis Vaccine Combined; the reason for using
aluminum hydroxide is explained under Alumi-
num Hydroxide Adsorbed Diphtheria Toxoid.

The U.S.P. indicates that this preparation con-
forms to the description and meets the require-
ments for antigenic value and packaging and stor-
age under Alum Precipitated Diphtheria and
Tetanus Toxoids and Pertussis Vaccine Com-
bined. Requirements of the National Institutes of
Health must also be met.

The uses and dose of this preparation are the
same as for the corresponding alum precipitated
product. The labeling data, except for the differ-
ence in name, are also identical for the two
products.

DIPHTHERIA TOXOID AND PER-
TUSSIS VACCINE COMBINED. N.F.

"Diphtheria Toxoid and Pertussis Vaccine Com-
bined is a sterile mixture of Diphtheria Toxoid
and Pertussis Vaccine combined in such propor-
tions as to yield a mixture containing an immu-
nizing dose of each in the total dosage prescribed
on the label. Diphtheria Toxoid and Pertussis

Vaccine Combined complies with the official po-
tency test and other requirements of the National
Institutes of Health of the United States Public
Health Service." N.F.

Description. — "Diphtheria Toxoid and Per-
tussis Vaccine Combined is a more or less turbid,
whitish liquid. It is nearly odorless. It must be
free from harmful substances detectable by ani-
mal inoculation, and must not contain an excessive
proportion of preservative." N.F.

Diphtheria Toxoid and Pertussis Vaccine Com-
bined is prepared by combination, aseptically, of
diphtheria toxoid and pertussis vaccine in a man-
ner similar to Alum Precipitated Diphtheria and
Tetanus Toxoids and Pertussis Vaccine Combined.
The combination of diphtheria toxoid and pertus-
sis vaccine was the first combination of prophylac-
tics developed for childhood immunization. It was
rapidly followed by a combination of diphtheria
and tetanus toxoids with pertussis vaccine and
this so-called "triple antigen" has largely replaced
the diphtheria-pertussis combination, for the of-
time obscure nature of tetanus infection in chil-
dren makes the immunization, against tetanus, of
all children a very desirable practice.

The usual dose, hypodermically, is 3 injections
of 0.5 or 1 ml., whichever is specified on the label,
every 3 to 4 weeks.

Labeling. — "The outside label must bear the
name Diphtheria Toxoid and Pertussis Vaccine
Combined, the manufacturer's lot number of the
Vaccine, the name, address, and license number
of the manufacturer, and the date beyond which
the Vaccine may not be expected to retain the
potency prescribed by the National Institutes of
Health of the United States Public Health Serv-
ice." N.F.

Storage. — Preserve "at a temperature between
2° and 10°, preferably at the lower limit. It must
be dispensed in the unopened glass container in
which it was placed by the manufacturer." N.F.

DOXYLAMINE SUCCINATE. U.S.P.

2-[a-(2-Dirnethylarninoethoxy)-a-rnethylbenzyl] pyridine
Succinate, Doxylaminium Succinate

/"XJCn-

~"6

C— 0— CH2CH2N (CH3)2

hc4h4o;

"Doxylamine Succinate, dried in a vacuum
desiccator over phosphorus pentoxide for 5 hours,
contains not less than 98 per cent of C17H22N2O.-
C4H6O4." U.S.P.

Phenyl-2-pyridylmethyl-/3-N,N-dimethylaminoethyl Ether
Succinate. Decapryn Succinate (Merrell).

Doxylamine base is an analog of diphenhydra-
mine base in which a phenyl group and the ali-
phatic hydrogen atom of the benzhydryloxy
component are replaced by a pyridyl and a
methyl group, respectively. Doxylamine may be
synthesized by the condensation of acetophe-
none with pyridine to phenyl-2-pyridylmethyl-
carbinol, the sodium derivative of which is

Part I

reacted with dimethylaminoethyl chloride to
produce doxylamine; this is neutralized with
succinic acid (see Sperber et al., J.A.C.S., 1949,
71, 887).

Description. — "Doxylamine Succinate occurs
as a white or creamy white powder with a
characteristic odor. Its solutions are acid to
litmus. One Gm. of Doxylamine Succinate dis-
solves in about 1 ml. of water, in 2 ml. of
alcohol, and in about 2 ml. of chloroform. It
is very slightly soluble in ether and in benzene.
Doxylamine Succinate melts between 100° and
104°." U.S.P.

Standards and Tests. — Identification. — (1)
A light yellow color is produced when 25 mg. of
doxylamine succinate is dissolved in 5 ml. of
sulfuric acid, the color disappearing when the
solution is diluted with 20 ml. of water, leaving
a clear solution. (2) A 1 in 25,000 solution
exhibits an ultraviolet absorbance maximum
at 260 mn ± 1 mix, and a minimum at
235 mn ± 1 m\i; the absorptivity, E(l%,lcm.),
at 260 mn is between 107 and 113. (3) Succinic
acid separated from the salt melts between 185°
and 188°. Loss on drying. — Not over 0.5 per cent,
when dried in a vacuum desiccator over fresh
phosphorus pentoxide for 5 hours. Residue on
ignition. — Not over 0.1 per cent. U.S.P.

Assay. — About 500 mg. of doxylamine succi-
nate, dried in a vacuum desiccator over phos-
phorus pentoxide for 5 hours, is assayed by the
nonaqueous titration method described under
Antazoline Hydrochloride, omitting the treatment
with mercuric acetate. Doxylamine succinate
reacts, in the acetic acid medium, as a diacidic
base. Each ml. of 0.1 N perchloric acid repre-
sents 19.42 mg. of C17H22N2O.C4H6O4. U.S.P.

Uses. — The antihistamine activity of doxyla-
mine succinate has been demonstrated in animals
and in patients by Brown and Werner (/. Lab.
Clin. Med., 1948, 33, 325; Ann. Allergy, 1948,
6, 122), by Brown, Weiss and Maher (ibid.,

1948, 6, 1) and by Feinberg and Bernstein (/.
Lab. Clin. Med., 1948, 33, 319). It ranked eighth
in order of effectiveness of 13 antihistaminics
tested by Sternberg et al. (J.A.M.A., 1950, 142,
969) for ability to raise the histamine whealing
threshold in man. Chronic toxicity studies have
been reported by Thompson and Werner
(/. A. Ph. A., 1948, 37, 311), and metabolic
studies by Snyder et al. (ibid., 1948, 37, 420).
Clinical efficacy of the drug has been confirmed
by Waldbott and Gadbaw (/. Michigan M. Soc,

1949, 48, 742) and by Loveless and Dworin
(Bull. N. Y. Acad. Med., 1949, 25, 473). In
common with similar findings with other anti-
histaminic agents, Matthews et al. (J.-Lancet,
1951, 71, 244) observed that the results from
its use in the treatment of the "common cold"
were equivalent to those obtained with a placebo.
Control of hyperpyrexia following use of meperi-
dine hydrochloride in a patient was reported by
Flipse and Flipse (South. M. J., 1949, 42, 395).

In patients with allergic disorders who re-
sponded poorly to oral antihistaminic therapy,
Spearmen (Ann. Allergy, 1952, 10, 192) reported
relief lasting several days following intravenous
injection of the drug. For patients sensitive

Drocarbil

495

to procaine penicillin, Simon and Feldman (Arch.
Dermat. Syph., 1950, 62, 314) combined 15 mg.
of the oil-soluble base doxylamine with 300,000
units of potassium penicillin G in sesame oil con-
taining 2 per cent of aluminum stearate for
intramuscular injection; the combination was an
effective dosage form of penicillin, being painless
on injection and well tolerated by 6 patients who
had previously reacted unfavorably to procaine
penicillin.

Doxylamine succinate causes drowsiness in
some patients. The drug does not absorb the
burning component of ultraviolet rays (Fried-
laender et al., J. Invest. Derm., 1948, 11, 397).
See also the general discussion of Antihistaminic
Drugs in Part II.

The usual dose of doxylamine succinate is 25
mg. (approximately %i grain) one to four times
daily by mouth, with a range of 12.5 to 25 mg.
The maximum safe dose is generally 25 mg. and
the total daily dose usually should not exceed
100 mg.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

DOXYLAMINE SUCCINATE
TABLETS. U.S.P.

"Doxylamine Succinate Tablets contain not
less than 93 per cent and not more than 107
per cent of the labeled amount of C17H22N2O.-
C4H6O4." U.S.P.

Assay. — The basic procedure described under
Antazoline Hydrochloride Tablets is employed,
the appropriate constants for doxylamine succi-
nate being substituted.

Usual Sizes. — 12.5 and 25 mg.

DROCARBIL. N.F.

COOCH3

0=As

NHCOCH,

"Drocarbil is the acetarsone salt of arecoline.
Dried to constant weight over phosphorus pentox-
ide in a vacuum, it contains not less than 34 per
cent and not more than 36.5 per cent of CsHi3-
NO2, and not less than 64 per cent nor more than
67 per cent of CsHioAsNOs." N.F.

Nemural (Winthrop-Stearns) .

For information concerning the components of
this salt see under Arecoline Hydrobromide and
Acetarsone.

Description. — "Drocarbil occurs as a nearly
white or slightly yellow odorless powder. It is
stable at ordinary temperatures. Drocarbil is
freely soluble in water." N.F.

Standards and Tests. — (1) A solution of
drocarbil yields, under the conditions of the test,
a yellow precipitate with hydrogen sulfide. (2) A
solution of drocarbil is alkalinized, extracted with
benzene, and the latter solution extracted with

496

Drocarbi!

Part I

0.1 N hydrochloric acid. On evaporating this solu-
tion in the presence of 30 per cent hydrogen
peroxide the residue yields with a solution of
resorcinol and sulfuric acid a blue to violet color.
Loss on drying. — Not over 2 per cent, when dried
to constant weight over phosphorus pentoxide in
a vacuum. N.F.

Assay. — For arecoline. — About 1 Gm. of dried
drocarbil is dissolved in water, the solution alka-
linized and the arecoline extracted with benzene.
From the latter solution the alkaloid is extracted
with 25 ml. of 0.1 N hydrochloric acid and the
excess of acid titrated with 0.1 N sodium hydrox-
ide. Each ml. of 0.1 N hydrochloric acid repre-
sents 15.51 mg. of C8H13NO2. For acetarsone. —
About 150 mg. of dried drocarbil is assayed as
directed under acetarsone. N.F.

Uses. — Drocarbil is used as a veterinary an-
thelmintic. For details of use, and of dosage, see
under Veterinary Uses and Doses of Drugs.

Storage. — Preserve "in well-closed containers."
N.F.

ABSORBABLE DUSTING POWDER.
U.S.P.

Starch-derivative Dusting Powder

"Absorbable Dusting Powder is an adsorbable
powder prepared by processing cornstarch. It
contains not more than 2 per cent of magnesium
oxide." U.S.P.

Bio-Sorb Powder (Ethicon).

This absorbable dusting powder, employed as
a substitute for talc when a lubricant is needed,
is prepared by treating starch with epichlorohy-
drin. Such treatment results in partial etherifica-
tion, whereby starch polymer chains are presum-
ably cross-linked by 1,3-diether glycerin groups
to the extent of not more than 2 per cent of the
original starch weight. This "tanning" process
with epichlorohydrin renders the starch granules
resistant to autoclaving without affecting either
tissue tolerance or absorbability of the starch as
long as it is dispersed as fine particles. The incor-
poration of not more than 2 per cent of mag-
nesium oxide facilitates maintenance of the starch
derivative in the state of a fine powder.

Description. — "Absorbable Dusting Powder
is a white, odorless powder." U.S.P.

Standards and Tests. — Identification. — (1)
After boiling 100 ml. of a 1 in 10 suspension of
the powder in water and allowing it to stand for
24 hours the volume of the settled powder is not
less than 35 ml. and not more than 65 ml. (2) A
1 in 10 suspension is colored purplish blue to deep
blue by iodine T.S. pH. — The pH of a 1 in 10
suspension is between 10.0 and 10.8. Loss on
drying. — Not over 12.0 per cent, when dried at
105° to constant weight. Residue on ignition. —
Not over 3.0 per cent. Chloride. — The limit is 0.2
per cent. Sulfate. — The limit is 0.8 per cent.
U.S.P.

Assay. — The residue from the ignition of 1
Gm. of powder is dissolved in diluted hydro-
chloric acid and the magnesium precipitated as
magnesium ammonium phosphate, which is ig-
nited to magnesium pyrophosphate and weighed.

Each mg. of magnesium pyrophosphate repre-
sents 0.3622 mg. of magnesium oxide. U.S.P.

Uses. — Absorbable dusting powder is intended
to be used as a surgeon's glove lubricant and for
other uses to which talcum powder is applied in
general hospital routines. Various investigators
have demonstrated that the starch derivative
powder is completely absorbed in living tissue
and that, in the event of wound contamination
resulting from perforation of gloves during surgi-
cal procedures, such a powder is less irritating
than nonabsorbable talc and may cause fewer ad-
hesions and granulomatous responses (Lee et al.,
Surg. Gynec. Obst., 1947. 84, 689; ibid., 1952,
95, 725; MacQuiddy and Tollman, Surgery, 1948,
23, 786). The importance of having a more satis-
factory substance than talc for lubricant pur-
poses may be inferred from the voluminous liter-
ature on the hazards and sequelae of wound con-
tamination with talc, and from the finding that
about 22 per cent of rubber gloves become per-
forated during operations (Weed and Groves,
Surg. Gynec. Obst., 1942, 75, 661).

Absorbable dusting powder should be sterilized
by autoclaving; any slight clumping that may
occur during sterilization may be readily disinte-
grated by applying moderate pressure. Dry wall
heat sterilization should be avoided because of
its bacteriologic inadequacy and because of the
possible inflammability of the powder. The pow-
der will flash only to about the same degree as
cotton, so that inflammability is not a hazard to
its use in surgery.

Storage. — Preserve "in sealed paper packets."
U.S.P.

COMPOUND EFFERVESCENT
POWDERS. N.F. (B.P.)

Seidlitz Powders, Pulveres Effervescentes Compositi

"The mixture in a blue paper weighs not less
than 9.5 Gm. and not more than 10.5 Gm.. and
contains not less than 23 per cent and not more
than 27 per cent of sodium bicarbonate
(NaHCOa), and not less than 73 per cent and
not more than 78 per cent of potassium sodium
tartrate (KNaC.jH4O6.4H2O). The white paper
contains not less than 2 Gm. and not more than
2.4 Gm. of tartaric acid." N.F. The B.P.
formula is given on a unit powder basis, and
differs only in the use of a somewhat larger
quantity of tartaric acid, namely, 2.5 Gm.

B.P. Compound Effervescent Powder; Pulvis Efferves-
cens Compositus. Pulvis Effervescens Laxans; Pulvis
-Erophorus Laxans. Fr. Poudre de Seidlits; Poudre gazo-
gene laxative. Ger. Abfiihrendes Brausepulver; Seidlitz-
pulver. It. Polvere di Seidlitz. Sp. Polvo gasifero lax-
ante ; Polvos Efervescentes Compuestos.

Mix 30 Gm. of dry sodium bicarbonate, passing
through a No. 60 standard mesh sieve, with 90
Gm. of dry potassium sodium tartrate, passing
through a No. 40 standard mesh sieve ; divide the
mixture into 12 equal portions, and wrap each
portion in a blue paper. Divide 26 Gm. of dry
tartaric acid, passing through a No. 40 standard
mesh sieve, into 12 equal portions, and wrap each
portion in a white paper. N.F.

Uses. — Seidlitz powders are employed for the
mild cathartic action provided by the potassium

Part I

Elm

497

sodium tartrate component of the powders and
to a lesser extent by the sodium tartrate formed
by the interaction of sodium bicarbonate and
tartaric acid. Though named after the famous
Seidlitz saline spring in Germany, there is no
resemblance in the composition of the powder
and the spring water, for the activity of the
latter is attributable to magnesium sulfate.

The formula of Seidlitz powders provides an
effervescent drink containing a slight excess of
tartaric acid which is not unpleasant to most per-
sons, particularly if the salts are dissolved in
rather cool water. Sometimes a little orange or
lemon syrup is added to one of the solutions
before mixing it with the other in order to im-
prove the flavor of the drink.

The powders should not be kept in a damp
place as the tartaric acid may deliquesce and
be absorbed into the paper; by such action the
content of the white paper has apparently disap-
peared in powders stored for two or three years.

Dose, one set of two powders, each dissolved in
about 60 ml. (2 fluidounces) of water, the solu-
tion mixed, and taken after effervescence begins
to subside.

Storage. — Preserve "in well-closed contain-
ers, in a' dry place." N.F.

ELM. N.F.

Elm Bark, Slippery Elm, Ulmus

"Elm is the dried inner bark of Ulmus rubra
Muhlenberg (Ulmus fulva Michaux) (Fam.
UlmacecB)." N.F.

Red Elm. Cortex Ulmi Pubescens; Ulmi Cortex. Get.
Schleimriisterrinde.

The slippery elm (Ulmus rubra) is a lofty tree,
fifty or sixty feet in height, with a trunk fifteen
or twenty inches in diameter. The bark of the
trunk is brown, that of the branches rough and
whitish. The leaves are petiolate. oblong-ovate,
acuminate, nearly equal at the base, unequally
serrate, pubescent, and very rough on both sides.
The buds, a fortnight before their development,
are covered with a dense russet down. The
flowers, which are apetalous, appear before the
leaves, are sessile, and in clusters at the extremi-
ties of the young shoots. The clusters of flowers
are surrounded by scales, which are downy like
the buds. The calyx is also downy. The stamens
are five, short, and of a pale rose color. The
fruit is a membranaceous samara, enclosing in
the middle one round seed, destitute of fringe.

Ulmus rubra is indigenous, growing in all parts
of the United States north of the Carolinas, but
most abundantly west of the Allegheny Moun-
tains. It extends westward to the Dakotas and
northward to western Quebec and Lake Huron.
It flourishes in open, elevated situations, and
requires a firm, dry soil. From the white elm
(U. americana L.) it is distinguished by its rough
branches, its larger, thicker, and rougher leaves,
its downy buds, and the character of its flowers
and seeds. Elm bark is gathered in the spring,
deprived of the cork and part of the cortex,
sawed into oblong pieces and dried.

Fremontia California Torr., or California slip-
pery elm, is not botanically allied to Ulmus rubra;

its bark is said, however, to have the same
properties as slippery elm bark.

Description. — "Unground Elm usually occurs
as broad, flat, oblong pieces from 1 to 4 mm. in
thickness. The outer surface is weak yellowish
orange, roughened by longitudinal striae and par-
tially detached bundles of bast fibers, and has
occasional thin, brown patches of adhering cork;
while the inner surface is weak yellowish orange,
and finely striate. The fracture is fibrous, with
projections of fine bast bundles. Elm has a dis-
tinctive odor, and a mucilaginous taste." N.F.
For histology see N.F. X.

"Powdered Elm is weak yellowish orange.
Phloem fibers are numerous, very long, usually
broken, up to 25 n in diameter, thick-walled,
unlignified or with only a thin outer sheath of
the wall lignified; calcium oxalate prisms from
10 to 35n in length; starch grains spheroidal or
polygonal, usually from 3 to 15 n in diameter,
occasionally up to 25 n in length; and numerous
mucilage fragments, frequently lamellated. Cork
cells are few or absent." N.F.

Standards and Tests. — Identification. — On
macerating 1 Gm. of finely powdered elm with 40
ml. of water for 1 hour, a thick mucilaginous
mixture, yellowish brown in color, is formed.
Outer bark. — Elm contains not more than 2 per
cent of adhering outer bark. Acid-insoluble ash.
— Not over 1 per cent. N.F.

Constituents. — Elm contains considerable
mucilaginous matter, which is readily extracted
with water. The mucilage is precipitated by solu-
tions of lead acetate and subacetate, but not by
alcohol. Elm mucilage contains a polysaccharide
which on hydrolysis yields D-galactose, 3-methyl-
D-galactose, L-rhamnose, and traces of glucose
and fucose (Hirst et al., J. Chem. S., 1951, 323).
Elm also contains a small amount of a variety of
tannin which colors iron solutions green.

Some of the bark brought into the market has
been of inferior quality, yielding comparatively
little mucilage. It has the characteristic odor of
the genuine bark, but is much less fibrous and
more brittle, breaking abruptly when bent, in-
stead of being capable, like the better kinds,
of being folded lengthwise without breaking.
Whether this inferiority is due to difference
in the species or the age, or to circumstances
in the growth of the tree producing it, is not
certain. Ground elm bark has been adulterated,
usually with substances containing starch.

Elm bark has the property of preserving fatty
substances from rancidity, a fact known to the
Indians, who prepared bear's fat by adding the
bark to melted fat, heating the mixture for a
few minutes, then straining off the fat.

Uses.— Elm bark is an excellent demulcent,
formerly extensively employed, especially in the
form of lozenges, to relieve irritation of the
pharynx. A warm infusion was a popular folk
remedy in the treatment of diarrheas, coughs,
etc. This was prepared by stirring an ounce of
the powdered bark in a pint of hot water, with
which it forms a mucilage which was taken ad
libitum.

The bark was used also as an emollient appli-
cation in cases of external inflammations. For

498

Elm

Part I

this purpose the powder was made into a poultice
with hot water, or the bark itself applied, previ-
ously softened by boiling. Elm bark was for-
merly used for making "tents" to dilate strictures
of the urethra, cervix of the uterus or rectum;
but is no longer used for that purpose.

EMETINE AND BISMUTH IODIDE
B.P.

Emetinae et Bismuthi Iodidum

Emetine and Bismuth Iodide is a complex iodide
of emetine and bismuth which may be obtained
by precipitation from a solution of emetine hydro-
chloride by the addition of a solution of potas-
sium bismuth iodide. It represents from 25.0 to
30.0 per cent of emetine and from 18.0 to 22.5 per
cent of bismuth, both calculated with reference
to the substance dried to constant weight at 105°.
B.P.

Bismuth and Emetine Iodide.

Description and Tests. — Emetine and bis-
muth iodide is a reddish-orange powder with a
bitter and somewhat acrid taste, practically in-
soluble in either water or alcohol, but soluble in
acetone. In aqueous solution of acids it undergoes
some decomposition but does not dissolve ; in solu-
tions of alkalies it is soluble with decomposition.
It gives the reactions characteristic of emetine,
bismuth, and iodide.

Assay. — The assay for emetine utilizes the
principles described under emetine hydrochloride.
Bismuth is determined gravimetrically by precipi-
tation as bismuth phosphate. B.P.

Uses. — Emetine and bismuth iodide is used in
the treatment of amebiasis. It was introduced into
medicine in the hope that, being insoluble, it
would not irritate the stomach and, therefore,
would be less nauseating than emetine hydrochlo-
ride. In the intestinal tract it is slowly decom-
posed, liberating emetine in high concentration.
Emetine and bismuth iodide may be used alone
or to supplement injections of emetine hydro-
chloride. It has not been popular in the United
States and is generally considered to be less
efficient than injections of soluble salts, but Jepps
and Meakins {Brit. M. J., 1917, 2, 645) claimed
that it is active against the "free-swimming"
forms of amebae, while parenterally injected
emetine is not.

Emetine and bismuth iodide is not as effective
as carbarsone or the iodohydroxyquinoline drugs.
When administered in tablets these should be
crushed. Wilmot et al. (/. Trop. Med., 1951, 54,
161) reporting 55.6 per cent of successful treat-
ments with crushed tablets and 39.7 per cent with
whole tablets; the efficacy of crushed tablets was
similar to that obtained with emetine hydrochlo-
ride intramuscularly or Diodoquin by mouth.

Toxicology. — The side effects of emetine and
bismuth iodide are similar to those of emetine.
Administration on an empty stomach in the morn-
ing or at bedtime, and use of opium tincture about
half an hour before the dose, minimizes side
effects. Patients should be confined to bed. and
maintained on a milk diet, during treatment with
the drug; it should not be administered to "car-
riers" of ameba in the intestine.

The usual dose is 200 mg. (approximately 3
grains) once daily by mouth, with a range of 60
to 200 mg. daily. The maximum single dose, or
during 24 hours, is 200 mg. The drug should be
given in capsules, tablets or pills, which disinte-
grate readily, on an empty stomach. Administra-
tion of the drug for 12 days generally constitutes
the course of treatment.

EMETINE HYDROCHLORIDE. U.S.P.,
B.P., LP.

Emetinium Chloride, [Emetinae Hydrochloridum]

2 CI". xH20

"Emetine Hydrochloride is a hydrated hydro-
chloride of an alkaloid obtained from ipecac or
prepared by methylation of cephaeline." U.S.P.
The B.P., which indicates seven molecules of
water of crystallization in the formula of the salt,
requires not less than 85.3 per cent and not more
than 88.3 per cent of emetine, calculated with
reference to the substance dried to constant weight
at 105°. The LP. states that variable proportions
of water of crystallization may be present, but
requires 85.0 to 90.0 per cent of emetine, calcu-
lated with reference to the material dried to con-
stant weight in vacuo over sulfuric acid.

I. P. Emetini Hydrochloridum. Emetinum Chlorhydri-
cum; Emetinum Hydrochloricum ; Emetina: Chlorhidras. Fr.
Chlorhydrate d'emetine. Ger. Emetinhydrochlorid. It.
Cloridrato di emetina. Sp. Clorhidrato de emetina.

Emetine may be isolated from ipecac by the
following process: The powdered drug is ex-
tracted with a mixture of benzol and benzin
which removes all of the alkaloids. This solution
is then extracted with dilute hydrochloric acid,
which in turn is extracted with ether, after making
alkaline with ammonia. In the latter process all
of the alkaloids except psychotrine are dissolved
by the ether. The ether solution is shaken with
sodium hydroxide which dissolves the cephaeline;
the ether solution is then concentrated by evapo-
ration. The residue is converted into hydrochloride,
hydrobromide, or hydroiodide and the correspond-
ing emetine salt crystallized out and then purified
by recrystallization. The other alkaloids are re-
covered at the stages where they are separated.

Emetine is also prepared by the methylation
of cephaeline with phenyltrimethylammonium hy-
droxide or with mixtures of compounds that form
this quaternary base. It is reported that good
yields are obtained and that the process yields a
less costly product than that obtained by direct
extraction. Other methods of methylating ce-
phaeline are also utilized.

Description. — "Emetine Hydrochloride is a
white or very slightly yellowish, odorless, crystal-
line powder. It is affected by light. Emetine Hy-
drochloride is freely soluble in water and in alco-
hol." UJS.P.

Standards and Tests. — Identification. — (1)
Precipitates are produced by a 1 in 100 solution

Part I

Emetine Hydrochloride 499

of emetine hydrochloride with iodine T.S., with
mercuric potassium iodide T.S., and with platinic
chloride T.S. (2) A bright green mixture results
when a solution of molybdic acid in sulfuric acid
is added to emetine hydrochloride. (3) It re-
sponds to tests for chloride. Water. — On drying
at 105° for 2 hours it loses not less than 8 per
cent and not more than 14 per cent of its weight.
Residue on ignition. — The residue from 200 mg.
is negligible. Readily carbonizable substances. — A
solution of 100 mg. in 5 ml. of sulfuric acid has
no more color than Matching Fluid H. Acidity. —
Not more than 0.5 ml. of 0.02 N sodium hydrox-
ide is required to neutralize 100 mg. of emetine
hydrochloride using methyl red T.S. as indicator.
Cepha'eline. — Not more than 4 mg. of this phe-
nolic alkaloid is present in 200 mg. of emetine
hydrochloride. U.S.P. The B.P. limits loss on dry-
ing to constant weight at 105° to the range of
15.0 to 19.0 per cent; the LP. limits the loss to
not more than 16.0 per cent.

For further discussion of properties of emetine
and other alkaloids o/ ipecac see under Ipecac.

Assay. — About 200 mg. of emetine hydro-
chloride is dissolved in water, the solution alkalin-
ized with sodium hydroxide, and the emetine base
extracted with ether. After washing the ether
extract with water, 10 ml. of 0.1 N acid (hydro-
chloric or sulfuric) and water are added to the
ether to extract the emetine and the excess acid
is titrated with sodium hydroxide, using methyl
red as indicator. B.P., LP.

Uses. — Ipecac was for centuries the standard
treatment for amebic dysentery, but since the
work of Vedder (1911) and Rogers {Brit. M. J .,
1912, 1, 1424) the alkaloid emetine has very
largely replaced ipecac. Emetine is much less toxic
than cephaeline and is at least equal, if not supe-
rior, to it as an antamebic (see under Ipecac, in
Part I). In studying the efficacy of other drugs in
amebiasis Wilmot et al. {J. Trop. Med. Hyg., 1951,
54, 161) used emetine therapy as the standard
(60 mg. administered intramuscularly daily for
15 days effecting the high cure rate of about 50
per cent in cases in South Africa). It is note-
worthy that oxytetracycline is less toxic, and
initial reports indicate it to be efficacious in
amebiasis. Martin et al. {J.A.M.A., 1953, 151,
1055) reported excellent initial response and the
lowest relapse rate in Korea following use of
oxytetracycline alone or in combination with
emetine, carbarsone, chiniofon, chloroquine or
bismuth glycolylarsanilate (glycobiarsol) and
chloroquine. Vegas {ibid., 1059) reported best
results following use of bismuth glycolylarsanilate
in combination with chloroquine in Venezuela.
But emetine still finds usage for rapid relief of
symptoms in acute intestinal or parenchymal
amebiasis.
V Emetine has a direct lethal effect on Endamceba
f histolytica, particularly against its motile forms.
In vitro, a concentration of 1:100,000 killed 100
per cent and 1:17 million killed 45 per cent of
organisms in 48 hours (Hansen and Bennett, Exp.
Parasitol., 1952, 1, 143); resistance to sub-lethal
concentrations did not develop on prolonged ex-
posure (Jones, ibid., 118). Variations in virulence
of different strains of organisms, requiring dif-

ferent dosage with emetine, has been observed in
experimental infections (Neal, Trans. Roy. Soc.
Trop. Med. Hyg., 1951, 44, 439). When used
alone, emetine cures only 10 to 15 per cent of
patients afflicted with amebiasis (but see reference
to Wilmot et al. above) ; although symptoms sub-
side rapidly, more than 50 per cent of treated
patients become carriers. Neither large doses nor
prolonged therapy tend to improve the rate of
cure and such measures may cause toxic effects.
Shrapnel et al. {Am. J. Trop. Med., 1946, 26,
293) reported having obtained promising results
in 15 of 20 patients receiving emetine hydrochlo-
ride orally in the form of enteric-coated tablets.
The alkaloid is extremely useful in relieving symp-
toms of acute amebic dysentery (Brown, J. A.M. A.,
1935, 105, 1319; Hargreaves, Lancet, 1945, 2,
68). It is best used in conjunction with one of the
poorly absorbed amebicides, particularly the ar-
senicals (see under Carbarsone).

Emetine alone, or combined with aspiration, is
usually effective in amebic hepatitis or actual
abscess formation. Miles and Bowers {Arch. Surg.,
1951, 62, 260) reported cure of 16 cases; peni-
cillin was also given for secondary infection and
relief of symptoms and was followed by a course
of diiodohydroxyquin. Roover and Van Steenis
{Nederland. Tijdschr. Geneesk., 1951, 95, 3316)
and Doerner et al. {Ann. Int. Med., 1951, 35, 331)
reported prompt symptomatic relief in hepatic
abscess with emetine though chloroquine was re-
quired for cure. Similar experience with a pulmo-
nary amebic abscess was reported by Lindsay
et al. {Dis. Chest, 1951, 20, 533). If systemic
therapy fails emetine may be injected into the
abscess cavity in the liver in 1:2500 solution.
Emetine is said to be useful also in the treatment
of schistosomiasis (Tyskalas, Wien. klin. Wchn-
schr., 1921, 34, 579), Guinea worm, and oriental
sore.

Toxicology. — Emetine is a general proto-
plasmic poison which, because of its slow elimina-
tion following parenteral administration, tends to
be cumulative. Very little of it is excreted into
the "Bowel after parenteral administration. It may
continue to be eliminated in the urine for 40 to v
60 days after it is given. The lethal dose is 10 to
25 mg. per Kilogram of body weight. Emetine
poisoning is characterized by muscular tremors,
weakness, and pains, especially in the extremities.
Purpura, dermatitis or hemoptysis may occur in
severe cases. "Neuritis" may be due to muscle
damage (Young and Tudhope, Trans. Roy. Soc.
Trop. Med. Hyg., 1926, 20, 93). Vertigo may
occur. Gastrointestinal symptoms, such as nausea,
vomiting, and diarrhea, are not infrequent. Bloody
diarrhea occurs, accompanied by prostration, and
may be mistaken for recurrence of the amebic
dysentery. The myotoxic effect is especially detri-
mental to the heart and may result in arrhythmias,
myocardial weakness with congestive failure or, at
times, sudden cardiac failure.

It has been recommended that an electrocardio-
gram be taken daily after the fifth day of paren-
teral emetine administration. Depression or even
inversion of the T wave is frequent and does not
require discontinuation of therapy during the
usual course in persons with no pre-existent myo-

500 Emetine Hydrochloride

Part I

K -4

cardial damage (Baer, Mil. Surg., 1951, 109,
120); changes seldom appear until a dose of 360
mg. or more is given and sometimes do not appear
until 2 weeks after the end of therapy. Electro-
cardiographic changes were found in all 26 care-
fully studied patients of Kent and Kingsland (Am.
Heart J., 1950, 39, 576) but no permanent dam-
age was observed and bed rest during therapy was
not considered essential unless otherwise indi-
cated. Sodeman et al. (Trans. Roy. Soc. Trop.
Med. Hyg., 1952, 46, 151; Am. Heart J., 1952,
43, 582) studied 111 patients treated with emetine
and recorded 5 instances of symptomatic, 3 of
neuromuscular, and 2 of cardiovascular untoward
effects. In a group of 38 patients 2 showed pro-
longation of P-R interval, 3 a deformity of the
QRS complex, and 10 a change in the T wave. In
cases with pre-existent heart disease, a total dose
of emetine of less than 10 mg. per Kilogram of
body weight is safe and is usually adequate to
control amebiasis. Charters (Trans. Roy. Soc.
Trop. Med. Hyg., 1950, 43, 513) reported tran-
sient myocardial damage in a patient receiving
injections of 60 mg. daily for 20 days; diarrhea
and dermatitis were observed in a patient treated
for 32 days.

No fatalities from a single dose of emetine have
come to our attention; several have resulted from
repeated doses, the smallest being 1.74 Gm. given
in 19 days. It appears that there is insufficient
absorption from oral administration to cause sys-
temic poisoning in humans.

Histologically, emetine toxicity is marked by
hyperemia, cloudy swelling and cellular degenera-
tion of the liver, kidneys, and skeletal and cardiac
muscle (Rinehart and Anderson. Arch. Path.,
1931, 11, 546).
vj Dose. — The usual dose, subcutaneously, of
emetine hydrochloride is 1 mg. per Kg. of body
weight, but never exceeding 60 mg. (approxi-
mately 1 grain), daily for 5 to 10 days; the range
of the total daily dose is 30 to 60 mg. The maxi-
jAfnum safe dose is usually 60 mg., this amount sel-
dom being exceeded in 24 hours. Emetine should
never be administered intravenously. The daily
dosage of emetine may be divided into two doses,
or given at once. Injections should not be given for
more than 10 days, or in excess of a total dose of
600 mg. (approximately 10 grains), correspond-
ing to 10 mg. per Kilogram; treatment should be
discontinued as soon as acute symptoms are re-
lieved. For children, the dose may be calculated
on the basis of 1 mg. of the alkaloid per Kilogram
of body weight daily, or 10 mg. per Kg. for the
course. The course of treatment should not be
repeated sooner than in-6„j4£e_ks. Carbarsone,
chiniofon. or Vioform may be used simultaneously
and for interval treatment. When emetine is being
given, the patient must be kept under close ob-
servation and the drug discontinued at the first
sign of toxicity. Emetine is contraindicated in
pregnancy. Enteric-coated tablets containing 20
mg. of emetine are used orally in a dose of 2 tab-
3 times daily for 12 days for adults, or 1 tablet
for children.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

EMETINE HYDROCHLORIDE
INJECTION. U.S.P. (B.P., LP.)

[Injectio Emetinae Hydrochloride

"Emetine Hydrochloride Injection is a sterile
solution of emetine hydrochloride in water for
injection. It contains an amount of anhydrous
emetine hydrochloride (C29H40N2O4.2HCI) equiv-
alent to not less than 84 per cent and not more
than 94 per cent of the labeled amount of eme-
tine hydrochloride. In preparing the Injection,
adjust it with hydrochloric acid or with sodium
carbonate or sodium hvdroxide to a pH of about
3.5." U.S.P.

The B.P. requires a content of emetine of not
less than 65.5 per cent and not more than 77.7
per cent of the content of emetine hydrochloride
stated on the label; the solution, which is pre-
pared with water for injection, may be sterilized
by heating with a bactericide (for process see
under Chlorocresol) or by filtration through a
bacteria-proof filter. The LP. rubric is the same
as that of the U.S.P.

B.P., LP. Injection of Emetine Hydrochloride. Ampuls
of Emetine Hydrochloride. Ampullae Emetinae Hydrochloridi;
Solutum Emetini Chlorhydrici; Injectio Chlorhydratis
Emetinae. Fr. Solute injectable de chlorhydrate d'emetine.
Sp. Inyeccion de clorhidrato de emetina ; Inyeccion de
emetina.

Assay. — A volume of injection representing
about 120 mg. of emetine hydrochloride is diluted
with water, alkalinized with ammonia T.S., and
the emetine alkaloid extracted with ether. After
evaporating the solvent from the ether solutions
the residue is dissolved in 2 ml. of neutralized
alcohol and 30 ml. of 0.02 N sulfuric acid, the
mixture being warmed gently. The excess of acid
is titrated with 0.02 N sodium hydroxide, using
methyl red T.S. as indicator. Each ml. of 0.02 N
sulfuric acid represents 5.536 mg. of anhydrous
emetine hydrochloride, C29H40N2O4.2HCI. U.S.P.

Storage. — Preserve "in single-dose, light-re-
sistant containers, preferably of Type I glass."
U.S.P.

Usual Sizes. — %, j4 and 1 grain (approxi-
mately 20, 30 and 60 mg.) in 1 ml.

EPHEDRINE. N.F, B.P.

[Ephedrina]

C6H5.CHOH.CH(CH3).NHCH3

"Ephedrine is anhydrous, or contains not more
than one-half molecule of water of hydration.
Anhydrous Ephedrine contains not less than 98.5
per cent of C10H15NO. Hydrated Ephedrine con-
tains not less than 94 per cent of C10H15NO."
N.F.

The B.P. defines ephedrine as the hemihydrate
of ( — )-2-methylamino-l-phenylpropanol, an al-
kaloid obtained from the plants described below
or prepared by synthesis; not less than 94.0
per cent and not more than 95.0 per cent of
C10H15ON is required.

l-Phenyl-2-methylamino-propanol-l. Ephedrinum. Fr.
Ephedrine. Ger. Ephedrin. Sp. Efedrina.

Under the name Ma-huang species of Ephedra
have been used as a medicine in China for thou-

Part I

Ephedrine 501

sands of years. Introduction of its principal alka-
loid, ephedrine, into Occidental practice is largely
attributable to the observations of Chen and
Schmidt (/. Pharmacol, 1924, 24, 339). The
Chinese name Ma-huang, according to some writ-
ers, means "astringent yellow"; others translate
it as "hemp yellow," apparently because it is
often dioecious like hemp, the male flowers being
yellow.

Ephedrine was first isolated in a pure form by
Nagai of Japan in 1887, from a plant which he
believed to be Ephedra vulgaris Rich. This is
not a valid name but the error was continued in
the literature for many years. In 192 7 Otto Stapf,
the outstanding authority on the genus Ephedra,
described a plant, based upon Chinese drug ma-
terial, which he named E. sinica. According to
Read and Liu (/. A. Ph. A., 1928, 17, 339), most
of the Chinese drug is from E. sinica Stapf or
E. equisetina Bunge although other species are
collected in certain localities. The alkaloid is also
extracted from some of the European species;
the statement that the latter yield only pseudo-
ephedrine is apparently incorrect.

Ephedrine also occurs in the leaves of the yew
(Taxus baccata), according to Gulland (J. Chem.
S., 1931, p. 2148); in Rcemeria refracta DC.
(Papaveracece) (Chem. Abs., 1940. 34, 2852) and
Freudenberg (/. A. C. S., 1937, 59, 2572) has ob-
tained it from Aconitum napellus.

The genus Ephedra belongs to the Gnetacece
or Joint-fir family of gymnosperms and contains
at least 43 distinct species which are distributed
in warmer and dryer localities of Asia. Europe,
Africa, Australia, North America and South
America. They are mostly low, much branched,
often procumbent, occasionally climbing shrubs,
with pale green, long jointed branches resembling
those of the Equisetums, or horsetails, bearing
minute, more or less parted, scale-like leaves in
pairs sheathing the stem at the nodes. Their
inflorescences are dioecious, seldom monoecious,
the male occurring as small spikes or aments in
the leaf axils and consisting of a series of bracts
attached to the rachis, each bract subtending a
pair of perianth sheaths in which are enclosed
2 to 8 stamens united into a column, the female
occurring as modified cones or galbulus terminat-
ing the branches, each consisting of a shortened
axis bearing 3 or more pairs of bracts, the upper
ones subtending pistillate flowers, the latter with
single ovule and urceolate perianth. Their fruits
are nutlets borne in cones which, in some species,
are provided with fleshy bracts forming a scarlet,
berry-like syncarp.

B. E. Read divided the various species of
Ephedra into four distinct groups depending upon
whether they yield ephedrine or some other con-
stituent, viz.: 1. Species which yield chiefly
ephedrine, as Ephedra distachya L., E. equisetina
Bunge, E. Gerardiana Wall., E. sinica Stapf.
2. Species yielding chiefly pseudoephedrine, as
E. intermedia Schrenk. 3. Species which yield
some alkaloid other than ephedrine, as E. mono-
sperma S. G. Gmel. 4. Species which yield no
alkaloids, as the American species (False Ma-
huang). (See Flora Sinensis, 1930, ser. B., vol.
24, 1.)

Ephedra sinica Stapf or Tsaopen Ma-huang is
a shrub attaining a height of 30 cm., branching
from the base, with grayish-green branchlets
simple or sparingly divided below, somewhat flat-
tened, 1 to 1.5 mm. thick, slightly striated longi-
tudinally, rough to the touch, their internodes
3 to 5 cm. long; leaves opposite and reduced to
2 membranous sheaths at each node, 4 mm. long,
up to one-half divided, their blades white, their
bases thick and reddish brown, subulate, their
summits recurved; inflorescences short spikes,
terminal or at the upper axils, dioecious, occa-
sionally monoecious, the male spike 4 mm. long
and 3 mm. wide consisting of 4 to 5 pairs of
bracts, arranged decussately with their bases con-
nected, each bract subtending one pair of perianth
sheaths in which is enclosed the staminal column
with 7 to 8 anthers, the female galbulus chiefly
terminal and 2 flowered with 3 to 4, rarely 5 pairs
of bracts, the lower and middle bracts ovate,
acute or subacute, 1 to 3 mm. long with mem-
branous margin, the uppermost pair belong alone
fertile and subtending 2 flowers; fruiting cones
ellipsoidal-globose, 6 to 8 mm. long, bracts at
first green, becoming red and fleshy at maturity,
the uppermost pair enclosing 2 seeds; seeds
oblong, blackish-brown, glabrous and shining, 5
mm. long, 2 to 3 mm. wide and 1.5 mm. thick
at middle, with hard testa.

Christensen and Hiner (7. A. Ph. A., 1939, 28,
199) reported favorably on experimental cultiva-
tion of this plant in South Dakota. Sievers (/. A.
Ph. A.. 1938, 27, 1221) described the experiments
of the U. S. Department of Agriculture in the
southwestern United States.

Ephedra equisetina Bunge, known as Mu Pen
Ma-huang, is a native of China, growing, accord-
ing to Liu, on clay or sandy soil chiefly along the
borderland between Chihli and Shansi, rarely in
the northern part of these two provinces and
Honan. It is a dioecious shrub attaining the height
of 1 to 2 meters whose stem is woody below and
bearing green, herbaceous, smooth branchlets
above, with internodes 1 to 3 cm. long. Its leaves
consist of 2 opposite brown, membranous to
coriaceous sheaths at the nodes which are about
2 mm. in length and connate through half or more
of their length.

Ephedra distachya L. is a shrub possibly native
to central China, attaining a height of about 38
cm. with a main stem showing branching from its
upper and lower parts. The branches are greenish-
yellow, rough terete with internodes 2.5 to 6 cm.
in length. Its leaves resemble somewhat those of
E. sinica. It has been reported as also occurring
in Europe. It has been collected in central China
and exported from Tientsin.

Both Ephedra sinica and E. equisetina are
gathered chiefly in the mountainous districts of
northern China. During 1940 there were imported
into the United States 1,430,517 pounds of
Ephedra, the supplies coming from China, Brit-
ish India, Japan and Spain; in 1952, imports
amounted to but 46,095 pounds, Pakistan and
Yugoslavia being the sole suppliers.

Description of Ma-huang. — Ephedra occurs
as branched or unbranched, jointed, rounded, and
more or less flattened green stems and branches

502 Ephedrine

Part I

or as the above-ground portions of the plants
with or without the upper part of the woody root
attached, fracture brittle, odor aromatic upon
crushing, taste aromatic, bitter and astringent.

A cross section through the stem of E. sinica
shows the following histological features: (1)
General outline ovate, the margin regularly scal-
loped by about 16 to 18 ridges. (2) Epidermis
of a single layer of nearly square cells, the outer
walls of which are heavily cutinized, especially
over the ridges. Sunken stomata occur between
the ridges which do not show lignification. Hypo-
dermal fibers are usually non-lignified and in
groups within the ridges adjacent to the inner
surface of the epidermis. These groups contain
from 3 to 20 fibers each. (3) Cortex, compara-
tively broad and consisting of several layers of
parenchyma cells, which are radiately elongated,
except the endodermal layer. Mesocortical fibers
are usually absent in this species, but if present
they are non-lignified and occur singly and in
scattered groups of from 2 to 4 fibers each.
Numerous small crystals, which dissolve without
effervescence in glacial acetic acid, are seen
through the cortical region, especially in inner
portions. Some of these crystals appear in the
walls of the cells. Little or no starch is present.
(4) Pericycle of crescent-shaped groups of non-
lignified fibers occurring just outside of the
phloem patches. These groups contain 3 to 8 fibers
each. (5) Fibrovascular bundles 8, the phloem
patches being very small and dome shaped, while
the xylem patches are small and triangular in out-
line. (6) Pith-region ovate to elliptical, the margin
scalloped by the protrusion of xylem patches.
Some of the cell walls show lignification while
scattered cells contain a yellowish-brown to red-
dish-yellow mucilaginous substance.

Mesocortical fibers are usually absent in E.
distachya and E. sinica; they are present in E.
equisetina, E. Gerardiana and E. nebrodensis,
being most numerous in E. equisetina. The gen-
eral outline, diameter of sections, number of
ridges present, number of fibers and their degree
of lignification. the degree of development of
phloem and xylem strands, the number of fibro-
vascular bundles, the presence or absence of
tracheae in the secondary xylem and the degree
of lignification of the walls of the pith cells in
the green stems depend to a considerable extent
upon the level at which sections are cut.

Powdered Ephedra. — Green to grayish- or
brownish-green; numerous thick fragments of
cutinized outer walls of epidermis varying from
colorless to varying shades of brown or red, frag-
ments of epidermis with rectangular or square
cells and granular contents, some with sunken
elliptical stomata; numerous fragments of scle-
renchyma fibers with extremely thickened, non-
lignified to lignified walls, narrow, often indistinct
lumina and pointed ends; fragments of vascular
tissue showing tracheids with bordered pits and
occasional spiral and pitted vessels, numerous
chlorenchyma cells, some containing starch and
small crystals, the latter also embedded in or
adhering to the walls; starch grains few. simple,
circular, subcircular, ovate, ovate-oblong, ellips-
oidal, beaked-ovate, ovate-truncate to subreni-

form, generally up to 12 n, rarely up to 20 \i in
diameter, fragments of lignified or non-lignified
pith-parenchyma, some of the cells containing a
yellowish, yellowish-red to reddish-brown mu-
cilaginous substance, scattered granules of calcium
oxalate. Fragments of cork tissue should be ab-
sent, if woody basal stems have been separated.

Constituents of Ephedra. — In 1887 the
Japanese chemist Nagai isolated from Ma-huang
an alkaloid to which he assigned the empirical
formula C10H15NO. Subsequent studies of the
structure of this base have shown that it is alpha-
hydroxy-beta-methyl-aminopropyl-benzene or 1-
phenyl-2-methylamino-propanol-l, and is, there-
fore, chemically closely related to epinephrine.
As there are two asymmetric carbon atoms, there
are possible four optically active isomers, all of
which have been found in one or another species
of Ephedra. These are known as d- and /-ephed-
rine and d- and l-pseudoephedrine (isoephedrine).
In addition to these alkaloids Smith isolated
nor-<f-pseudoephedrine (a lower homologue of
d-pseudoephedrine) and /-N-methylephedrine,
Xagai and Kanao found d-N-methylpseudo-
ephedrine, Kanao identified the presence of Unor-
ephedrine and Chen, Stuart and Chen isolated
and identified methylbenzylamine. All of these
bases are more or less active physiologically but
they differ among themselves not only in their
relative power but also somewhat in the kind of
action. The alkaloid ephedine, C8H18N2O3, was
reported by Chou (Chem. Abs., 1934, 28, 5178).
Chen and Anderson (ibid., 1935, 29, 4084) state
that it lowers blood pressure, contracts the iso-
lated guinea-pig uterus and augments peristaltic
movement of isolated rabbit small intestine.

Isolation of ephedrine from the plant is effected
by alkalinization with sodium carbonate or cal-
cium hydroxide and subsequent extraction with
alcohol or benzene. The solvent is distilled off,
the residue of impure alkaloid is dissolved in
dilute acid and, after treatment of the solution
with decolorizing carbon, it is filtered, then
alkalinized, and the alkaloid reextracted with ether
or a similar solvent. The alkaloid recovered from
the ether extraction is purified by crystallization
from hot water.

Synthesis. — The several methods for syn-
thesizing ephedrine nearly all lead to the racemic
product, which may be separated into the d- and
/- forms. The racemic product, while it has been
stated to be somewhat less active than the /-
isomer, used for the same purposes as /-ephed-
rine; the N.F. recognizes the hydrochloride of the
racemic variety under the name Racephedrine
Hydrochloride. In one method of synthesizing
ephedrine, ethyl-phenylketone is brominated to
a-bromoethyl-phenylketone; the latter is aminated
with monomethylamine, resulting in the formation
of a-methylamino-propylphenone. Upon reduc-
tion of the latter with hydrogen a mixture of
racemic ephedrine and racemic pseudoephedrine
results. The two forms can be separated by treat-
ing the hydrochlorides with chloroform, in which
the pseudo form is much more soluble. Pseudo-
ephedrine can also be converted into ephedrine by
heating with hydrochloric acid for several hours.
Racemic ephedrine can be separated into its opti-

Part I

Ephedrine 503

cally active constituents by resolution of the
tartrates; the levo form is recognized by the N.F.
and B.P.

By reduction of ephedrine the hydroxyl group
is replaced by hydrogen, forming the therapeu-
tically useful compound desoxy ephedrine , more
commonly known as methamphetamine and official
in the form of Methamphetamine Hydrochloride.

Description. — "Ephedrine occurs as an
unctous, almost colorless solid, or white crystals
or granules. It gradually decomposes on exposure
to light. It melts between 33° and 40°, the vari-
ability in melting point being due to differences
in the moisture content, anhydrous Ephedrine
having a lower melting point than the hemi-
hydrate of Ephedrine. Its solutions are alkaline
to litmus paper. Ephedrine is soluble in water, in
alcohol, in chloroform, and in ether, and is mod-
erately and slowly soluble in liquid petrolatum,
the solution in the latter becoming turbid if the
Ephedrine contains more than about 1 per cent
of water." N.F.

The B.P. provides the following solubility data:
Soluble, at 20°, in 36 parts of water, in less than
1 part of alcohol, in ether, and in chloroform with
separation of water. Soluble, at 15.5°, in 20 parts
of glycerin, and in 25 parts of olive oil; soluble
in 100 parts of liquid paraffin, with separation of
water. The melting point, without previous dry-
ing, is between 40° and 41°.

The solubilities of the two official forms of
ephedrine in light liquid petrolatum have been
determined by Rosin et al. (J. A. Ph. A., 1941,
30, 275). They found that the anhydrous alkaloid
dissolves to the extent of 2.23 per cent at 20°,
and 3.1 per cent at 25°; a saturated solution of
the hydrated form contains, at 20°, 0.84 per cent,
and at 25°, 1.24 per cent, of anhydrous ephedrine.

Read (Chem. Abs., 1937, 31, 4767) stated that
the hemihydrate is stable up to 42°, but when
mixed with the anhydrous base may melt as low
as 34°. In warm weather ephedrine slowly vola-
tilizes at room temperature; at 100° it may
volatilize completely in 4 or 5 hours (/. pharm.
chim., 1938, 28, 145).

Standards and Tests. — Identification. — (1)
A reddish purple color develops on adding 0.1 ml.
of cupric sulfate T.S., then 1 ml. of 1 in 5 sodium
hydroxide solution, to a solution of 10 mg. of
ephedrine in 1 ml. of water containing 1 or 2
drops of diluted hydrochloric acid. On adding
1 ml. of ether to the mixture and shaking, the
ether is colored purple and the water layer blue.
(2) On dissolving 10 mg. of ephedrine in 10 ml.
of chloroform, allowing the solution to stand
overnight in a closely covered vessel, then allow-
ing it to evaporate spontaneously, white crystals
of ephedrine hydrochloride, which respond to
tests for chloride, appear. Specific rotation. — Not
less than —33° and not more than —35.5°, in a
solution containing 500 mg. of ephedrine hydro-
chloride, prepared by interaction of ephedrine
with hydrochloric acid, in 10 ml. Residue on
ignition. — Not over 0.1 per cent. Chloride. — The
limit is 280 parts per million. Sulfate. — No tur-
bidity develops within 10 minutes on addition of
1 ml. of barium chloride T.S. to a solution of
100 mg. of ephedrine in 40 ml. of water to which

1 ml. of diluted hydrochloric acid has been added.
N.F.

Assay. — About 500 mg. of ephedrine, not
dried, is dissolved in 10 ml. of neutralized alco-
hol; a measured excess of 0.1 iV hydrochloric acid
is added and the solution titrated with 0.02 N
sodium hydroxide, using methyl red T.S. as indi-
cator. Each ml. of 0.1 N hydrochloric acid repre-
sents 16.52 mg. of C10H15NO. N.F.

Incompatibilities. — Ephedrine differs from
most alkaloids in that it is soluble in water, pro-
ducing a solution having a strongly alkaline re-
action. Because of this it may exhibit the incom-
patibilities of an alkali if prescribed in aqueous
solution. With iodine, either in aqueous or oily
media, ephedrine produces an insoluble com-
pound. Tannic acid precipitates the alkaloid but
not its salts. The hydrochloride of ephedrine is
incompatible with silver salts and with amino-
pyrine. Ephedrine sulfate does not produce any
precipitation with silver salts. Frequent or pro-
longed exposure to moist air may cause the ab-
sorption of sufficient water to prevent the prep-
aration of a clear solution in oil. Anhydrous
calcium chloride has been used to clarify such
a solution. Trituration of the alkaloid with an
equal weight of oleic acid renders it more soluble
in liquid petrolatum. Camphor, menthol, thymol
and certain oils also increase its solubility.

McLeod and DeKay (/. A. Ph. A., 1940, 29,
277) reported that ephedrine base reduces silver
salts in aqueous solution to metallic silver, while
salts of ephedrine do not. They succeeded in pre-
paring a stable preparation from ephedrine nitrate
and silver tartrate.

Uses. — Ephedrine is a sympathomimetic sub-
stance with stimulating effect on the central nerv-
ous system. It is widely used as a local and sys-
temic vasoconstrictor (vasopressor) drug (see
discussion of Sympathomimetic Amines in Part

II).

Action. — The pharmacological actions of
ephedrine are in many ways similar to those of
epinephrine (q.v.), to which it is chemically re-
lated. Some of the effects of ephedrine may be
due to an inhibition of the enzyme amine- oxidase,
which destroys epinephrine in the body (see
Beyer, Physiol. Rev., 1946, 26, 169) ; it may thus
protect epinephrine and permit continuance of its
actions. However, this explanation cannot account
for all of the actions of ephedrine. Ephedrine is
more stable than epinephrine and is effective even
when given by mouth; its action is less intense,
but more prolonged, than that of epinephrine.
Ephedrine causes contraction of the arterioles
with consequent rise in blood pressure; there is no
secondary arterial dilatation as there is with epi-
nephrine. It causes dilatation of the pupil, re-
laxation of the intestinal and bronchial muscles,
and hyperglycemia (see Wilson, J. Pharmacol.,
192 7, 30, 209). Unlike epinephrine it has a power-
ful stimulating effect on the central nervous
system.

Therapeutic Uses. — Ephedrine and its salts
are used for therapeutic effect both locally and
systemically.

In Allergic Syndromes. — Salts of ephedrine are
useful in allergic states; they relieve nasal con-

504 Ephedrine

Part I

gestion in hay fever, relax bronchiolar muscle
spasm in bronchial asthma, and are especially
useful in preventing asthmatic attacks in chronic
cases (Rubitsky et al, J. Allergy, 1950, 21, 559).
Effects appear in 30 minutes to 1 hour following
oral administration. When used continuously,
ephedrine often has to be combined with a hyp-
notic, such as one of the barbiturates, to prevent
sleeplessness. Asthmatic patients often become
unresponsive after 3 or 4 days of therapy with
ephedrine, but are benefited again after discon-
tinuing the drug for several days (Herxheimer.
Brit. M. J., 1946, 1, 350). Ephedrine is useful in
controlling urticaria, especially when associated
with angioneurotic edema.

As Central Stimulant. — Because of its stimulant
effect on the central nervous system ephedrine,
in the form of one of its salts, is beneficial in the
treatment of narcolepsy (Collins, Ann. Int. Med.,
1932, 5, 1289), although its use has now been
largely superseded by the chemically related sub-
stance amphetamine. Ephedrine is an antidote
for poisoning by central nervous system depres-
sants such as morphine (Poppe, Klin. Wchnschr.,
1928), the barbiturates, and alcohol.

In Hypotension. — Systemically, ephedrine is
useful for prevention of hypotension during spinal
anesthesia, for this purpose from 35 to 50 mg.
being given subcutaneously about 30 minutes
prior to anesthesia (Weinstein and Barron, Am. J.
Surg., 1936, 31, 154; Baldwin, U. S. Armed Forces
M. J., 1950, 1, 1495). A 40 per cent prolongation
of anesthesia when 0.5 to 1 ml. of a 5 per cent
solution of ephedrine salt is added to the procaine
mixture used in spinal anesthesia was reported by
Romberg (Anesth. & Analg., 22, 252). Ephedrine
is similarly employed in infiltration anesthesia. It
is also used to maintain blood pressure in patients
with postural hypotension, or with heart block
(Weiss, Ann. Int. Med., 1935, 8, 920).

Miscellaneous Systemic Uses. — Ephedrine has
been used to prevent nitritoid crises by giving 50
mg. of a salt orally prior to injection of arsphen-
amine or other substance which may give rise to
such a state. Ephedrine may increase pulmonary
function in obstructive emphysema when the dis-
ease is associated with asthma or chronic bron-
chitis (Alexander, Proc. Mayo, 1935, 10, 377).
It may have some beneficial effect in patients with
carotid sinus syncope (Weiss, Arch. Int. Med.,
1936, 58, 407). It may be successful in treating
some forms of petit mal epilepsy which do not
respond to barbiturates or bromides. Excellent
results from its use in treatment of nocturnal
enuresis or dribbling due to poor sphincter tone
have been reported (Kittredge and Brown, New
Orleans Med. Surg. J., 1944, 96, 562, and others).
In doses of 10 to 25 mg. orally ephedrine is bene-
ficial in combating the muscular weakness of
myasthenia gravis, although larger doses aggravate
the weakness ; it is most effective when combined
with neostigmine (Slezinger, I.A.M.A., 1952, 148,
508). The decrease in blood eosinophil count fol-
lowing an injection of epinephrine or ephedrine
has not proved to be an adequate criterion of the
functional ability of the pituitary-adrenal mech-
anism (Best et al, J.A.M.A., 1953, 151, 702).

In Nasal Obstruction. — Ephedrine, in the form

of a salt, is applied in 0.5 to 1 per cent concentra-
tion in an isotonic solution containing sodium
chloride to nasal mucous membranes to relieve
the congestion and swelling from hay fever,
allergic rhinitis, and upper respiratory infections;
sometimes an oil solution of the base is similarly
used by spraying or dropping. As there is no sec-
ondary dilatation, as with epinephrine, use of
ephedrine is not followed by an aggravted swell-
ing. Continued use appears not to be harmful to
mucous membranes. Ephedrine is not sufficiently
potent to be useful for relief or prevention of
hemorrhage when applied locally.

As a Mydriatic. — Ephedrine may be used as a
mydriatic, when applied in the form of a 4 per
cent solution of one of its salts. It has short dura-
tion of action, and does not cause cycloplegia or
increased intraocular pressure, [v]

Toxicology. — Large doses of ephedrine will
cause nervousness, insomnia, headache, vertigo,
palpitation, sweating, nausea and vomiting, and
occasionally precordial pain. In therapeutic doses
it sometimes causes vesical sphincter spasm, with
resulting difficulty in voiding. In males with pros-
tatic enlargement there may even be urinary re-
tention (Valentine and Fitzgerald, /. Urol., 1935,
34, 314). Ephedrine should be given with caution
to patients with chronic heart disease. In com-
bination with digitalis, serious disturbances of
cardiac rhythm may occur (Seevers and Meed,
J. Pharmacol., 1935, 53, 295). Contact derma-
titis due to hypersensitivity to the drug has been
reported following topical application (Zeller,
I.A.M.A., 1933, 101, 1725).

Dose. — The usual dose of ephedrine. as the
hydrochloride or sulfate, is 25 mg. (Y$ grain),
every 4 hours by mouth, or subcutaneously, with
a range of 25 to 50 mg. The maximum safe dose
is usually 50 mg. ; the total dose in 24 hours sel-
dom exceeds 150 mg. The base is used topically.

Labeling. — "The label shall declare whether
the Ephedrine is hydra ted or anhydrous. When
the quantity of Ephedrine is indicated in the
labeling of any preparation of Ephedrine, this
shall be understood to be in terms of anhydrous
Ephedrine." N.F.

Storage. — Preserve "in tight, light-resistant
containers, in a cold place." N.F.

EPHEDRINE SPRAY.

Nebula Ephedrinae

N.F.

"Ephedrine Spray contains, in each 100 ml.,
not less than 0.90 Gm. and not more than 1.10
Gm. of C10H15NO." N.F.

Warm 10 Gm. of ephedrine, dried over sulfuric
acid, and 2 ml. of methyl salicylate in a suitable
container on a water bath at 40° until solution
results; then add enough light liquid petrolatum,
rendered anhydrous but not heated at a tempera-
ture above 40°, to make 1000 ml. Agitate the
mixture until it is clear. N.F.

Both the ephedrine and light liquid petrolatum
must be rendered anhydrous in order to prevent
precipitation of hydrated ephedrine. Rosin et al.
(J. A. Ph. A., 1941, 30, 375) showed that ephed-
rine hemihydrate is soluble in light liquid petro-
latum only to the extent of 0.84 per cent, while

Part I

Ephedrine Hydrochloride Tablets 505

anhydrous ephedrine dissolves to the extent of
2.23 per cent, at 20°. A convenient method of
drying the liquid petrolatum is to add some re-
cently dried sodium sulfate to the liquid, warm-
ing it slightly while agitating the mixture for sev-
eral minutes, then filtering it through paper.

Uses. — This is a popular preparation for ob-
taining the local therapeutic action of ephedrine,
especially in acute coryza. It is applied with an
atomizer or by instilling one or two drops into
the nostril by means of a dropper.

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." N.F.

COMPOUND EPHEDRINE SPRAY.
N.F.

Compound Ephedrine Inhalant, Nebula Ephedrinae
Composita

"Compound Ephedrine Spray contains, in each
100 ml., not less than 0.90 Gm. and not more
than 1.10 Gm. of C10H15NO." N.F.

Warm 10 Gm. of ephedrine, dried over sulfuric
acid, 6 Gm. of camphor, 6 Gm. of menthol, and
3 ml. of thyme oil in a suitable container on a
water bath at 40° until a uniform liquid is ob-
tained; then add enough light liquid petrolatum,
rendered anhydrous but not heated at a tempera-
ture above 40°, to make 1000 ml. Agitate the
mixture until it is clear. N.F.

For comments applicable to the preparation of
this solution see under Ephedrine Spray.

Uses. — This preparation combines the vaso-
constrictor action of ephedrine with the local
anesthetic effect of menthol and camphor but it
is likely to irritate in acute inflammations.

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." N.F.

EPHEDRINE HYDROCHLORIDE.
N.F., B.P., LP.

Ephedrinium Chloride, [Ephedrinae Hydrochloridum]

"Ephedrine Hydrochloride, dried at 105° for
3 hours, contains not less than 98 per cent of
C10H15NO.HCI." N.F. The B.P. has no assay
rubric; the LP., which defines Ephedrine Hydro-
chloride as the hydrochloride of /-l-hydroxy-2-
methylamino-1-phenylpropane, requires not less
than 80.0 per cent and not more than 82.5 per
cent of C10H15ON.

Ephedrinum Chlorhydricum. Fr. Chlorhydrate d'ephe-
drine. Ger. Ephedrinhydrochlorid. Sp. Clorhidrato de
Efedrina.

Ephedrine hydrochloride is obtained by neu-
tralizing ephedrine with hydrochloric acid.

Description. — "Ephedrine Hydrochloride oc-
curs as fine, white, odorless crystals or powder.
It is affected by light. One Gm. of Ephedrine
Hydrochloride dissolves in about 3 ml. of water
and in about 14 ml. of alcohol. It is insoluble in
ether. Ephedrine Hydrochloride melts between
217° and 220°." N.F.

Standards and Tests. — Identification. — (1)
Ephedrine hydrochloride responds to identifica-
tion test (1) under Ephedrine. (2) It responds
also to tests for chloride. Acidity or alkalinity. —
A solution of 1 Gm. of ephedrine hydrochloride
in 20 ml. of water requires not more than 0.1 ml.

of 0.02 N sulfuric acid, or 0.2 ml. of 0.02 N
sodium hydroxide, to neutralize it, using methyl
red T.S. as indicator. Specific rotation. — Not less
than —33° and not more than —35.5°, when de-
termined in a solution containing 500 mg. of dried
ephedrine hydrochloride in each 10 ml. Loss on
drying. — Not over 2 per cent, when dried at 105°
for 3 hours. Residue on ignition. — Not over 0.1
per cent. Sulfate. — As in the corresponding test
for Ephedrine. N.F.

Assay. — About 400 mg. of ephedrine hydro-
chloride, previously dried at 105° for 3 hours, is
transferred to a separator containing saturated
solution of sodium chloride. The solution is
alkalinized with sodium hydroxide, and the liber-
ated ephedrine base is extracted with several por-
tions of ether. The combined ether extract is
washed with sodium chloride solution, and the
latter is washed with ether, which is added to the
main ether extract. A measured excess (25 ml.)
of 0.1 N sulfuric acid is added to the ether solu-
tion and after thorough stirring to permit inter-
action of ephedrine and acid the ether is vola-
tilized by warming and the excess acid in the
aqueous solution is titrated with 0.02 N sodium
hydroxide, using methyl red T.S. as indicator.
Each ml. of 0.1 N sulfuric acid represents 20.17
mg. of C10H15NO.HCI. N.F.

Uses. — The action and uses of ephedrine hy-
drochloride are the same as those of ephedrine
(q.v.)M

The usual dose of the hydrochloride is 25 mg.
(approximately }i grain), administered orally or
subcutaneously; the range of dose is 15 to 50 mg.,
the frequency of administration being every 2 to
6 hours. For local application to mucous mem-
branes the concentration range of solutions is
from 0.25 to 4 per cent. For Proetz displacement
therapy of paranasal sinuses the concentration of
ephedrine hydrochloride generally should not ex-
ceed 0.25 per cent.

Storage. — Preserve "in well-closed, light re-
sistant containers." N.F.

EPHEDRINE HYDROCHLORIDE
CAPSULES. N.F.

"Ephedrine Hydrochloride Capsules contain
not less than 92 per cent and not more than 108
per cent of the labeled amount of C10H15NO.-
HC1." N.F.

Usual Sizes. — Y% and Y\ grain (25 and 50
mg.).

EPHEDRINE HYDROCHLORIDE
TABLETS. N.F. (B.P., LP.)

"Ephedrine Hydrochloride Tablets contain not
less than 93 per cent and not more than 107 per
cent of the labeled amount of C10H15NO.HCI."
N.F. The corresponding limits of the B.P. are
90.0 and 107.5 per cent; those of the LP. are the
same as of the N.F.

B.P. Tablets of Ephedrine Hydrochloride; Tabellae
Ephedrinae Hydrochloridi. I. P. Tablets of Ephedrine
Hydrochloride; Compressi Ephedrini Hydrochloridi.

Usual Sizes. — J/A, H, */>, and K grain (ap-
proximately 15, 25, 30, and 50 mg.).

506 Ephedrine Sulfate

Part I

EPHEDRINE SULFATE. U.S.P.

Ephedrinium Sulfate, [Ephedrinz Sulfas]

CH — CH— N— CH3
I I H

OH CH3

so;

"Ephedrine Sulfate is the sulfate of an alkaloid
which may be obtained from Ephedra eqidsetina
Bunge, and other species of Ephedra (Family
Gnetacece), but is usually produced synthetically."
U.S.P.

Sp. Sulfato de Efedrina.

Ephedrine sulfate is obtained by neutralization
of ephedrine with sulfuric acid.

Description. — "Ephedrine Sulfate occurs as
fine, white, odorless crystals or as a powder. It is
affected by light. One Gm. of Ephedrine Sulfate
dissolves in 1.3 ml. of water and in about 90 ml.
of alcohol." U.S.P.

Standards and Tests. — Identification. — (1)
Ephedrine sulfate responds to identification test
(1) under Ephedrine. (2) It responds also to tests
for sulfate. Specific rotation. — Not less than
—30.0° and not more than —32.0°, when deter-
mined in a solution containing 500 mg. of dried
ephedrine sulfate in each 10 ml. Acidity or alka-
linity.— This is identical with the corresponding
specification under Ephedrine Hydrochloride. Loss
on drying. — Not over 2 per cent, when dried at
105° for 3 hours. Residue on ignition. — Not over
0.1 per cent. Chloride. — The limit is 0.15 per
cent. U.S.P.

Uses.— Ephedrine sulfate is probably the most
popular dosage form of ephedrine; its actions
and uses are discussed under Ephedrine. There
appears to be no important difference between
the effects of ephedrine sulfate and ephedrine
hydrochloride, although some laryngologists be-
lieve the sulfate to be slightly more irritant.
However, the sulfate is more frequently used in
the formulation of aqueous solutions for applica-
tion to nasal mucosa. Such solutions generally
contain from 0.5 to 1 per cent of ephedrine
sulfate, should be made isotonic with sodium chlo-
ride, and buffered to pH 6 (Fabricant, J. A.M. A..
1953, 151, 21). In acute upper respiratory infec-
tions the use of such a solution to relieve nasal
obstruction, even though its instillation must be
repeated every few hours, should not be neglected,
as has been the trend in this period of enthusiasm
for antibiotic therapy. For typical formulas of
solutions for such use see Tozer and Arrigoni,
/. A. Ph. A., 1941, 30, 189. S

The usual dose of ephedrine sulfate is 25 mg.
(approximately }i grain) every 4 hours, orally
or subcutaneously, with a range of 25 to 50 mg.
The maximum safe dose is usually 50 mg., and
the total dose in 24 hours should seldom exceed
150 mg. For nasal instillation the concentration
varies from 0.25 to 1 per cent, and depends on
the quantity of solution to be instilled.

Storage. — Preserve "in well-closed, light-re-
sistant containers." US.P.

EPHEDRINE SULFATE CAPSULES.
U.S.P.

[Capsulae Ephedrinz Sulfatis]

"Ephedrine Sulfate Capsules contain not less
than 92 per cent and not more than 108 per cent
of the labeled amount of (CioHi5NO)2.H2SC»4."
US.P.

Usual Sizes. — }i and }4 grain (approximately
25 and 50 mg.).

EPHEDRINE SULFATE INJECTION.
U.S.P.

[Injectio Ephedrinz Sulfatis]

"Ephedrine Sulfate Injection is a sterile solu-
tion of ephedrine sulfate in water for injection.
It contains not less than 95 per cent and not more
than 105 per cent of the labeled amount of
(CioHi5NO)2.H2S04." U.S.P.

The pH of the injection is required to be be-
tween 4.5 and 7.0. US.P.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass."
US.P.

Usual Sizes. — y% and $4 grain (approximately
25 and 50 mg.) in 1 ml.

EPHEDRINE SULFATE JELLY. N.F.

Ephedrine Jelly, Gelatum Ephedrinz Sulfatis

"Ephedrine Sulfate Jelly yields, from each 100
Gm., not less than 800 mg. and not more than
1.2 Gm. of (CioHi5NO)2.H2S04." N.F.

Dissolve 10 Gm. of ephedrine sulfate in 830 ml.
of purified water, add 150 Gm. of glycerin, 10
Gm. of tragacanth, 0.1 ml. of methyl salicylate,
1 ml. of eucalyptol, and 0.1 ml. of dwarf pine
needle oil. Mix well, and keep in a closed con-
tainer for 1 week, mixing occasionally. If desired,
1.6 Gm. of sodium phosphate may be added as
a stabilizer. N.F.

Because of the great variation in the viscosity
of jellies prepared with different samples of traga-
canth there has been complaint that this formula
produces a too-fluid preparation (see the studies
of Nichols on viscosity of tragacanth jellies,
/. A. Ph. A., 1937, 26, 823; 1939, 28, 98). This
difficulty could be surmounted by specifying a
test for control of viscosity and permitting ad-
justment of the amount of tragacanth employed
to yield a product of constant viscosity but it was
not considered advisable to adopt such specifica-
tions which might discourage pharmacists from
preparing the jelly.

Uses. — Ephedrine sulfate jelly is employed to
obtain the local effects of ephedrine when applied
in the nose.

Storage. — Preserve "in tight containers, pref-
erably in collapsible dispensing tubes." N.F.

EPHEDRINE SULFATE SOLUTION.
X.F.

Liquor Ephedrinz Sulfatis

"Ephedrine Sulfate Solution yields, from each
100 ml., not less than 2.7 and not more than 3.2
Gm. of (CioHi5NO)2.H2S04." NJ.

Dissolve 30 Gm. of ephedrine sulfate, 3.6 Gm.

Part I

Epinephrine 507

of sodium chloride and 5 Gm. of chlorobutanol
in enough purified water to make 1000 ml.; filter,
if necessary, until the product is clear. N.F.

Description. — "Ephedrine Sulfate Solution is
a clear, colorless solution with a slightly camphor-
aceous odor and taste. It is neutral or acid to
litmus paper." N.F.

This solution is usually too strong for applica-
tion to the mucous membrane of the nose; it may
be diluted with from one to five parts of isotonic
sodium chloride solution. For its therapeutic uses
see Ephedrine.

Storage. — Preserve "in tight containers " N.F.

EPHEDRINE SULFATE SYRUP. N.F.

[Syrupus Ephedrinae Sulfatis]

Dissolve 4 Gm. of ephedrine sulfate, 1 Gm. of
citric acid, and 0.4 Gm. of caramel in 450 ml. of
purified water; to this add a solution of 0.125
ml. of lemon oil, 0.25 ml. of orange oil, 0.06 ml.
of benzaldehyde, and 0.016 Gm. of vanillin in
25 ml. of alcohol. Now add 4 ml. of amaranth
solution and 800 Gm. of sucrose and agitate to
effect solution. Finally add sufficient purified
water to make the product measure 1000 ml. N.F.

Alcohol Content. — From 2 to 4 per cent,
by volume, of C2H5OH. N.F.

This is a palatable form of administering ephed-
rine sulfate in solution; it is given in doses of
4 to 8 ml. (approximately 1 to 2 fluidrachms),
representing 16 to 32 mg. (approximately % to
Yi grain) of ephedrine sulfate.

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." N.F.

EPHEDRINE SULFATE TABLETS.
U.S.P.

[Tabellae Ephedrinae Sulfatis]

"Ephedrine Sulfate Tablets contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of (CioHi5NO)2.H2S04."
U.S.P.

Sp. Tabletas de Sulfato de Efedrina.

Usual Sizes. — }i, l/2, 24 and l §ram (ap-
proximately 25, 30, 50 and 60 mg.).

EPHEDRINE SULFATE AND
PHENOBARBITAL CAPSULES. N.F.

[Capsulae Ephedrinae Sulfatis et Phenobarbitalis]

"Ephedrine Sulfate and Phenobarbital Capsules
contain not less than 91 per cent and not more
than 109 per cent of the labeled amounts of
(CioHi5NO)2.H2S04 and of C12H12N2O3." N.F.

Assay. — For phenobarbital. — The contents of
not less than 20 capsules are dissolved, as far as
possible, in sodium hydroxide T.S. mixed with
distilled water, the mixture filtered and diluted to
100 ml. An aliquot of the solution, representing
300 mg. of phenobarbital, is acidified with hydro-
chloric acid and the phenobarbital extracted with
ether (the aqueous liquid is retained for the de-
termination of ephedrine sulfate). The solvent
is evaporated from the ether solution and the
residue of phenobarbital (C12H12N2O3) is dried
at 105° for 2 hours. For ephedrine sulfate — The
aqueous solution, or an aliquot of it representing

300 mg. of ephedrine sulfate, remaining after the
extraction of the phenobarbital is heated with
hydrochloric acid to hydrolyze starch which may
interfere with the subsequent distillation of
ephedrine, then the solution is alkalinized and the
ephedrine base is distilled into a measured excess
of 0.1 N hydrochloric acid, the excess of which
is titrated with 0.1 N sodium hydroxide. N.F.

Uses. — This combination is used in the treat-
ment of bronchial asthma, hay fever and other
allergic disorders as a sedative, bronchial relaxant,
and vasoconstrictor.

The usual dose is one capsule, usually con-
taining 25 mg. (approximately }i grain) of ephed-
rine sulfate and 30 mg. (approximately ^ grain)
of phenobarbital; it may be repeated in four
hours.

Usual Sizes. — >s and Y\ grain (approximately
25 and 50 mg.) of ephedrine sulfate and lA, Y
and 1 grain (approximately 15, 30 and 60 mg.)
of phenobarbital.

EPINEPHRINE. U.S.P. (B.P, LP.)

/-3,4-Dihydroxy-a-(methylaminomethyl) benzyl Alcohol,
[Epinephrina]

°~*\ //-™*z-\

CH,

The B.P. and LP. name this substance Ad-
renaline, the former defining it as ( — )-l-3':4'-
dihydroxyphenyl-2-methylaminoethanol and the
latter as L-a-3 :4-dihydroxyphenyl-P-methylamino-
ethanol.The B.P. states that it is an active prin-
ciple of the medulla of the suprarenal gland, and
that it may be prepared from an acid extract of
the suprarenal glands of certain mammals, or by
synthesis.-

B.P. Adrenaline; Adrenalina. I. P. Adrenalinum. Adren-
alin {Parke, Davis) ; Suprarenalin {Armour) ; Suprarenin
{JVinthrop) ; Supranephrin {Rorer) . Suprareninum. Fr.
Adrenaline. Ger. Suprarenin. It. Adrenalina. Sp. Adrena-
lina; Epinefrina.

In 1897 Dr. John J. Abel (Bull. Johns Hopkins
Hosp., July, 1897) separated from the medullary
portion of the suprarenal the benzoyl derivative
of a hormonal base to which he gave the name
epinephrine. The pure base was isolated in 1901
almost simultaneously by von Fiirth, who named
it suprarenin, and Takamine, who named it ad-
renalin and obtained patent and trade-mark rights
in the product and name. For description of supra-
renal glands, see under Suprarenal.

The study of the structure of this substance
led eventually to the conclusion that it is a 3,4-
dihydroxy-a-(methylaminomethyl)benzyl alcohol
or, naming it as a derivative of ethanol, l-(3,4-
dihydroxyphenyl) -2 -methylaminoethanol- 1 .

In 1904 Stolz (Ber., 1904, 37, 4149) succeeded
in synthesizing racemic epinephrine, which dif-
fered from the natural alkaloid in being optically
inert and much weaker physiologically. Cushny
(/. Physiol, 1908, 37 and 38) later demonstrated
that the levorotatory isomer is nearly 15 times
more active than the dextrorotatory form, thus
explaining the lesser activity of the racemic mix-

508 Epinephrine

Part I

ture of the two isomers. The /-epinephrine now
made by synthesis is identical with the naturally
occurring base.

The method of extracting this principle from
suprarenal capsules, as given by Takamine (Am.
J. Pharm., 1901, p. 523), is described in the
U.S.D., 22nd ed., p. 429.

Several methods of synthesizing epinephrine are
available. A typical process is as follows: Pyro-
catechol. CrtH-i(OH)2 1:2, is reacted with chlor-
acetyl chloride, CH2CICOCI, which forms a con-
densation product known as chloracetocatechol.
CeH3(OH)aCOCHoCl. This is reacted with
methylamine, CH3XH2, which produces adrtn-
alone (methylaminoacetocatechol), CeH3(OH)2-
COCH2XHCH3. The latter is reduced by nascent
hvdrogen to vield racemic epinephrine. CeHx-
(OH)2CH(OH)CH2XHCH3. The racemic com-
pound may be resolved into its optically active
components by means of the fractional precipi-
tation of their tartrates, and also biologically by
using Penicillium glancum.

Description. — "Epinephrine occurs as a white
or light brownish, microcrystalline, odorless pow-
der, gradually darkening on exposure to air. It
combines with acids, forming salts which are
readily soluble in water, and from these solutions
the base may be precipitated by ammonia water
or by alkali carbonates. Its solutions are alkaline
to litmus. It is affected by light. Epinephrine is
very slightly soluble in water and in alcohol. It is
insoluble in ether, in chloroform, and in fixed and
volatile oils." U.S.P.

Standards and Tests. — Identification. — A
solution of epinephrine produces with iodine a
deep red color after the excess iodine is decolorized
with sodium thiosulfate. Specific rotation. — Not
less than —50° and not more than —53.5°, when
determined in 0.5 N hydrochloric acid solution
containing 200 mg. of dried epinephrine in each
10 ml. Loss on drying. — Not over 2 per cent,
when dried in a vacuum over sulfuric acid for 18
hours. Residue on ignitioti. — The residue from
100 mg. is negligible. Limit of arterenol. — 5 mg.
of epinephrine produces withbeta-naphthoquinone-
4-sodium sulfonate no more intense red or purple
color in the test than that obtained with 0.40 mg.
of levarterenol bitartrate similarly treated. Plant
alkaloids. — Solutions of trinitrophenol, tannic
acid, phosphomolybdic acid, mercuric-potassium
iodide, or platinic chloride do not visibly affect an
acid solution (1 in 1000) of epinephrine. U.S.P.
The B.P. gives the melting point of epinephrine as
between 205° and 212°. with decomposition, the
rate of rise of temperature in determining this
constant being 10° per minute.

Incompatibilities. — In solution epinephrine
is readily oxidized to one or more inert products,
the solution becoming pink and. finally, brown.
Air. light and heat accelerate its decomposition.
Reducing agents, particularly bisulfites or sulfites,
have a preservative effect. Stability is enhanced
in acid solution; alkaline solutions deteriorate
especially rapidly. Certain metals, as copper, iron,
and zinc, hasten decomposition of epinephrine.

Uses. — Epinephrine is the hormone formed in
the adrenal medulla (see Cori and Welch,
J. A.M. A., 1941. 116, 2590); it is probably syn-

thesized from the amino acid tyrosine, with ar-
terenol (see under Levoarterenol) being formed
as an intermediate substance. Epinephrine is a
sympathomimetic drug; it acts on effector cells
and imitates all actions of the sympathetic nerv-
ous system except those on the arteries of the face
and the sweat glands (see discussion under Sym-
pathomimetic Amines, in Part II, also under
Ephedrine, in Part I). Denervation of effector
organs increases sensitivity to epinephrine. Cocaine
potentiates its effect; ergot alkaloids, in large
doses, block its effect.

In full dosage epinephrine has two effects on
the arterioles of the skin, mucosa and conjunctiva:
it first causes constriction which is accompanied
by a rise in blood pressure and then produces
dilatation for a shorter period with subsequent fall
of blood pressure. This is attributable to the fact
that while epinephrine constricts certain arterioles,
especially those of the skin, it dilates others, as
those of skeletal muscle. The effect of epinephrine
on systemic blood pressure is the resultant of the
intensity and persistence of these two actions.
Epinephrine has no significant effect on cerebral
blood flow (Sensenbach et al., J . Clin. Inv., 1953.
32, 226). In small subcutaneous doses the vaso-
dilator effect of epinephrine may be the only one
seen. Its effect on the heart is that of stimulating
the myocardium and the conductive tissue, in-
creasing the work of the heart and its consump-
tion of oxvgen, and causing tachycardia (Starr.
ibid., 1937' 16, 799; Raab. Exp. 'Med. & Surg.,
1943, 1, 188). The increased irritability of the
myocardium may result in extrasystoles or even
in ventricular fibrillation, especially in the pres-
ence of anesthesia (chloroform, cyclopropane,
etc.) or heart disease (see Whitehead and Elliott.
/. Pharmacol., 1927. 31, 145). Epinephrine in-
creases oxygen consumption and elevates the blood
sugar level by mobilizing sugar from the liver. It
relaxes the smooth muscle of bronchi. In the
gastrointestinal tract smooth muscle is relaxed by
epinephrine (Grace et al., Arch. Surg., 1950. 61,
1036 ) except for the pyloric and ileocecal sphinc-
ters, which are contracted, although under certain
unpredictable circumstances they likewise may be
relaxed. The spleen is contracted. The reaction of
the smooth muscle of the uterus varies somewhat,
depending upon the time in the menstrual cycle or
of gestation; commonly weak contraction occurs
with large doses (Miller et al., Am. J. Obst. Gyn.,
1937. 33, 154) and inhibition with usual doses
(Kaiser and Harris, ibid., 1950. 59, 775). Epi-
nephrine is destroyed in the gastrointestinal tract
and must therefore be administered parenterally
or topically.

Topical Vasoconstrictor Uses. — The con-
strictive action of epinephrine on arterioles makes
it useful for topical application in stopping hemor-
rhages of the skin, nose, mouth, pharynx, larynx,
etc., but it has no effect on internal hemorrhage.
It will reduce nasal congestion, but the secondary
vasodilative effect results in a return of the swell-
ing which is often of even greater degree than
initially. Epinephrine is used to reduce congestion
and swelling of the conjunctiva. When used with
local or spinal anesthetics it limits their absorp-
tion and prolongs the anesthetic action. For this

Part I

Epinephrine Inhalation 509

purpose a concentration of epinephrine hydro-
chloride of 1 part in 200,000 is generally sufficient,
though even this low concentration should not be
used in the fingers, toes, ears, nose, penis or
scrotum because of the danger of sufficient vaso-
constriction to produce sloughing of tissue.

Systemic Uses. — Epinephrine is seldom useful
in shock since the arterioles are already constricted
and the pulse is rapid; it may even be harmful
(see under Levarterenol, in Part I). Because of
its accelerating action on the heart it may be used
in syncope of the Stokes-Adams type (heart
block) (Nathanson and Miller, Am. Heart J.,
1950, 40, 374); however, one should watch for
symptoms of myocardial irritability. Occasionally
the intravenous or intracardiac use of epinephrine
results in dramatic resuscitation (see Greuel,
Klin. Wchnschr., 1921, 63, 1381) in cases of
drowning, electric shock or death due to anes-
thesia; the results warrant the risk in such cases.
If heart sounds can be heard, it should be given
intravenously; if not, the epinephrine should be
injected directly into the lumen of the auricle.
Leeds (J. A.M. A., 1953, 152, 1409 J recommends
administration of 0.5 to 2 ml. of a 1:5000 solu-
tion of epinephrine hydrochloride in the presence
of weak but regular contractions. If ventricular
fibrillation is present the treatment is contra-
indicated; in cases of asystole caution should be
observed.

Uses in Allergic Disorders. — Epinephrine is
of great utility in many allergic conditions. In
bronchial asthma hypodermic injection of the sub-
stance relieves bronchial spasm during the acute
attack; its administration may be repeated at
intervals of 10 to 15 minutes, if required. In
status asthmaticus continuous injection of 0.15
mg. every 15 to 60 seconds was recommended by
Hurst (Pharm. J., 1934, 2, 705). Unfortunately
many of these cases are refractory to epinephrine;
moreover, intravenous use of aminophylline has
become rather common (Zanfagna, Bull. U. S.
Army M. Dept., April, 1945, p. 100). After about
12 hours refractory cases often respond again to
epinephrine. Although a patient may develop toler-
ance to epinephrine, he will not develop addiction.
In severe and chronic asthmatic patients epi-
nephrine may be given intramuscularly in oil
solution to effect prolongation of action for 4 to
24 hours (see /. Allergy, 1939, 10, 215, 459, 590);
the drug may also be given by inhalation to such
patients. It may relieve the symptoms of urticaria,
reduce the swelling of angioneurotic edema, and
provide some relief in serum sickness and nitritoid
crises. In severe serum reactions or anaphylactoid
reactions of any origin it may be life-saving. Epi-
nephrine is a fair antidote for an overdose of
histamine.

Miscellaneous Uses. — Injection of epineph-
rine may hasten onset of inoculation malaria or
aid in diagnosis or treatment since by mobilizing
stagnant blood (as in the spleen) the number of
parasites in the blood stream is increased (Ascoli,
Munch, med. Wchnschr., 1937, 84, 370). In the
hypoglycemia of insulin shock, epinephrine will
temporarily raise the blood sugar level, provided
glycogen is present in the liver. If one dose of
epinephrine is ineffective in such a case, it should

not be repeated. The concentration of ketones in
the blood is also increased (Miiller, Ztschr. klin.
Med., 1953, 150, 407); that of potassium in the
plasma is decreased (Dury et al., J. Clin. Inv.,
1952, 31, 440 j. Occasionally epinephrine may give
some relief in cardiac asthma when an element
of bronchial spasm is present. It should, however,
be given with extreme caution, particularly in the
presence of coronary thrombosis, angina pectoris,
and hypertension. The initial enthusiasm over
eosinopenic response in the blood following injec-
tion of epinephrine as a test of pituitary-adrenal
function has not been sustained (Best et al.,
J. A.M. A., 1953, 151, 702); patients with bilateral
adrenalectomy showed the greater than 50 per
cent decrease in blood eosinophil count which was
alleged to indicate normal adreno-cortical func-
tion. Furthermore, no increase in blood 17-hy-
droxycorticoids or urinary 17-ketosteroids occurs
after injection of epinephrine even in the presence
of a marked decrease in blood eosinophils.

Toxicology. — In some individuals (or in all
persons following large doses), epinephrine causes
mild restlessness, anxiety, headache, tremor, weak-
ness, dizziness, and palpitation. These reactions
are exaggerated in hyperthyroidism. In cases of
hypertension or cerebral arteriosclerosis the sharp
rise in blood pressure which epinephrine causes
may result in cerebral hemorrhage. In patients
with angina pectoris epinephrine may induce an
attack. It is contraindicated during anesthesia
with chloroform, trichloroethylene or cyclopro-
pane, which sensitize the heart to fibrillation
after epinephrine.

Dose. — The usual dose, expressed in terms of
epinephrine base, is 0.5 mg. (about Vrzo grain)
subcutaneously every 4 hours, or more frequently
if necessary; the range of dose is 0.2 to 1 mg.
The maximum safe dose is usually 1 mg., and the
total dose in 24 hours seldom exceeds 5 mg.
Epinephrine is generally employed in the form
of a 1 : 1000 aqueous solution of its hydrochloride
salt, the preparation being official as Epinephrine
Injection. This should not be confused with Epi-
nephrine Inhalation, which contains 10 times as
much epinephrine. Massage of the injection site
increases the rate of absorption of epinephrine.
For infiltration of tissue, as when a local anes-
thetic is used, the total amount of epinephrine
injected should not exceed 1 mg., and the concen-
tration of epinephrine in the solution should not
exceed 1:50,000.

For topical application to the skin or mucous
membranes Epinephrine Solution, which is of
1 : 1000 concentration, may be used undiluted or
diluted to 1:50,000 concentration. Epinephrine
hydrochloride is sometimes employed in an oint-
ment or rectal suppository in a concentration of
1 :1000. The uses of epinephrine bitartrate are dis-
cussed in a subsequent monograph, [v]

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

EPINEPHRINE INHALATION. U.S.P.

Epinephrine Solution 1:100, [Inhalatio Epinephrines]

"Epinephrine Inhalation is a solution of epi-
nephrine in purified water prepared with the aid

510 Epinephrine Inhalation

Part I

of hydrochloric acid. It contains not less than 0.9
Gm. and not more than 1.15 Gm. of C9H13NO3
in each 100 ml." U.S.P.

"Note. — Do not use Epinephrine Inhalation if
it is brown in color or contains a precipitate."
U.S.P.

Sp. Inhalation de Epinefrina.

Assay. — The assay is identical with that speci-
fied for Epinephrine Solution. U.S.P.

Uses. — Inhalation of this stronger solution of
epinephrine has proved valuable in the manage-
ment of patients with asthma or other conditions
in which bronchospasm is an important factor. It
was introduced by Graeser and Rowe (/. Lab.
Clin. Med., 1936, 21, 1134) to produce more
rapid action without the side effects of parenteral
administration. The tip of a special hand-bulb
nebulizer, which produces a very fine mist, is held
in the mouth and the bulb compressed by hand
during inhalation. The secretions of the nose and
throat may be colored pink by the drug when
administered in this fashion ; plugging the anterior
nares with cotton during the treatment minimizes
the drying and irritation of the nasal mucosa. This
direct route of administration may be effective
when subcutaneous injections have failed.

Richards et al. (Am. J. Med. Sc, 1940, 199,
225) vaporized the solution with the aid of a
stream of oxygen, 4 or 5 liters per minute, passed
through the nebulizer. From 10 to 15 minutes is
required to nebulize 0.5 ml. of solution in this
manner. They employed this procedure in asthma,
virus pneumonia, and certain forms of poisoning
by war gases; marked increases in vital capacity
were demonstrated. Barach (/. Allergy, 1943, 14,
296) used the same procedure in the management
of intractable asthma. A warm, alkaline mouth
wash and gargle after the treatment minimizes
drving and irritation of the pharvnx. Galgiani and
Tainter {J. A.M. A., 1939, 112," 1929) cautioned
against inflammatory changes produced in the
trachea by this inhalation.

The usual dose is 0.5 to 1 ml. (approximately
8 to 15 minims), by inhalation every 2 to 4 hours.

Storage. — Preserve "in small, well-filled, light-
resistant, tight containers." US P.

EPINEPHRINE INJECTION.
U.S.P. (B.P., I.P.)

[Injectio Epinephrine]

"Epinephrine Injection is a sterile solution of
epinephrine in water for injection prepared with
the aid of hydrochloric acid. It contains not less
than 90 mg. and not more than 115 mg. of
C9H13XO3 in each 100 ml." U.S.P.

"Note. — Do not use Epinephrine Injection if it
is brown in color or contains a precipitate." U.S.P.

The corresponding preparation of the B.P. and
I.P. is designated Injection of Adrenaline and is
prepared from epinephrine bitartrate; it is made
by dissolving 0.1 Gm. of sodium metabisulfite in
10 ml. of water for injection, adding 0.18 Gm. of
epinephrine bitartrate, then a solution of 0.8 Gm.
of sodium chloride in 75 ml. of water for injec-
tion and, finally, sufficient water for injection to
produce 100 ml. The solution is sterilized by heat-

ing in an autoclave to maintain it at 115° to 116°
for 30 minutes. This injection represents the same
concentration of epinephrine base as the U.S.P.
injection.

B.P. Injection of Adrenaline; Injectio Adrenalins.
I.P. Injectio Adrenalini. Fr. Solute injectable d'adren-
aline. Sp. lnyeccion de Epinefrina.

For comments applicable to the preparation of
this injection see under Epinephrine Solution. It
would appear that both the U.S.P. injection, which
represents a solution of epinephrine hydrochloride,
and the solution of epinephrine bitartrate of the
B.P. and I.P. are essentially identical when both
contain the same stabilizing agent and have the
same pH; some claim that the solution of the
bitartrate is the more stable of the two (see under
Epinephrine Solution) but others consider the
hydrochloride to be equally stable if the same
antioxidant is included. It is of particular interest
that the U.S.P. requires the pH of its injection to
be between 2.5 and 5.0, while the B.P. specifies it
to be between 3.2 and 3.6, and the I.P. provides a
range of 2.5 to 4.0.

For uses and dose see under Epinephrine.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I or
Type III glass, protected from light." U.S.P.

Usual Sizes. — 1-ml. ampuls and 30-ml. mul-
tiple-dose vials containing 1:1000 solution.

EPINEPHRINE SOLUTION.
U.S.P. (B.P.)

Epinephrine Solution 1:1000, Liquor Epinephrinae

"Epinephrine Solution is a solution of epineph-
rine in purified water prepared with the aid of
hydrochloric acid. It contains not less than 90 mg.
and not more than 115 mg. of C9H13XO3 in each
100 ml." U.S.P.

"Note. — Do not use the solution if it is brown
or contains a precipitate." U.S.P.

B.P. Solution of Adrenaline Hydrochloride, Liquor
Adrenalinae Hydrochloride Adrenalin Chloride Solution
1:1,000 {Parke, Davis); Suprarenalin Solution 1:1,000
(Armour); Suprarenin Solution 1:1,000 (Winthrop); Supra-
nephrin Solution 1:1,000 (Rarer). Solutum Adrenalini Offi-
cinale; Solutio Chlorhydratis Adrenalinae. Fr. Solute d'-
adrenaline. Ger. Suprareninhydrochloridlosung. It. Soluzi-
one di cloridrato di adrenalina. Sp. Solucion de clorhi-
drato de adrenalina (1 X 1,000); Solucion de clorhidrato
de epinefrina; Solucion de Epinefrina.

Because of the uncertainties attending the prep-
aration of a stable solution of epinephrine hydro-
chloride in the absence of the special facilities
required for its manufacture and control, the
U.S.P. does not provide a formula for this solu-
tion. The B.P. formula calls for 1 Gm. of epi-
nephrine, 5 Gm. of chlorobutanol, 9 Gm. of so-
dium chloride, 0.5 Gm. of sodium metabisulfite,
3 ml. of dilute hydrochloric acid, and sufficient
recently boiled and cooled distilled water to make
1000 ml. of solution.

Many studies have been undertaken to deter-
mine the optimum conditions for preparing and
storing epinephrine hydrochloride solutions; the
results of the work of different investigators are
sometimes contradictory. In some of these studies
the criterion of stability has been absence of color
development; in view of the fact that colorless
solutions may have undergone considerable loss

Part I

Epinephrine Bitartrate 511

of potency such a measure of stability is of little
significance.

West (Quart. J. P., 1945, 18, 267) believes that
there are two main routes of destruction of epi-
nephrine; one is apparently due to oxidation, the
other is a heat effect. The addition of 0.1 per cent
of sodium metabisulfite and storage of the solu-
tion in filled containers, protected from light, ap-
parently prevent oxidation but do not prevent
destruction by heat; the latter effect, at any con-
stant temperature, appears to be a function of the
pH of the solution. Earlier West had reported that
a solution of epinephrine in dilute hydrochloric
acid, adjusted to a pH of approximately 4.2 and
containing 0.1 per cent of metabisulfite, retained
practically all of its activity even when sterilized
by autoclaving for 30 minutes at 115°. Later (loc.
cit.) he proposed as a more stable solution, espe-
cially for parenteral administration, one containing
epinephrine bitartrate. His formula for such a
solution is as follows: Epinephrine bitartrate, 1.9
Gm. (equivalent to 1 Gm. of epinephrine) ; so-
dium chloride, 9 Gm.; sodium metabisulfite, 1
Gm.; distilled water, to 1000 ml. This is essen-
tially the formula which was adopted by B.P. for
its Injection of Adrenaline. For multiple dose con-
tainers 0.1 per cent of chlorocresol or 0.5 per cent
of chlorobutanol is also added. This solution is
sterilized by autoclaving at 115° for 30 minutes,
with negligible loss of activity. The pH before
autoclaving is 3.6 to 3.7, changing to 3.4 on auto-
claving, and eventually dropping to 2.9. West and
Whittet (ibid., 1948, 21, 225) reported that for
optimum storage of solutions of epinephrine in
vials it is essential to use rubber caps which have
been soaked in a 0.2 per cent solution of sodium
metabisulfite for several days.

Many other suggestions for the stabilization
of epinephrine hydrochloride solutions have been
offered. Carbon dioxide has been advocated for
the purpose of displacing oxygen from solutions;
sulfur dioxide, various sulfites and bisulfites,
ascorbic acid, cysteine hydrochloride, sucrose,
methyl p-hydroxybenzoate, and sodium formalde-
hyde sulfoxylate also have been recommended as
preservatives. For other papers on the subject
see Goris and Legroux (Bull. sc. Pharmacol.,
1936, 43, 494) ; Rowlinson and Underbill (Quart.
J. P., 1939, 12, 392); Woolfe (ibid., 1941, 14,
234); Krantz et al. (J. A. Ph. A., 1936, 25, 979);
Biichi and Horler (Pharm. Acta Helv., 1945, 20,
274); West (Pharm. J., 1945, 155, 86), Foster
et al. (Quart. J. P., 1945, 18, 267).

Description. — "Epinephrine Solution is a
nearly colorless, slightly acid liquid, gradually
turning dark on exposure to air and light. U.S.P.

Assay. — The U.S.P. XV assay is based on con-
version of epinephrine in the solution to triacetyl-
epinephrine (03,04,N-triacetylepinephrine) ; this
is extracted from the solution and finally weighed,
but in order to make certain of the identity and
purity of the residue its specific rotation in chloro-
form solution is determined, and the content of
epinephrine in the original solution is calculated
from the weight of the triacetyl derivative and
its specific rotation.

The assay employed in earlier revisions of the
U.S.P. was biological and was based on observa-
tion of the dosage of a dilution of the sample to
be tested required to produce the same elevation
of blood pressure in a dog as that following ad-
ministration of a dilution of a standard solution
prepared from a suitable epinephrine reference
standard (Epinephrine Bitartrate Reference Stand-
ard was used by U.S.P. XIV). For further dis-
cussion of this and certain colorimetric assays see
U.S.D., 24th ed., p. 415.

For uses of this solution see under Epinephrine.

Storage. — Preserve "in small, well-filled, light-
resistant, tight containers." U.S.P.

Off. Prep. — Procaine Hydrochloride and Epi-
nephrine Injection, U.S.P., B.P.

STERILE EPINEPHRINE
SUSPENSION. U.S.P.

Epinephrine in Oil Injection. U.S.P. XIV

"Sterile Epinephrine Suspension is a sterile
suspension of epinephrine in oil. It contains not
less than 90 per cent and not more than 120 per
cent of the labeled amount of C9H1.3NO3." U.S.P.

The commercially available form of this injec-
tion contains 0.2 per cent of epinephrine sus-
pended in a vegetable oil, such as peanut or
sesame oil.

This suspension is used for the same purposes
as the aqueous injection. The important difference
between the two types of injections is that the
oil suspension acts over a period of 8 to 16 hours
while the aqueous solution is effective for 1 to 4
hours. The oil injection is given intramuscularly
(for technique of administration see under Bis-
muth Subsalicylate Injection) ; it is important to
use a dry syringe and needle in order to avoid
unusual rates of absorption (Dorwart, J.A.M.A.,
1940, 114, 647).

The usual dose range is 0.2 to 1.5 ml. of the
0.2 per cent suspension, representing 0.4 to 3 mg.
of epinephrine base, which is given every 8 to 16
hours. The initial dose for an adult should not
exceed 0.5 ml. until the susceptibility of the indi-
vidual has been determined. It should be kept in
mind that 1 ml. of this injection contains as much
epinephrine as 2 ml. of Epinephrine Injection,
which is a 0.1 per cent solution.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." U.S.P.

Usual Size. — 1:500 suspension in 1-ml. con-
tainers.

EPINEPHRINE BITARTRATE.

U.S.P. (B.P., LP.)

Epinephrinium Bitartrate, [Epinephrinas Bitartras]

The B.P. defines Adrenaline Acid Tartrate as
the acid tartrate of ( — )-l-3':4'-dihydroxyphenyl-
2-methylaminoethanol; no purity rubric is speci-
fied. The LP. requires 95.0 to 101.0 per cent of
C9H13O3N.C4H6O6, calculated with reference to
the anhydrous substance.

B.P. Adrenaline Acid Tartrate. LP. Adrenaline Bi-
tartrate; Adrenalini Bitartras. Suprarenin Bitartrate
( W inthrop-S teams) .

512 Epinephrine Bitartrate

Part I

This salt, which is the rf-bitartrate of /-epineph-
rine, is the form in which the physiologically
potent /-isomer of epinephrine is precipitated in
the course of separating it from the relatively
inactive d-isomer which is simultaneously obtained
in synthesizing the hormone. Use of the bitartrate
thus simplifies the epinephrine manufacturing
process to some extent; further advantages of
using this salt are that because it is somewhat less
acid it is less irritating than the hydrochloride,
and that it is possibly somewhat more stable in
aqueous solution.

Description. — "Epinephrine Bitartrate occurs
as a white, or grayish white or light brownish gray,
crystalline powder. It is odorless and slowly
darkens on exposure to air and light. Its solutions
are acid to litmus, having a pH of about 3.5. One
Gm. of Epinephrine Bitartrate dissolves in about
3 ml. of water, and in about 550 ml. of alcohol.
It is almost insoluble in chloroform and in ether.
Epinephrine Bitartrate melts between 147° and
152°." U.S.P. The B.P. gives the melting point as
about 150°, with decomposition; the LP. specifies
it as being between 147° and 154°, with decom-
position. The B.P. gives the pH of a 1 per cent
w/v solution as between 2.8 and 3.8, while the
corresponding LP. range is 3.5 to 5.0.

Standards and Tests. — Identification. — Epi-
nephrine liberated from the bitartrate is required
to respond to the identification test for epineph-
rine and also to have the specific rotation of the
latter. Loss on drying. — Not over 0.5 per cent,
when dried in vacuum over sulfuric acid for 3
hours. Residue on ignition. — The residue from
100 mg. is negligible. Limit of arterenol. — The
test described under epinephrine is employed.
Nitrogen content. — Not less than 4.1 per cent and
not more than 4.3 per cent, when assayed by the
Kjeldahl method. U.S.P. The LP. allows up to
1.0 per cent of water, as determined by the Karl
Fischer method; the residue on ignition may not
exceed 0.2 per cent; a colorimetric limit test for
arterenol is provided; a limit for adrenolone is
established.

Assay. — The LP. assay is spectrophotometry,
the absorbancy in 0.01 N hydrochloric acid solu-
tion being determined at 279 mn; the specific
absorbancy at this wavelength is taken as 81.0.

Uses. — Epinephrine bitartrate is particularly
well suited for preparation of solutions and oint-
ments of epinephrine ; such products are generally
less irritant and more stable than those prepared
from epinephrine and hydrochloric acid. Besides
the official preparations described in the following,
the B.P. injection of epinephrine (adrenaline) is
prepared from the bitartrate salt. For uses see
under Epinephrine, also the articles which follow.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

EPINEPHRINE BITARTRATE OPH-
THALMIC OINTMENT. U.S.P.

Unguentum Epinephrine Bitartratis Ophthalmicum

Dissolve 1 Gm. of epinephrine bitartrate in 10
ml. of purified water and incorporate it with suffi-
cient hydrophilic petrolatum to make 100 Gm. of

product. U.S.P.

By virtue of the epinephrine bitartrate reducing
intraocular tension, this ointment is useful in the
treatment of chronic simple glaucoma. The bitar-
trate is particularly useful for this purpose because
it is less irritant than the hydrochloride.

Storage. — Preserve "in collapsible tubes."
U.S.P.

EPINEPHRINE BITARTRATE OPH-
THALMIC SOLUTION. N.F.

Liquor Epinephrine Bitartratis Ophthalmicus

Dissolve 2 Gm. of epinephrine bitartrate and
2 Gm. of boric acid in sufficient purified water to
make 100 ml. of solution; filter, if necessary.
The solution should be freshly prepared, as re-
quired. N.F.

Uses. — Application of this solution to the con-
junctiva produces dilatation of the pupil, local
diminution in the blood supply, and reduction of
intraocular tension. Because of this last effect, the
solution may be used in treating chronic simple
glaucoma. A single instillation of solution into the
conjunctival fold is usually sufficient to reduce
pressure, but two or three instillations at 10- to
20-minute intervals may be necessary; subse-
quently a single instillation at intervals of 3 or 4
days will generally suffice to maintain reduced
tension. The temporary stinging sensation caused
by the solution may be avoided by prior applica-
tion of a few drops of 0.5 per cent tetracaine
hydrochloride solution as a local anesthetic.

ERGONOVINE MALEATE.
U.S.P. (B.P, LP.)

Ergometrine Maleate, Ergonovinium Bimaleate,
[Ergonovinas Maleas]

H0-CH2CH
I
CH3

~*Qc£

/ \

H CH,

HCW^

"Ergonovine Maleate, dried over sulfuric acid
for 4 hours, contains not less than 98 per cent of
C19H23N3O2.C4H4O4." U.S.P. The B.P. and LP.
both define Ergometrine Maleate as the acid
maleate of an alkaloid, ergometrine, obtained
from ergot; the B.P. requires not less than 95.0
per cent of C19H2.3O2N3.C4H4O4. calculated with
reference to the substance dried to constant
weight at 100° at a pressure not exceeding 5 mm.
of mercury, while the LP. requires not less than
98.0 per cent of the active component, calculated
with reference to the substance dried over sul-
furic acid for 4 hours.

B.P. Ergometrine Maleate; Ergometrinae Maleas. I. P.
Ergometrini Maleas. Ergotrate (Lilly). Sp. Maleato de
Ergonovina.

Ergonovine base (also called ergometrine, er-
gotocin, ergostetrine and ergobasine) is the most
important of the water-soluble alkaloids of ergot
(q.v.). The proportion of the alkaloid in ergot,

Part I

Ergonovine Maleate 513

calculated as ergonovine acid maleate (the proper
name for the official ergonovine maleate), varies
from about 0.01 per cent to approximately 0.03
per cent; from the studies of Grove and Vos
( J. A. Ph. A., 1945, 34, 256) it appears that the
amount of ergonovine (calculated as acid maleate)
present is from V15 to Y10 of the total alkaloid con-
tent of ergot (calculated as ergotoxine ethane-
sulfonate).

Isolation of ergonovine from ergot may be car-
ried out in several ways. U. S. Patent 2,192,460
(March 5, 1940) describes the following method
of separating ergostetrine (one of the names for
ergonovine) : Defatted, powdered ergot is mixed
with an aqueous alkali solution or suspension,
extracted with an organic solvent, the resulting
solution of total alkaloids evaporated to dryness
under vacuum, the residue dissolved in acetone,
the water-insoluble alkaloids precipitated by dilu-
tion with water and the ergostetrine recovered
from the solution by evaporating the water.

The official ergonovine maleate is the salt
formed from a molecule of ergonovine and one of
maleic acid; it is therefore properly designated
ergonovine acid maleate.

Ergonovine has been synthesized by Kornfeld
et al. (J.A.C.S., 1954, 76, 5256). For further in-
formation see Constituents, under Ergot.

Description. — "Ergonovine Maleate occurs as
a white, or faintly yellow, odorless, microcrystal-
line powder. It is affected by light. One Gm. of
Ergonovine Maleate dissolves in about 36 ml. of
water, and in about 120 ml. of alcohol. It is in-
soluble in ether and in chloroform." U.S. P. The
B.P. and LP. give the melting point as between
195° and 197°, with decomposition.

Standards and Tests. — Identification. — (1)
Solutions of ergonovine maleate have a blue
fluorescence. (2) A 1 in 10,000 solution of ergo-
novine maleate develops a blue color within 10
minutes after mixing with 2 volumes of £-di-
methylaminobenzaldehyde T.S. Specific rotation.
— Not less than +50° and not more than +55°,
when determined in a solution containing 100 mg.
of dried ergonovine maleate in 10 ml. Loss on
drying. — Not over 2 per cent, when dried over
sulfuric acid for 4 hours. Ergotoxine and ergota-
mine. — Ergonovine maleate does not evolve am-
monia when heated to boiling with a 1 in 10 solu-
tion of sodium hydroxide. Foreign alkaloids and
ergotamine. — A 1 in 5000 solution does not yield
a precipitate with mercuric-potassium iodide T.S.
U.S.P. The B.P. and LP. also limit loss on drying
to 2.0 per cent, the former directing the substance
to be dried to constant weight at 100° at a pres-
sure not exceeding 5 mm. of mercury, the latter
following the U.S.P. method. Both the B.P. and
LP. require the specific rotation, determined in
1.5 per cent w/v aqueous solution, to be between
+ 53° and +56°, calculated to dried material.

Assay. — About 100 mg. of ergonovine maleate,
previously dried for 4 hours over sulfuric acid,
is dissolved in a mixture of alcohol and stronger
ammonia T.S.; saturated solution of sodium chlo-
ride is added, and the ergonovine is extracted
with ether. The ether is evaporated and the resi-
due of ergonovine dissolved with 25 ml. of 0.02 N
hydrochloric acid; the excess of acid is titrated

with 0.02 N sodium hydroxide, using bromophenol
blue T.S. as indicator. Each ml. of 0.02 N hydro-
chloric acid represents 8.830 mg. of C19H23N3O2.-
C4H4O4. U.S.P. The B.P. and LP. both utilize
the blue color produced by the alkaloid with
/>-dimethylaminobenzaldehyde as the basis of their
respective assays; the standard used for compari-
son by the B.P. is pure ergonovine maleate, while
that used by the LP. is pure ergotamine tartrate.

Many methods for biological estimation of
ergonovine when present in ergot or in mixtures
of its alkaloids have been proposed. As stated
under Ergot neither the cock's comb nor the
Broom-Clark method is applicable in the presence
of the ergotoxine-like alkaloids. Powell et al.
(J. A. Ph. A., 1941, 30, 255) developed a method
for separating the ergot alkaloids into the ergo-
novine and the ergotoxine-like-alkaloids fractions,
then estimating the former by the isolated rabbit's
uterus method and the latter by a modification
of the Broom-Clark method. DeBeer and Tullar
(Quart. J. P., 1941, 71, 256), observing that
ergonovine has a greater mydriatic effect than
does ergotoxine, and that the latter has a greater
hyperthermal effect than ergonovine in the rabbit,
proposed an assay for ergonovine in which both
effects are measured simultaneously. Vos (/. A.
Ph. A., 1943, 31, 138) developed an assay based
on the fact that large doses of ergonovine stimu-
late contraction of the isolated rabbit uterus more
promptly than small doses; he used as the cri-
terion of potency the latent period, i.e., the time
interval between addition of ergonovine and the
first contraction of the uterus. Vos claims that
moderate amounts of ergotoxine and ergometrinine
do not interfere seriously with the assay.

Many chemical methods have likewise been
proposed; in each of these the other ergot alka-
loids are first removed, and the ergonovine esti-
mated by observation of the intensity of blue
color obtained with p-dimethylaminobenzaldehyde.
Grove and Vos (/. A. Ph. A., 1945, 34, 256)
stated that the results obtained by chemical meth-
ods are undoubtedly high due to contamination
of the ergonovine fraction with impurities that
give a similar color with the reagent. Substances
such as ergometrinine, the ergines, lysergic acids,
and possibly even traces of the ergotoxine group
are believed by them to be responsible for the
interference. They propose a method for extract-
ing ergonovine from ergot which gives, on the
average, results only 15 per cent higher than
those obtained by the isolated rabbit uterus
method of Vos; their chemical method also em-
ploys the />-dimethylaminobenzaldehyde color re-
action. Extraction of the ergot is effected with
ether in the presence of lead subacetate solution;
the ether extract is shaken with tartaric acid
solution to remove total alkaloids, which may
be estimated colorimetrically. An aliquot of the
solution is made alkaline with ammonia to pre-
cipitate the water-insoluble alkaloids, which are
filtered off; the filtrate is used to obtain, after
a series of purification steps, a tartaric acid solu-
tion of the ergonovine.

Uses. — Action. — The physiological effects of
ergonovine in a general way are quite similar to
those of "ergotoxine" and ergotamine (see under

514 Ergonovine Maleate

Part I

Ergot) though, as Moir {Brit. M. J., 1932, 2,
1119) discovered, the liquid remaining after re-
moval of "ergotoxine" and ergotamine from fluid-
extract or aqueous extract of ergot — and which
contained ergonovine — was considerably more
effective than the separated alkaloids. The fol-
lowing differences have been reported by various
pharmacologists: (1) Ergonovine is decidedly
more powerful in its effects on the uterus than
are the other alkaloids of ergot; this difference
is more marked on the puerperal than on the
nongravid uterus. (2) Oertel and Bachmann
{Arch. exp. Path. Phartn., 1937, 185, 242) re-
ported that the first effect of ergonovine is a
heightening of uterine tonus followed by increased
rhythmical contractions. On the contrary Brown
and Dale {Proc. Roy. Soc. London, 1935, 118,
446) found that its chief action is to produce
rhythmic contractions. (3) Ergonovine has a dis-
tinct exciting action on the sympathetic nerves
causing the dilatation of the pupil and inhibition
of intestinal movements. (4) It does not cause
"epinephrine reversal*' which is so characteristic
of ergotoxine. (5) Its absorption from the ali-
mentary canal is much more rapid than the other
alkaloids so that after oral administration uterine
stimulation may be apparent in a few minutes.

(6) The duration of its action is less than that
of . ergotoxine but longer than that of pituitrin.

(7) Although in sufficient dose it is capable of
causing gangrene it is, in proportion to its
ecbolic dose, much less toxic than ergotoxine or
ergotamine.

Oxytocic Uses. — Ergonovine is used therapeu-
tically almost exclusively in accidents of parturi-
tion. It is superior to "ergotoxine" in that its
action is much more prompt which may be a
matter of vital importance in cases of post-
partum hemorrhage. It has also been employed
after cesarean section and during the puerperium.
Its use in menorrhagia, metrorrhagia and incom-
plete abortion is not well established. To a great
extent it has replaced posterior pituitary injec-
tion for the prevention of post-partum hemor-
rhage (Reich, Am. J. Obst. Gyn., 1939, 37, 224).
Although its action on the uterus is almost as
prolonged as that of ergotamine tartrate, it has
been used in combination with the latter both
orally and parenterally, or with ergot fluidextract,
to obtain both a rapid and a prolonged action.
Davis {Am. J. Surg., 1940, 48, 154) used an
intravenous injection of ergonovine in the second
stage of labor and claimed that it reduced the
loss of blood and the frequency of third stage
complications. Davis and Boynton {Am. J. Obst.
Gyn., 1942, 43, 775) employed the following
procedure: as the anterior shoulder of the fetus
comes under the arch of the pubis, give 0.2 mg.
of ergonovine maleate intravenously; wait about
30 seconds before delivering the posterior shoul-
der; as soon as the fetus is delivered, express
the placenta, which has been separated by the
strong contraction induced by the ergonovine,
from the vagina. Improper timing may result in
incarceration of the placenta in the iower uterine
segment and require manual removal with anes-

thesia to produce relaxation of the uterus. It is
also prescribed orally during the puerperium to
hasten involution of the uterus. Doses as high
as 1.5 mg. by mouth, 0.75 mg. intramuscularly
and 0.2 mg. intravenously have been used without
toxic manifestations.

Other Uses. — For migraine it is less effective
than ergotamine, but is better absorbed from the
gastrointestinal tract and has little tendency to
cause nausea, vomiting, diarrhea, etc. (Lennox,
Am. J. Med. Sc, 1938, 195, 458). For those cases
in which it is effective it is preferable to ergota-
mine. Ergonovine maleate (0.2 mg. in 1 ml. of
water for injection) was given intravenously to
test coronary circulation in patients with angina
pectoris but no abnormalities in their resting
electrocardiogram; electrocardiograms were taken
before and 1, 5, 10 and 15 minutes after injec-
tion. Appearance of significant abnormalities in
the electrocardiogram indicates impaired coro-
nary circulation, but a negative test does not
exclude the presence of coronary disease (Stein
and Weinstein, /. Lab. Clin. Med., 1950, 36, 66).
Doses as high as 0.6 mg. were given intravenously
without untoward effects other than pain, which
was controlled with nitroglycerin. S

Related Preparations. — Commercial prepa-
rations containing ergonovine, in one form or
another, include the following: Baser gin (San-
doz), an ergonovine tartrate, available in ampuls
containing 0.2 mg. and in tablets containing 0.25
mg. of the salt; Ergotole (Sharp and Dohme), a
purified aqueous extract representing in each ml.
the water-soluble constituents from 2.4 Gm. of
standardized ergot; Ergotora (Upjohn), in tab-
lets representing in each water-soluble ergot
alkaloids equivalent to not less than 0.2 mg.
of ergonovine maleate; Neo-Gynergen (Sandoz),
in ampuls or tablets each containing 0.25. mg. of
ergotamine tartrate and 0.125 mg. of ergonovine
tartrate.

Methylergonovtne Tartrate, N.N.R. Meth-
ergine Tartrate (Sandoz). — A homologue of
ergonovine which contains one more CH2 group
than the latter has been synthesized by Stoll
and Hofmann (U.S. Patents 2,265,207 and 2,265,-
217) and found to be a good oxytocic. It is
available in the form of the tartrate, which con-
tains two molecules of methanol of crystallization;
the substance is a white to pinkish tan, micro-
crystalline powder, very soluble in water.

The pharmacological action of methylergono-
vine on the uterus is similar to that of ergonovine
(Kirchhof et al., West. J. Surg. Obst. Gyn., 1944,
52, 197). In the immediate postpartum period
it induces uterine contractions within y2 to I
minute after intravenous injection, 2 to 5 min-
utes after intramuscular injection, and 3 to 5
minutes after oral administration (Schade and
Gernand, Am. J. Obst. Gyn., 1950, 59, 627).
It appears to have oxytocic activity somewhat
greater and more prolonged than that of ergono-
vine (maleate) and less prolonged than that of
ergotamine (tartrate), and has less vasopressor
action than either ergonovine or ergotamine.
Rapid completion of the third stage of labor and
even less bleeding than with ergonovine is re-

Part I

Ergonovine Maleate Injection 515

ported to have followed intravenous administra-
tion of 0.2 mg. of methylergonovine tartrate at
the time of appearance of the fetal shoulder
under the pubic arch or immediately after de-
livery of the fetus (Tritsch and Schneider, Am.
J. Obst. Gyn., 1945, 50, 434). Intravenous ad-
ministration of 10 ml. of 20 per cent solution of
calcium gluconogalactogluconate immediately fol-
lowing injection of methylergonovine tartrate is
advocated to potentiate uterine contraction
(Sandin and Hardy, ibid., 1951, 61, 1087).

In the absence of expert obstetrical supervision
of the patient, it may be safer to delay adminis-
tration of this oxytocic until the placenta is
expelled, since strong uterine contraction may
cause retention of the placenta and require man-
ual removal (Brougher, West. J. Surg. Obst.
Gyn., 1945, 53, 276).

Comparing the effects of 0.2 mg. of methyl-
ergonovine tartrate with those of 0.2 mg. of
ergonovine maleate administered intravenously
on the second or third postpartum day, Forman
and Sullivan (Am. J. Obst. Gyn., 1952, 63, 640)
observed abdominal cramps in almost 80 per cent
of the patients with either drug, bradycardia and
rise in blood pressure twice as frequently with
ergonovine (in 36 and 48 per cent, respectively,
of patients), and headache and dizziness about
twice as frequently with methylergonovine (in
about 25 per cent of the patients). Tinnitus,
sweating, palpitation and dyspnea occurred in-
frequently with either drug. In a similar study
Schade (ibid., 1951, 61, 188) observed significant
rise in blood pressure in 29.5 per cent of patients
receiving ergonovine but in only 11 per cent
receiving methylergonovine.

The usual dose of methylergonovine tartrate is
0.2 mg., intravenously, immediately following
delivery of the anterior shoulder or after delivery
of the placenta. If atony or bleeding persists,
the dose may be repeated at intervals of 2 to 4
hours. Orally, 0.2 mg. may be given 3 or 4 times
daily for subinvolution in the post-partum pe-
riod. Methergine tartrate is available in ampuls
of 1 ml. containing 0.2 mg., or tablets containing
0.2 mg.

Lysergic Acid Diethylamide. — Ergonovine
being a lysergic acid propanolamide, it was quite
natural that a number of derivatives of it should
be synthesized. One of these was lysergic acid
diethylamide which, while having activity on
the uterus, is of interest because of its psycho-
somatic actions (Solms, Schweiz. med. Wchnschr.,
1953, 83, 356). Its sedative action in a dose of
1 mg. by mouth is about equal to that of 1 to 3
Gm. of chloral hydrate. In normal humans, 0.25
mg., given orally, causes for about 15 minutes
irritative sensomotor and vegetative symptoms,
including salivation, tears, sweating, ataxia,
paresthesia and increased tendon reflexes. Then
there follows suddenly a schizophrenia-like psy-
chosis, persisting for about 90 minutes, with
asthenia, indifference, disturbance of volition and
depersonalization without sleep. Larger doses
cause hallucinations. Following this there is fa-
tigue and deep sleep. The drug has a desirable
sedative action on some cases of schizophrenia
or oligophrenia. Horita and Dille (Science, 1954,

120, 1100) observed that the substance produces
in normal rabbits, cats and dogs a rise in body
temperature following intravenous or subcutane-
ous administration (see also under Anhalonium,
in Part II).

Dose. — The usual dose of ergonovine maleate
is 0.2 mg. (approximately Vzoo grain) orally, in-
tramuscularly or subcutaneously, with a range
of dose of 0.2 to 0.5 mg. The maximum dose is
usually 0.5 mg., and the total dose in 24 hours
seldom exceeds 2 mg. The parenteral dose may
be repeated after 2 to 3 hours, if required; orally
the drug may be given 3 or 4 times daily.

Storage. — Preserve "in tight, light-resistant
containers." U.S. P.

ERGONOVINE MALEATE
INJECTION. U.S.P. (B.P., LP.)

[Injectio Ergonovinae Maleatis]

"Ergonovine Maleate Injection is a sterile
solution of ergonovine maleate in water for in-
jection. It contains not less than 90 per cent and
not more than 110 per cent of the labeled amount
of C19H23N3O2.C4H4O4." U.S.P.

For Injection of Ergotamine Maleate the cor-
responding limits of the B.P. are 85.0 and 110.0
per cent; those of the LP. are the same as the
U.S.P. limits. The B.P. directs adjustment of
the pH to 3.0 with maleic acid; the LP. requires
adjustment of pH between 2.7 and i.i without
specifying the acid to be used. Both pharma-
copeias direct the solution to be placed in ampuls
in which the air has been replaced by nitrogen,
and the sealed ampuls to be sterilized by heating
in an autoclave.

B.P. Injection of Ergometrine Maleate; Injectio Ergo-
metrinae Maleatis. LP. Injectio Ergometrini Maleatis.
Sp. Inyeccion de Maleato de Ergonovina.

Assay. — An accurately measured volume of
injection, representing 2 mg. of ergonovine male-
ate, is diluted to 50 ml. To a 1-ml. portion of
this solution, contained in a suitable tube, 1 ml.
of water and 4 ml. of />-dimethylaminobenzalde-
hyde T.S. are added and the mixture is allowed
to stand in subdued light for an hour. The result-
ing blue color is not lighter than that of a control
prepared with 0.9 ml. of a solution containing
4 mg. of dried Ergonovine Maleate Reference
Standard in 100 ml., nor darker than that of
another control prepared from 1.1 ml. of the
same standard solution. A photoelectric colori-
meter may be used for evaluation of the color,
in which case only one standard is necessary.
U.S.P. The B.P. and LP. utilize the same color
reaction in their respective assays.

Labeling. — "The label for Ergonovine Male-
ate Injection states an expiration date which is
not later than 2 years after the date of removal
for distribution from the manufacturer's place
of storage, which shall be maintained at a tem-
perature between 0° and 12°." U.S.P.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass. Preserve the Injection
at a temperature above 0° but preferably not
above 12°, and protected from light." U.S.P.

Usual Sizes. — 0.2 and 0.5 mg. in 1 ml.

516 Ergonovine Maleate Tablets

Part I

ERGONOVINE MALEATE TABLETS.
U.S.P. (B.P., LP.;

[Tabellae Ergonovinae Maleatis]

"Ergonovine Maleate Tablets contain not less
than 90 per cent and not more than 110 per cent
of the labeled amount of Ci9H^N;{02.C4H404."
U.S.P. The LP. provides the same limits, but
those of the B.P. are 85.0 and 1 10.0 per cent.

B.P. Tablets of Ergometrine Maleate. I. P. Compressi
Ergometrini Maleatis. Sp. Tabletas de Maleato de
Ergonovina.

Usual Sizes. — 0.2 and 0.5 mg. (approximately
}4)0 and V120 grain).

ERGOT. N.F., LP.

Rye Ergot, [Ergota]

"Ergot is the dried sclerotium of Claviceps
purpurea (Fries) Tulasne (Fam. Hypocreacea)
developed on plants of rye, Secale cereale Linne
(Fam. Graminece). Ergot yields not less than
0.15 per cent of the total alkaloids of Ergot cal-
culated as ergotoxine. and water-soluble alkaloids
equivalent to not less than 0.01 per cent of
ergonovine." N.F.

The LP. requires ergot (Latin title. Secale
Cornutum) to contain not less than 0.15 per cent
of total alkaloids, calculated as ergotamine, and
not less than 0.023 per cent of water-soluble alka-
loids, calculated as ergometrine. The LP. also
recognizes Standardized Powdered Ergot, requir-
ing 0.2 per cent (limits, 0.19 to 0.21) of total
alkaloids, calculated as ergotamine. and not less
than 0.030 per cent of water-soluble alkaloids,
calculated as ergometrine.

Mother of Rye; Spurred Rye; Horn-seed; Rye Smut.
Fungus Secalis; Clavus Secalinus. Fr. Ergot de seigle ;
Seigle ergote. Ger. Mutterkorn ; Hungerkorn; Roggen-
mutter; Kriebelkorn ; Schwarzkorn. It. Segale cornuta;
Grano speronato. Sp. Cornezuelo de centeno; Espolon de
centeno.

In all the Graminece., or grass family, and in
some of the Cyperacea, the place of the grains
or fruits is sometimes occupied by a morbid
growth which, from its resemblance to the spur
of a cock, has received the name of ergot,
adapted from the French. This product is most
frequent in the rye, Secale cereale, and from that
grain was adopted in the first edition of the
U.S.P., under the name of secale cornutum, or
spurred rye. In the edition of 1840 the name
was changed to ergota.

It is probable that this fungus infects a variety
of grasses and that many of the apparently dis-
similar ergots are specifically identical, their ap-
pearance being modified by the species of grasses
which they infest. Among the members of the
grass family whose ergots have been reported to
be ecbolic are the wild rice, wild rye. oats, wheat
and the Algerian diss (Ampelodesma tenax). The
ergot of wheat as well as rye is now being pro-
duced commercially in Minnesota and, according
to Youngken and associates (/. A. Ph. A., 1942,
31, 136), the alkaloidal content of these domestic
ergots is considerably higher than that reported
for Spanish and Russian ergots. For information
concerning the appearance of the ergots of wild
rice, wheat and diss see U.S.D., 22nd ed., p. 433.

Investigations of Tulasne have shown that
ergot represents the sclerotium of a fungus,
Claviceps purpurea Tulasne. This fungus has
three stages in its life history which is as follows:

In the spring or early summer the spores of
this fungus are conveyed by insects or air-cur-
rents to the young developing ovaries of the rye.
At the base of each ovary — where moisture oc-
curs during damp weather — they germinate into
filamentous hyphae which penetrate the tissues by
enzymic action. From here the hyphal filaments
spread over the pistil enveloping it except at the
summit and penetrating its outer coat. During
all this time the hyphae secrete enzymes which
decompose the outer tissues of the ovary into a
white, caseous mass called the sphacelia. The
ovary enlarges and its upper end takes on a
spongy appearance. This is due to the projec-
tion of twisted strands of hyphae which here ab-
strict off chains of oval conidiospores. A yellow
mucoid, saccharine exudate, issuing from the
hyphae and called honey dew. now envelops the
conidiospores. The honey dew attracts ants, flies,
weevils, etc.. which carry the spores to the ovaries
of other spikes of grain, so disseminating the dis-
ease. This terminates the sphacelia stage. At
the base of the sphacelia and later extending
upward through the ovarian substance, the hyphal
threads penetrate deeper and deeper into the inte-
rior of the ovary consuming its substance until
there ultimately forms a dense, compact tissue
(pseudo-parenchyma), violet black without and
whitish within, that eventually replaces the de-
veloping grain with a violet or purplish curved
body known as the sclerotium. This structure
represents the resting or sclerotial stage in the
life history of Claviceps and is collected as the
official ergot.

The ergot which is not collected falls to the
ground where, the following spring, it ' absorbs
moisture and sprouts into several stalked pro-
jections terminated by globular heads which are
called ascocarps or stromata. Each head de-
velops in its peripheral parts flask-shaped invagi-
nations called perithecia. From the base of each
perithecium several sacs or asci develop. Within
each of the latter there originate eight thread-
like spores called ascospores. When these are
mature the ascus ruptures and the ascospores are
discharged. They are carried by air-currents to
fields of grain, there to infect young ovaries and
begin new life cycles.

Ergot has nothing in common with normal
grain. The anatomical structure and all the physi-
cal characters of ergot are those of a sclerotic
mycelium. The pseudo-parenchyma, which is
whitish and brittle, consists in all its parts of
irregular, globular, or polyhedric thick-walled
cells, intimately united, and filled with a limpid
oil, but feebly colored by iodine. The superficial
mycelial layers, which are colored, have an outer
wall thicker than the inner, and the color of
these is what gives its characterisitc hue to ergot.
Not the least trace of starch is to be detected.
If ergot is planted in a suitable soil, evidences of
germination are seen in about three months.

Artificial infection of rye flowers by spraying
them with a suspension of conidiospores in water

Part I

Ergot 517

is practicable and is being increasingly utilized
in the production of ergot. Ergot grains (sclero-
tia), sown in autumn in boxes of earth and
exposed to the frosts of winter, germinate in the
spring, producing ascocarps which liberate asco-
spores. These quickly germinate on nutritive
gelatin and when transferred to suitable media
produce large numbers of conidiospores (conidia)
(Schweiz. Apoth.-Ztg., 1921, 59, 277). In 1951
approximately 220.000 pounds of ergot were
produced by artificial inoculation; in 1953 about
1000 pounds were similarly produced in Michi-
gan and Minnesota from rye.

The ergot usually projects out of the glume or
husk beyond the ordinary outline of the spike
or ear. In some spikes the place of the seeds is
wholly occupied by the ergot, in others only two
or three spurs are observed. It is said to be much
more energetic when collected before than after
harvest. Rye has generally been thought to be
most subject to the disease in poor and wet soils,
and in rainy seasons, and intense heat succeeding
continued rains has been said to favor its devel-
opment, especially if these circumstances occur at
the time the flower is forming. It is now, how-
ever, asserted that moisture has little or nothing
to do with its production.

Ergot is gathered in Spain, Galicia, Russia,
Austria and Germany, being either picked by
hand or threshed and separated from the rye by
special machinery. Ergot enters commerce
chiefly from Russia, Germany, and Spain. The
grains of the Spanish ergot are usually larger
than those of the German or Russian. Several
varieties of ergot are produced on a commercial
scale in Minnesota and neighboring states. These
are obtained not only from the rye plant but
also from various varieties of wheat. According
to Youngken and associates (/. A. Ph. A., 1942,
31, 136) the alkaloidal contents of these domestic
ergots average considerably higher than that re-
ported by Hampshire and Page for the Spanish
and Russian ergots. For detailed description of
these domestic ergots see the paper of Youngken
and associates.

Description. — "Ungroitnd ergot is a cylindra-
ceous, obscurely 3-angled, somewhat curved
sclerotium which usually tapers toward both ends,
the ends being more or less obtuse. The scle-
rotium is from 0.7 to 4.5 cm. in length and up
to 5 mm. thick. It is longitudinally furrowed,
occasionally transversely fissured, and is nearly
black or purplish brown externally. The fracture
is short and the internal color is usually white
although occasional sclerotia may be tinged with
pink, lavender, or gray. Ergot has a character-
istic odor free from mustiness or rancidity and
an only, somewhat acrid, disagreeable taste."
N.F. For histology see N.F. X.

"Powered ergot. — Powdered Ergot is grayish
to purplish brown. It contains fragments of the
outer tissue and of the thin-walled hyphal cells."
N.F.

Standards and Tests. — Identification. — One
Gm. of powdered ergot is shaken with 20 ml. of
ether and 15 drops of 20 per cent sulfuric acid
for 5 minutes; the mixture is filtered and the
filtrate shaken with 15 drops of cold, saturated

aqueous solution of sodium bicarbonate. A red
or violet color appears in the aqueous layer.
Purity. — No rancid or ammoniacal odor develops
on adding hot water to crushed or powdered ergot.
Seeds, fruits, and other foreign organic matter. —
Not over 4 per cent. Loss on drying. — Not more
than 8 per cent, when dried at 105° for 3
hours. N.F.

The internal color of ergot depends upon the
stage of development and the rapidity of its
drying. Young sclerotia, if examined immediately
after collection, show centrally a pearly white
mass of mycelial tissue surrounded by a violet
to bluish more compact outer layer. After the
sclerotia have matured the coloring matter of
the outer layer tends to penetrate slowly into the
inner mycelial tissue. This diffusion apparently
continues until drying renders the inner mass
too hard for further penetration. Sometimes
there is a tendency of the coloring matter to
pass toward the center along definite lines, prob-
ably because of some separation of the tissues
during the process of drying.

Deterioration. — It has long been known that
ergot loses much of its activity when kept. The
finding of Wood and Hofer (Arch. Int. Med.,
1910, 6, 388) that rapidity of deterioration was
largely determined by the degree of moisture
has been confirmed by Rowe (J. A. Ph. A., 1937,
26, 312), by Christensen and Reese (J. A. Ph. A.,
1939, 28, 343) and others. If the content of
moisture is less than 8 per cent the loss of potency
in 18 months is too slight to be measurable.
When drying ergot it is essential that the tempera-
ture in the drying oven does not rise above 45°.
Ergot is particularly liable to attacks by insects.

Old ergot which has been exposed to moisture,
either in transit or storage, usually possesses a
brownish to dark purple internal color; the color
is sometimes brightened by the use of a fixed
oil.

Assay. — The assay of ergot has been, through
the many years of official recognition of the
drug, a major research problem on which much
study was expended. For a long time biological
methods of assay were considered to be more
reliable than chemical procedures. The two
methods most frequently employed, prior to the
discover}' that the highly important water-soluble
alkaloid ergonovine was not quantitatively esti-
mated by either of them, was the cock's comb
test of Houghton, and the epinephrine reversal
method of Broom-Clark. The former method,
which was the official assay method as recently
as in U.S. P. XII, was based on the fact that a
fluid preparation of the ergot to be assayed
produced when injected into the breast muscle
of a white Leghorn cock a characterstic darken-
ing of the comb which was at least as intense
as that produced by a threshold dose of a
standard solution of ergotoxine ethanesulfonate.
The epinephrine-reversal method of Broom-
Clark (/. Pharmacol., 1923, 22, 59) was based
on the fact that what at that time was referred
to as the alkaloid ergotoxine (see discussion under
Constituents), and also ergotamine, destroyed
the sensitivity of the uterine muscle (of the
rabbit) for the stimulant effect of epinephrine.

518 Ergot

Part I

Both methods are described in some detail in
U.S.D., 24th ed., p. 421.

With the discovery of ergonovine chemical
methods have been developed to the point of
being able to determine, presumably with rea-
sonable accuracy as well as with precision, both
the content of total alkaloids and of ergonovine.
Final estimation of the alkaloids is based on the
fact that ergot alkaloids, in an acid aqueous
solution, yield with £anz-dimethylaminobenzalde-
hyde (Ehrlich's reagent) a blue color, the inten-
sity of which is compared with that produced
by a suitable standard, which in the present N.F.
is Ergonovine Maleate Reference Standard. The
complication is that only a small portion of the
alkaloids of ergot consists of ergonovine, and
while the result of the assay for water-soluble
alkaloid content may be reasonably expressed in
terms of ergonovine, it is hardly proper to express
the content of total alkaloids in terms of an
alkaloid which comprises only a small part of
the total. Inasmuch as for some years ergotoxine
ethanesulfonate, even though it may be a mix-
ture of alkaloids as is now known, was a satis-
factory standard for evaluation of ergot both by
chemical and certain biological assays, it was
natural that ergotoxine should have been selected
as the substance in terms of which the total
content of alkaloids would be expressed.

In the N.F. assay the total alkaloids of ergot
are extracted by what is essentially a conven-
tional procedure of alkaloidal assay; an aliquot
portion of a sulfuric acid solution of the alkaloids
is treated with ^-dimethylaminobenzaldehyde and
the resulting blue color is compared with that
produced by a solution containing Ergonovine
Maleate Reference Standard but the result is
expressed in terms of the equivalent amount of
ergotoxine. The determination of water-soluble
alkaloids is performed on another aliquot portion
of an acid solution of the total alkaloids; this
portion is made slightly alkaline with ammonia,
the "ergotoxine-like" alkaloids are extracted
with carbon tetrachloride (this solution is dis-
carded), after which the aqueous phase is satu-
rated with sodium chloride and the ergonovine
is extracted with ether. From the ether solution
the ergonovine is transferred to an acid solution,
in which the color with />-dimethylaminoben-
zaldehyde is developed and the intensity of the
color is evaluated. The LP. employs a simpler
modification of this assay.

Constituents. — Ergot contains, besides a
number of alkaloids which are characteristic of it,
also carbohydrates, lipids, amino acids, quater-
nary ammonium bases and various amines, and
dyes.

The physiologically active constituents are un-
doubtedly the several basic principles found in
the drug. Such constituents as choline, betaine
and trimethylamine contribute little, if anything,
to the therapeutic effect of the drug. The three
bases histamine, tyramine, and acetylcholine may
modify its action. The most important principles,
however, are six pairs of stereoisomeric alkaloids.
As knowledge of the complex system of alkaloids
of ergot unfolded it was quite natural that what
may have at first appeared to be a chemical in-
dividual would turn out to be a mixture of

alkaloids; also that different names would be
proposed for the same alkaloid by different in-
vestigators, and that when the pattern of the
relationship between the component alkaloids of
each pair was established some changes of nomen-
clature were desirable.

The first alkaloid was discovered by Tanret, in
1875, and was called ergotinine; in all likelihood
this is identical with the alkaloid ergocristinine,
to be described later. The alkaloid is physiologi-
cally practically inert. In 1906, Barger and Carr
in England, and Kraft in Germany, almost si-
multaneously announced discovery of a second
alkaloid; the former called it ergotoxine and
Kraft named it hydro ergotinine to indicate its
relation to Tanret's alkaloid. A third alkaloid,
designated ^-ergotinine, was for a time consid-
ered to be associated with the two others (Smith
and Timmis, /. Chem. S., 1931, 1888); this al-
kaloid is practically devoid of physiological
activity. It is generally accepted to be identical
with ergocorninine, also to be described later.
In 1937 Stoll and Burckhardt (Ztschr. physiol.
Chem., 1937, 250, 1) announced the isolation of
a new complex from the mother liquors after
crystallization of ergotoxine; this complex was
found to be a molecular compound of ergosinine
(see the following) and the new alkaloid ergo-
cristine, a levorotatory, physiologically active
alkaloid having the composition represented by
C35H39N5O5. On heating ergocristine in methanol
solution it is converted to its dextrorotatory, rela-
tively inactive stereoisomer ergocristinine. In
later experiments Stoll and Hofmann (Helv.
Chim. Acta, 1943, 26, 1570) showed that ergo-
toxine, although it had been obtained in crystal-
line form, was nevertheless not homogeneous
and consisted of a variable mixture of three
isomorphous alkaloids; these were ergocristine
and the two new levorotatory alkaloids ergocryp-
tine, C32H41N5O5, and ergocornine, C31H39N5O5.
Thus ergotoxine ceased to exist as a chemical
individual. The dextrorotatory counterparts of
ergocryptine and ergocornine, designated ergo-
cryptinine and ergocorninine respectively, were
obtained by boiling a methanol solution of the
levorotatory isomers. It appears now that ergo-
corninine is identical with the ip-ergotinine of
Smith and Timmis.

Earlier Stoll had isolated the alkaloid ergota-
mine, C33H35N5O5, a levorotatory compound,
almost insoluble in water, but physiologically
active (see Arch. exp. Path. Pharm., 1928, 138,
111); like the other levorotatory alkaloids it is
readily converted to a dextrorotatory stereoiso-
mer, called ergotaminine, which is physiologically
practically inert. An equimolecular mixture of
ergotamine and ergotaminine, at the time of its
separation considered to be a new alkaloid, has
been called sensibamine. The supposed chemical
individual ergoclavine, reported by Kussner
{Arch. Pharm., 1934, 44, 503), was subsequently
established as an equimolecular mixture of the
stereoisomers ergosine and ergosinine, C30H37-
N5O5, the former levorotatory and the latter
dextrorotatory (Smith and Timmis, /. Chem. S.,
1937, 6). Then Kharasch and LeGault (J.A.C.S.,
1935, 57, 1140) isolated an alkaloid which they
called ergotocin and almost simultaneously Dud-

Part I

Ergot 519

ley and Moir (Brit. M. J., April 6, 1935) an-
nounced a new alkaloid to which they gave the
name ergometrine, Thompson (/. A. Ph. A., 1935,
24, 24) reported an alkaloid which he called
ergostetrine, and Stoll and Burckhardt (Bull. sc.
Pharmacol., 1935, 42, 247) described the new
substance ergobasine. Soon afterwards these ex-
perimenters joined in expressing the opinion that
the four alkaloids were identical one with another
(Science, 1936, 83, 206). The Council on Phar-
macy and Chemistry of the American Medical
Association then suggested the name ergonovine
for this alkaloid, and this name has been adopted
in the United States. The alkaloid is levorotatory,
and physiologically active (see Ergonovine Male-
ate) ; its dextrorotatory stereoisomer, called
ergometrinine or ergobasinine, has been found
to be relatively inactive in its physiological effect.

An alkaloid, ergomonamine, having a composi-
tion represented by C19H19NO4, was reported
by Holden and Diver (Quart. J. P., 1936, 9,
230); it is sparingly soluble in water and in
ether and is differentiated from other ergot al-
kaloids by its not producing a blue color with
Keller's reagent or Ehrlich's reagent (see under
Assay). The substance cornutine, described by
Robert in 1884, is probably an artefact and is
not considered today as one of the principles
of ergot.

The six established pairs of stereoisomeric
alkaloids have been divided by Stoll (see Chem.
Rev., 1950, 47, 197) into three groups, based on
differences in chemical structure: (1) the ergota-
mine group, including the pairs ergotamine-ergota-
minine, and ergosine-ergosinine ; (2) the ergotoxine
group, including the pairs ergocristine-ergocristi-
nine, ergocryptine-ergocryptinine, and ergocornine-
ergocorninine ; (3) the ergobasine group, contain-
ing only the ergobasine (ergonovine) -ergobasinine
pair. The naturally occurring levorotatory alka-
loids of ergot all contain the tetracyclic compound
lysergic acid, C16H16N2O2, which behaves both
as an acid and a base, similarly to amino acids;
the isomeric dextrorotatory members of the
several pairs all contain isolysergic acid, which
is readily obtained by rearrangement of lysergic
acid, and vice versa. The alkaloids of the ergota-
mine and ergotoxine groups are polypeptides, in
which the lysergic acid or isolysergic acid is
joined to other amino acids; the ergobasine-
ergobasinine pair, however, have a simpler struc-
ture, with lysergic acid or isolysergic acid being
combined with the amino alcohol 2-amino-l-
propanol. Ergobasine has been synthesized from
lysergic acid and L-2-amino-l-propanol (Stoll
and Hoffmann, Helv. Chim. Acta, 1943, 26, 944);
lysergic acid was recently synthesized by Korn-
feld et al. (J.A.C.S., 1954, 76, 5256). It is note-
worthy that the presence of the indole group in
lysergic acid and isolysergic acid accounts for the
blue reaction with ferric chloride (Keller's re-
agent) given by all ergot alkaloids, except ergo-
monamine.

Uses. — The alkaloids of ergot, while differing
in their physiological actions, unite in increasing
the contractions of the pregnant uterus. "Ergo-
toxine" (which is now known to be a mixture
of isomorphous alkalkoids, as discussed under
Constituents) and ergotamine directly stimulate

all nonstriated muscles. A moderate and prolonged
increase in tone and amplitude of uterine con-
tractions is produced. The parturient uterus is
far more sensitive than other smooth muscles to
ergot. Much larger doses are required to stimu-
late the urinary bladder, the intestine and the
blood vessels. A rise in blood pressure results
from constriction of peripheral arteries; brady-
cardia is associated either as a reflex from the
peripheral vasoconstriction or as a result of the
inactivation of cholinesterase by ergot principles.
As discussed under Toxicology, capillary stasis,
thrombosis and gangrene may result. The ten-
dency to vascular damage varies with different
species; whereas it is difficult to produce in the
rat, the chicken is susceptible and the human is
very sensitive.

In large dose ergot depresses the excitatory
responses to epinephrine or to stimulation of
the sympathetic nerves; this gives rise to what
is known as the "vasomotor reversal"; that is, if
epinephrine is injected after the ergot the blood
pressure falls instead of rising. An analogous ef-
fect is the basis of the Broom-Clark assay method
described above. It does not prevent the release
of sympathin E or I (see under Sympathomimetic
Amines, in Part II) when the nerve is stimu-
lated but it blocks the response of the muscle or
gland cell to the augmentor effects of epinephrine
or the nerve stimulation (sympathin E). This
may be contrasted with atropine, which blocks
both the augmentor and the inhibitor effects of
stimulation of the parasympathetic nerves. In the
human, with clinically safe doses, this sympatho-
lytic action of "ergotoxine" or ergotamine seems
to be negligible, if it is present at all. With
therapeutic doses, action on the central nervous
system is unimportant but larger doses stimulate
the sympathetic centers.

"Ergotoxine" and ergotamine are very poorly
absorbed from the gastrointestinal tract; at least
four times the dose which is effective parenterally
is required and the response is unpredictable.
After intramuscular injection these alkaloids act
upon the uterus in about 20 minutes. The
alkaloids are metabolized in the liver (Kopet
and Dille, /. A. Ph. A., 1942, 31, 109).

The action of ergotamine seems to be quali-
tatively the same as that of "ergotoxine." Ergo-
novine differs, apparently, in that it has less
marked effect on the sympathetic nerves. The
action of ergonovine on the uterus is the same
as that of "ergotoxine" or ergotamine except
that it acts immediately after intravenous injec-
tion and within a few minutes after intramuscular
or oral administration. It is well absorbed from the
gastrointestinal tract. Its action on the uterus
persists for several hours; the duration is almost
as long as with ergotamine (Davis, Adair and
Pearl, J. A.M. A., 1936, 107, 261; Reich, Am. J.
Obst. Gyn., 1939, 37, 224). Ergonovine has very
little other effect on the human. It is not sympa-
tholytic and is only slightly stimulating to the
sympathetic nervous system; a slight rise in
blood pressure may be produced. Gangrene has
not been reported in the human with ergonovine
although it has in animals with large doses. It
is about one quarter as toxic as ergotamine. It

520

Ergot

Part I

produces cyanosis but not gangrene in the cock's
comb.

For description of the physiological actions of
the amines of ergot see Histamine Phosphate
(Part I) and Tyr amine (Part II).

When a dose of ergot fluidextract is injected
intravenously there occurs a rise in the blood
pressure, sometimes preceded by a transient fall,
and accompanied by a reduction in the rate of
the pulse. The elevation of the pressure is due
to a contraction of the blood vessels, the result
of a direct stimulant action upon their muscular
coats. The effect of a small dose of ergot upon
the uterus is to increase both the vigor of its
contraction, and its muscular tone. If the dose
is larger, the increase in muscle tone becomes
relatively more and more pronounced, until even-
tually the organ may be thrown into a perma-
nent spasmodic contraction.

On the continent of Europe ergot has long been
empirically employed by midwives for promoting
contraction of the uterus, and its German name
"Mutterkorn" implies the popular acceptance of
its characteristic powers. Ergot was first intro-
duced to the regular medical profession as the
result of the writings of Stearns in 1807. Its
injudicious use may do much harm, and even
prove fatal to either the mother or the child.
When used freely, ergot may transform the
normal intermittent contractions of the partu-
rient uterus into one violent spasm. If this spas-
modic contraction occurs too early in the course
of the birth process it may lead to asphyxiation
of the child, to wide lacerations of the birth
canal, or even to rupture of the uterus. In the
third stage of labor, however, no such accidents
can occur, and many obstetricians have recom-
mended routine use of ergot at this time, as a
prophylactic against postpartum hemorrhage.
Ergot was also used as a stimulant to the non-
pregnant uterus to check bleeding in menorrhagias
and metrorrhagias. (For discussion of the thera-
peutics of the ergot alkaloids see under
Ergotamine Tartrate and Ergonovine Maleate.)
Under the name of "ergotin," usually with
the name of the maker attached, several more
or less purified extracts of ergot were formerly
available. The doses of these varied according to
their potency. Bonjean's ergotin was made by
exhausting ergot with water, evaporating to the
consistency of syrup, precipitating the albumen,
gum, etc., with alcohol, decanting the clear liquid
and evaporating to the consistency of the soft
extract. A powdered form of this preparation
was also marketed.

Toxicology. — Acute Poisoning. — Ergot can
hardly be considered a poison, since an ounce
of the fluidextract rarely produces, except in
the pregnant, any obvious symptoms unless it
be nausea. Large doses may, it is true, produce
abortion in pregnant women, but even this result
is uncertain. Acute poisoning is rare. Death may
result from the abortion. The symptoms of the
recorded cases of poisoning have been paleness,
and. as most characteristic, an especial coldness
of the surface, partial paralysis with numbness
and tingling in the limbs, feebleness of the pulse,
restlessness, and finally stupor or delirium. Vom-
iting, diarrhea, thirst, fever, pruritus and cyanosis

may be present. Management consists of an
emetic or gastric lavage with a dilute solution of
tannic acid, purgation with magnesium sulfate
and administration of whisky, aromatic ammonia
spirit, etc.

Chronic Poisoning. — On the other hand,
long continued and free use of ergot is highly
dangerous, even when no immediate effects are
perceptible. Fatal epidemics in different parts of
the continent of Europe, particularly in certain
provinces of France, have long been ascribed to
the use of bread made from rye contaminated
with this fungus. An epidemic of ergotism oc-
curred in Russia after the cold wet summer of
1926. Epidemics have not occurred in the United
States. Ergotism appeared when there was 1 per
cent of ergot in the rye; an inadequate diet in-
creases the tendency to poisoning (see J. A.M. A.,
1945, 127, 1057). Dry gangrene, and disorder
of the nervous system attended with convulsions,
are the forms of disease which have followed the
use of this unwholesome food (see Barger, Ergot
and Ergotism, 1931).

The chronic poisoning of animals has been re-
investigated (Kaunitz. Am. J. Path., 1930. 6,
299; Arch. Int. Med., 1931, 47, 548; Arch. Surg.,
1932. 25, 1135; Fitzhugh, Nelson and Calvery.
/. Pharmacol., 1944, 82, 364). Vascular lesions
resembling thromboangiitis obliterans are pro-
duced in chickens but are not observed when
ergot is fed to the usual laboratory animals.
However, McGrath (Arch. hit. Med., 1935, 55,
942) produced vascular lesions in rats with in-
jections of 25 to 100 mg. of ergotamine tartrate
per Kg. of body weight. Male rats were more
susceptible and estrogenic substance diminished
the vascular damage. A high incidence of neuro-
fibromas in the ears of rats was reported by
Fitzhugh et al. (loc. cit.).

Clinically, chronic poisoning has occurred par-
ticularly in patients with sepsis or impaired liver
function. Von Storch (Med. Clin. North America,
1938, 22, 689) collected 42 instances of poison-
ing; 23 were in obstetrical cases and 11 in pa-
tients with hyperthyroidism; gangrene was
present in 21 cases and 8 died. The use of ergota-
mine tartrate for the pruritus of jaundice has
resulted in gangrene (Vater and Cahill. JAMA.,
1936, 106, 1625). Lewis (Clin. Sc, 1935, 2, 43)
ascribed the necrosis in the cock's comb to stasis
resulting from constriction of the arteries with
dilatation of their capillaries. Histological exami-
nation (Kaunitz, loc. cit.) showed injury and
proliferation of the intima of the arteries fre-
quently associated with thrombosis and at times
recanalization of the thrombus; sclerotic and
hyalin degeneration of the arteries was ob-
served; the overlying skin showed changes simi-
lar to scleroderma and dermatomyositis; gan-
grene was the end result. In the human the
vascular changes commence in the toes and may
involve the fingers. Angina pectoris has been re-
ported; tachycardia or bradycardia and elevation
or depression of the blood pressure have been
recorded. Other manifestations have been head-
ache, nausea, vomiting, diarrhea, vertigo, weak-
ness, formication, drowsiness and convulsions.
Miosis, hemiplegia and tabetic-like conditions
have been reported.

Part I

Ergotamine Tartrate 521

Management of such poisoning consists of
discontinuance of the ergot preparation and use
of vasodilator measures. Perlow and Bloch {J. A.
M.A., 1937, 109, 27) reported recovery when 30
mg. of papaverine hydrochloride was given in-
travenously or orally every 4 hours. Acetyl-3-
methylcholine chloride or nitroglycerin is indi-
cated. The involved extremities should be kept
cool, but not refrigerated, while the rest of the
body may be kept warm to favor peripheral
circulation; other physical therapeutic measures
are indicated. Atropine is indicated for nausea
and vomiting; weakness and pain in the extremi-
ties without obvious vascular changes may be
relieved by massage, exercise and intravenous
injections of calcium gluconate.

The contraindications for the use of ergot or
its alkaloids are: pregnancy and the first and
second stages of labor, severe or persistent sepsis,
peripheral vascular disease, hepatic or renal dis-
ease with impaired function. The use of ergot
or its alkaloids is not justified for the following:
internal hemorrhage other than from the uterus,
pneumonia, pulmonary edema, typhoid fever,
diabetes insipidus, night sweats as in tuberculosis
or other conditions, peripheral circulatory col-
lapse.

Prior to the availability of ergonovine maleate,
ergot fluidextract was in general use in obstetrics
because it was effective on oral administration
and because its action was more rapid than that
of ergotamine or ergotoxine. A sterile preparation
of the same potency as the fluidextract was given
intramuscularly in doses of 1 to 2 ml. at the
time of injection of posterior pituitary solution
in the third stage of labor. In doses of 1 to 2 ml.
three times daily the fluidextract was used orally
to promote involution of the uterus during the
puerperium. 53

Dose. — Ergot has been given in doses of 150
mg. to 1 Gm. (approximately 2}4 to 15 grains);
the maximum dose in 24 hours has been given as
5 Gm.

Storage. — "Preserve Ergot in a dry place
under all conditions of storage and transporta-
tion." N.F.

ERGOT FLUIDEXTRACT. N.F.

[Fluidextractum Ergotae]

Pack 1000 Gm. of ergot, recently ground to a
coarse powder, in a cylindrical percolator, and
slowly percolate with petroleum benzin until a
few drops of percolate leave no greasy stain on
evaporation from filter paper; dry the defatted
drug in air until the odor of benzin is no longer
apparent. Prepare a fluidextract from the de-
fatted drug, by Process C (see under Fluid-
extracts), using a menstruum of 2 volumes of
hydrochloric acid and 98 volumes of diluted
alcohol. Macerate the drug during 48 hours and
obtain 1000 ml. of finished fluidextract. A fluid-
extract may alternately be prepared from ergot
by Process C, using the menstruum employed in
the foregoing procedure, but chilling the 1000 ml.
of combined reserve percolates to —14°, removing
the congealed fat by filtration at —14°, and finally

adding enough of the mentsruum to make 1000
ml. N.F.

Alcohol Content. — From 37 to 42 per cent,
by volume, of C2H5OH. N.F.

Some years ago considerable significance was
attached to the findings of the then U.S. P. assay
for ergot fluidextract as an indication of the
probable clinical value of the preparation; the
discovery of ergonovine has served largely to dis-
credit that assay and none is required by the
N.F. at present. Though the use of ergot and
various preparations of the whole drug has ma-
terially decreased since the several pure alkaloids
have been available, so long as the former are
officially recognized it would appear that one of
the several methods which have more recently
been proposed for the assay of ergot would be
better than none at all. Powell et al. (J. A. Ph. A.,
1941, 30, 255), who proposed a method for de-
termining both ergonovine and the ergotoxine-
like alkaloids of ergot, showed that there is a
wide variation in the potency of official ergot
fluidextract; the ergonovine content of samples
they tested varied from 2.5 to 18.2 mg. per 100
ml. and the ergotoxine-like alkaloids content
varied from 12 to 70 mg. per 100 ml.

A further disadvantage of ergot fluidextract is
its instability. Control of pH, storage at low
temperature, and avoidance of exposure to air
are all factors which retard, but do not avoid,
deterioration. Here again, the advantage is with
the relatively stable preparations of the pure
ergot alkaloids.

Incompatibilities. — This preparation has an
acid reaction due to the hydrochloric acid used
in the menstruum. Since this acidity is essential
to the stability of the product alkaline substances
are incompatible with it.

The N.F. usual dose of ergot fluidextract is
2 ml. (approximately 30 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
and to excessive heat." N.F.

ERGOTAMINE TARTRATE.
U.S.P., B.P., LP.

[Ergotaminium Tartrate]

H CH,

C4H40«

"Ergotamine Tartrate contains not less than
97 per cent of (CsaHssNsOs^.GiHeOe, calcu-
lated on the dried basis." U.S.P.

The B.P. defines this compound as the tartrate
of an alkaloid, ergotamine, obtained from certain
species of ergot; no assay rubric is provided. The
LP. gives the formula of ergotamine tartrate as
(CaaHssNsOsh.CiHcOe^CHsOH, indicating that
the substance contains two molecules of methanol

522 Ergotamine Tartrate

Part I

of crystallization; no assay rubric is provided.

Gynergen (Sando:). Sp. Tartrato de Ergotamina.

Ergotamine tartrate may be prepared by re-
action between ergotamine and tartaric acid in
alcoholic solution. To extract the ergotamine
Stoll's process may be used; in this ergot is
defatted, in the presence of the weakly acid alu-
minum sulfate, with ether or benzene, the drug
alkalinized and again extracted with either of
these solvents; upon evaporation of the solution
crystalline ergotamine may be obtained from the
residue and purified by crystallization from aque-
ous acetone solution. Smith and Timmis (/.
Chem. S., 1930, p. 1390) found that ergot from
Festura grasses is likely to give better yields
of ergotamine; they reported details of a method
for isolating this alkaloid in pure form.

Description. — "Ergotamine Tartrate occurs
as colorless crystals or as a white, crystalline
powder. It melts at about 180° with decomposi-
tion. One Gm. of Ergotamine Tartrate dissolves
in about 500 ml. of water and in 500 ml. of al-
cohol." U.S. P. The B.P. states that it softens at
about 187° and decomposes at about 192° with-
out melting.

Standards and Tests. — Identification. — (1)
A blue color with a red tinge develops on slowly
adding, while cooling the mixture, 1 ml. of sul-
furic acid to 1 ml. of a solution of 1 mg. of
ergotamine tartrate in a mixture of 5 ml. of
glacial acetic acid and 5 ml. of ethyl acetate; on
adding 0.1 ml. of ferric chloride T.S. diluted
with 0.1 ml. of water, the red tinge becomes less
apparent and the blue color more pronounced.
(2) A deep blue color develops on slowly adding
2 ml. of dimethylaminobenzaldehyde T.S. to 1
ml. of a solution of 1 mg. of ergotamine tartrate
in 5 ml. of a 1 in 100 solution of tartaric acid.
Specific rotation of ergotamine base. — Not less
than —150° and not more than —160°, in chloro-
form solution. Loss on drying. — Not over 5 per
cent, when dried at 60° in vacuum for 4 hours.
U.S.P. The B.P. and LP. provide a test for
absence of foreign substances, these being ex-
cluded by specifying certain physical character-
istics of ergotamine base separated in the test. The
B.P. and LP. both limit loss on drying to 5.0 per
cent, the former compendium specifying that
ergotamine tartrate be dried to constant weight
at 105°, the latter that it be dried to constant
weight at 100°.

Assay. — An aliquot portion of an aqueous
solution of ergotamine tartrate, representing 0.05
mg. of the salt, is treated with /(-dimethylamino-
benzaldehyde T.S. and the intensity of the blue
color is compared, in a photoelectric colori-
meter, with that of a solution of Ergonovine
Maleate Reference Standard, similarly treated.
U.S.P.

Uses. — Oxytocic Action. — As described un-
der Ergot, the physiological effects of ergota-
mine are qualitatively not distinguishable from
those of "ergotoxine" ; it is, however, slightly
less toxic. It was introduced originally for the
purpose of providing a crystalline principle, which
would produce the characteristic effects of ergot,

suitable for parenteral injection. It has been used
to a considerable extent as a stimulant of the
uterus either during labor or in the treatment
of other uterine hemorrhages. It was injected
intramuscularly at the end of the second stage
of labor at the same time as posterior pituitary
solution was injected for immediate action. More
recently it has been combined with 0.125 mg.
of ergonovine maleate with the same idea, but
the duration of action of ergonovine is almost
as long as that of ergotamine.

Migraine. — Maier (Rev. neurol., 1926, 33,
1104) recommended ergotamine for the relief
of migraine. It has proved so efficacious for this
purpose (von Storch, Med. Clin. North America,
1941, 25, 1317) that its uterine effects have
become of secondary interest. Carter (J.A.M.A.,
1940, 114, 2298), after review of the literature
and from his own personal experience, concluded
that it is the most effective agent known for
symptomatic relief of migraine, although it is
of little use in other types of headache. In fact
it may cause headache. The benefit in migraine
is not due ot a sympatholytic action because
this action of the alkaloid does not occur with
therapeutic doses. Furthermore, the pain phase of
migraine is associated with dilatation rather than
spasm of the cranial arteries; arterial spasm oc-
curs transiently in some cases at the onset of the
attack at the time of the visual scotomata.
Ergonovine, which has no sympatholytic action, is
effective in the treatment of migraine. Decreased
pulsation in the temporal artery has been corre-
lated with the relief of headache induced by
ergotamine (Graham and Wolff, Arch. Neurol.
Psychiat., 1938, 39, 737; Wolff, Trans. A. Am.
Phys., 1938, 53, 93).

The smallest effective dose should be employed
and the patient should lie down in a quiet and
darkened room for 2 hours after the medication.
The earlier ergotamine is given in an attack the
smaller is the dose required and the more rapid
is the effect; during the prodromal period oral
administration may prove effective (Charles,
Postgrad. Med., 1950, 7, 33). When the attack
is well established, ergotamine may fail to con-
strict the distended and thickened arteries
(Torda and Wolff, Arch. Neurol. Psych'at., 1945,
53, 329) and much larger doses are required to
produce much slower relief. Intramuscular ad-
ministration is preferred as it produces much
more certain and more rapid relief. Von Storch
(loc. cit.) reported relief in 90 per cent of at-
tacks and no effect on the frequency of attacks.
Atkinson (/. M. Soc. New Jersey, 1944, 41, 11),
however, claimed that ergotamine therapy in-
creased the frequency of attacks in some patients.
It is not used regularly as a preventive measure
because of the infrequency of attacks and the
danger of ergotism. Perelson (J.A.M.A., 1944,
125, 92) reported relief of attacks of persistent,
throbbing abdominal pain with tenderness of the
abdominal aorta in allergic patients with ergota-
mine tartrate. Von Storch (J. A.M. A., 1938, 111,
293) advised great caution in using it with pa-
tients having arteriosclerosis, scurvy, or diseases
of the kidney or liver, and that early doses should

Part I

Ergotamine Tartrate 523

be small until the sensitivity of the individual
patient be determined.

Better results have been reported to follow use
of a tablet containing 100 mg. of caffeine and
1 mg. of ergotamine tartrate (Caj ergot Tablets,
N.N.R., Sandoz) ; 3 tablets were taken during the
aura before the migraine headache and then 1
tablet every 30 minutes for as many as 3 doses if
needed (Cohen and Criep, New Eng. J. Med.,
1949, 241, 896; Ryan, /. Missouri M. A., 1950,
47, 107). Rectal suppositories containing 2 mg.
of ergotamine tartrate and 100 or 200 mg. of
caffeine were used in 57 cases of migraine with
excellent relief in 62 per cent of them and good
effect in 21 per cent (Magee et al., Neurol., 1952,
2, 477); patients were of the opinion that sup-
positories were more promptly effective, with less
side effects (nausea) than with tablets adminis-
tered orally. Only 4 out of 20 cases with histaminic
cephalgia and not one of 23 with tension headache
were relieved. An aerosol of 0.5 to 1 mg. of
ergotamine tartrate was used effectively in some
cases by Tabart (Presse med., 1950, 58, 1351).

Adrenergic Blocking Action. — Under the er-
roneous impression that ergotamine had useful
sympatholytic action in humans, it was employed
in several conditions in which there is hyperactiv-
ity of the sympathetic nervous system. In hyper-
thyroidism the results have been poor and ergot-
ism has been frequent. Griffith and Comroe (/.
Pharmacol., 1940, 69, 34) found that rats under
the influence of thyroxin are more susceptible to
ergotamine, and advised, therefore, caution in its
use in thyrotoxic patients. Heath and Powder-
maker (J.A.M.A., 1944, 125, 111) advocated 2
mg. of ergotamine tartrate every 3 hours by
mouth for ten days in the treatment of "acute
battle reaction" characterized by jitteriness,
tremor, empty sensation in the stomach, thump-
ing in the head, palpitation, perspiration and in-
somnia. Grinker and Spivey (J.A.M.A., 1945,
127, 159) reported failure with this therapy in
instances of fatigue with sympathetic overactivity
and toxic effects occurred with this dose. The
rational of its use in certain psychoses, epilepsy,
hypertension and cord bladder is also question-
able. Although it may be effective in postural
hypotension, ephedrine, etc., are safer remedies.
See also the discussion of hydrogenated ergot
alkaloids in the article on Adrenergic Blocking
Agents, in Part II.

Miscellaneous. — Ergotamine is often effective
in the relief of generalized pruritus in jaundice,
leukemia, Hodgkin's disease and uremia. Patients
with liver and kidney disease, however, tolerate
the drug poorly. In questionable cases of rheu-
matic fever an intravenous injection of 0.5 mg.
has been used to bring out the diagnostic pro-
longation of the "P-R" interval; tracings were
taken 30 and 60 minutes after the injection (Proc.
Soc. Exp. Biol. Med., 1945, 58, 303). S

Toxicology. — In proper dosage and in the
absence of contraindications (see under Ergot),
ergotamine is a relatively safe drug, although in
larger doses effects characteristic of ergotism
may appear. Untoward effects were reported in
13 of 19 cases in which large and frequently re-
peated doses were given for headache (Peters and

Horton, Proc. Mayo, 1951, 26, 153); a case of
ischemic neuritis in the leg and one of angina
pectoris were described. Dependency on ergot-
amine was found in 7 cases with headaches, but
no nausea or vomiting when the drug was discon-
tinued. A case of intermittent claudication in a
woman who had received subcutaneous injections
for headaches during 8 years was described
(Thompson et al., Arch. Int. Med., 1950, 85,
691) ; the symptoms were relieved by intravenous
administration of 140 mg. of sodium nicotinate.

Dihydroergotamine. — Seeking to find a drug
which could be used for treating migraine with-
out incurring the toxic reactions manifested by
ergotamine, Horton et al. (Proc. Mayo, 1945, 20,
241) investigated the derivative dihydroergot-
amine (D.H.E.-4S, Sandoz), commonly employed
as the methanesulfonate salt. In a comparative
study of ergotamine tartrate and dihydroergot-
amine on 120 patients, the latter compound was
found to be just as effective as the former in
relieving acute attacks of headache, and gave rise
to toxic reactions with but one-third the frequency
of ergotamine. Friedman and Friedman (Ohio
State M. J., 1945, 41, 1099) injected 1 mg. of
the dihydroergotamine salt intramuscularly in 20
patients during attacks of migraine and reported
dramatic relief in 18 patients within 20 to 30
minutes; no undesirable side effects were ob-
served. Hartman (Ann. Allerg., 1945, 3, 440) re-
ported results almost as good. Unlike ergotamine,
the dihydro derivative does not cause blanching or
pain in the extremities.

While dihydroergotamine has been described
as having no uterine effect, Baskin and Crealock
(West. J. Surg. Obst. Gyn., 1950, 58, 302) re-
ported shortening of both the first and second
stages of labor, with no untoward effects, follow-
ing intravenous administration of 1 mg. of the
compound when the cervix had dilated to 5 to 6
cm. in diameter (meperidine was also used to
relieve intestinal cramps after this dose). An initial
decrease, followed by a steady increase in uterine
contractions and uterine work during early stages
of labor, in either the primipara or multipara,
followed intravenous administration of dihydro-
ergotamine in a dose of 0.002 mg. per Kg. of body
weight, injected at a rate of 0.1 mg. in 30 minutes
of a solution containing 1 mg. in 500 ml. of 5 per
cent dextrose (Bruns et al., Obst. & Gynec, 1953,
1, 188). With a dose of 0.02 mg. per Kg. uterine
contractions were greatly increased. In single in-
travenous doses of 0.25 to 1 mg. dihydroergot-
amine has the same action, indications and contra-
indications as pituitary extract or other active
oxytocic drug. Except as an oxytocic in the third
stage of labor, a dose of 0.002 mg. per Kg., intra-
venously, should not be exceeded during preg-
nancy. Benefit in roentgen illness following
administration of dihydroergotamine has been
reported (Werner, Schweiz. med. Wchnschr., 1953,
83, 431).

Dose. — The usual dose of ergotamine tartrate
is 2 mg. (approximately Ho grain), by mouth,
followed by 1 mg. every 30 minutes; the range of
dosage is 1 to 6 mg. The maximum safe dose is
6 mg., and the total dose in 24 hours is seldom
more than 10 mg. Intramuscularly the usual dose

524 Ergotamine Tartrate

Part I

is 0.25 mg., which may be repeated in an hour if
necessary; the range of dosage by this route is
0.25 to 0.5 mg., with a maximum safe dose of
0.5 mg.

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S.P.

ERGOTAMINE TARTRATE
INJECTION. U.S.P. (B.P., LP.)

"Ergotamine Tartrate Injection is a sterile
solution of ergotamine tartrate in water for in-
jection. It contains not less than 90 per cent and
not more than 110 per cent of the labeled amount

Of (C33H35N505)2.C4H606." U.S.P.

The B.P. defines Injection of ergotamine tar-
trate as a sterile solution of ergotamine tartrate
in injection of sodium chloride, the acidity of the
solution being adjusted to pH 3.5 by addition of
tartaric acid, the solution placed in ampuls the
air in which is replaced by nitrogen, and the
ampuls sterilized by heating in an autoclave; the
content of ergotamine tartrate is not less than
90.0 per cent and not more than 110.0 per cent
of the labeled amount.

The LP. injection is defined as a sterile solu-
tion of ergotamine tartrate in water for injection,
containing not less than 90.0 per cent and not
more than 110.0 per cent of the labeled content
of ergotamine tartrate, calculated as (C33H35-
OoNo)2.C4H606.2CH30H. The solution is directed
to be sterilized by adding 0.2 per cent w/v of
chlorocresol or 0.002 per cent w/v of phenyl-
mercuric nitrate and heating at 98° to 100° for
30 minutes, or by bacteriological filtration.

All three pharmacopeias require the pH of the
solution to be between 3 and 4, and also specify
assay of the solution by the reaction summarized
under Ergotamine Tartrate.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." U.S.P.

Usual Sizes. — 0.25 mg. in 0.5 ml.; 0.5 mg.
in 1 ml.

ERGOTAMINE TARTRATE
TABLETS. U.S.P. (B.P., LP.)

"Ergotamine Tartrate Tablets contain not less
than 90 per cent and not more than 110 per cent
of the labeled amount of (C33H3oN50s)2.-
C4H.6O6." U.S.P. The B.P. and LP. limits are
identical with this, except that the LP. rubric is
in terms of ergotamine tartrate containing 2 mole-
cules of methanol of crystallization.

B.P. Tablets of Ergotamine Tartrate. LP. Compressi
Ergotamini Tartratis.

Usual Sizes. — 1 mg.

ERIODICTYON. N.F.

Yerba Santa, [Eriodictyon]

Eriodictyon is the dried leaf of Eriodictyon
californicum (Hooker et Arnott) Torrey (Fam.
Hydrophyllacece)." N.F.

Mountain Balm; Gum Bush; Bear's Weed. Sp.
Yerbasanta.

Eriodictyon californicum is a low evergreen
shrub growing abundantly upon dry hills in Cali-

fornia. It is glabrous, resinous, having alternate,
short petiolate, long lanceolate leaves, irregularly
more or less serrate, whitened beneath between
the reticulations by a minute and close tomen-
tum. glabrous above. The corolla is tubular fun-
nel-form, violet or white in color; the calyx being
sparsely hirsute. The fruit is a 2-celled capsule.
The commercial supplies of eriodictyon come
from California.

E. tomentosum, which grows often along with
E. californicum, especially in the southern part of
California, is readily distinguished by its dense
coat of short villous hairs, whitish or rusty-col-
ored with age. It is also a larger shrub than
E. californicum, has its corolla somewhat salver-
form, and its leaves oblong or oval, and obtuse.

Description. — "Unground Eriodictyon usually
occurs in fragments, but when it is entire the leaf
is lanceolate, from 5 to 15 cm. in length and from
1 to 3 cm. in breadth. The apex is acute and the
base tapers slightly into a short petiole. The
margin is irregularly serrate or crenate-dentate.
The upper surface is weak brown to moderate
olive-brown, and is covered with a more or less
glistening resin while the lower surface is yel-
lowish brown to weak greenish yellow, reticulate
with conspicuous veins, and minutely tomentose
between the reticulations. The leaf is quite thick
and brittle. Eriodictyon has an aromatic odor and
a balsamic, bitter taste which becomes sweetish
and slightly acrid." N.F. For histology see N.F. X.

"Powdered Eriodictyon is yellow. It contains
unicellular, undulate, thick-walled, non-glandular
hairs up to 250 \i in length and up to 10 \x in
width; glandular hairs with 1- to 3-celled stalks
and multicellular heads consisting usually of 8
cells, the heads being up to 120 \i in diameter;
fragments of palisade tissue containing regularly
arranged columnar parenchyma cells, most of
which contain a rosette aggregate of calcium
oxalate; and tracheae with spiral thickenings or
simple pores usually associated with lignified
fibers. The calcium oxalate rosette aggregates are
numerous and are from 5 to 30 n in diameter."
N.F.

Standards and Tests. — Stems. — Not over 5
per cent. Foreign organic matter. — Not over 2 per
cent other than stems. Acid-insoluble ash. — Not
over 2 per cent. N.F.

Constituents. — Mohr (Am. J. Pharm., 1879,
549) found in eriodictyon tannic acid, also an
acrid, bitter resin, upon which its activity is be-
lieved to depend, and a small amount of volatile
oil. Power and Tutin (Proc. A. Ph. A., 1906,
209) and Tutin and Clewer (/. Chem. S., 1908,
95, 81) reported the constituents eriodictyol,
homoeriodictyol, triacontane, penta-triacontane,
xanthoeridol, chrysoeriol and eriodonol as being
present. Homoeriodictyol (4'.5,7-trihydroxy-3'-
methoxyflavanone), C16H14O6. is a methyl deriva-
tive of eriodictyol (3',4'5.7-tetrahydroxyflava-
none), C15H12O6, and is also isomeric with hes-
peretin (3'5,7-trihydroxy-4'-methoxyflavanone),
which substance is the aglycone of hesperidin, a
constituent of the peel of citrus fruits. A further
relationship of interest is that citrin, also known
as vitamin P and obtained from citrus fruits, con-
sists of hesperidin (a rhamnoglucoside of hes-

Part I

Erythrityl Tetranitrate Tablets 525

peretin), eriodictyol rhamnoside, and quercitrin.
Both eriodictyol and homoeriodictyol have been
synthesized.

Uses. — Eriodictyon has long been used in
California as a bitter tonic, and also as a stimu-
lant balsamic expectorant. It is claimed to be
useful in asthma and chronic bronchitis; also in
chronic inflammation of the genitourinary tract.
In cases of asthma, eriodictyon has been some-
times used by smoking.

In 1879 Kier called attention to the remark-
able power of eriodictyon of masking the taste
of quinine. Eriodictyon is similarly effective for
many other bitter medicines. Fantus and Dynie-
wicz (/. A. Ph. A., 1933, 22, 323) attributed
this property to the power of its resin to adsorb
basic substances. They found that the adsorptive
power is selective, as the drug will not lessen
the bitterness of acidic drugs, such as barbital,
nor remove acid dyes from solution. They ob-
served that 1 ml. of the fluidextract will markedly
mitigate the bitterness of 40 mg. of quinine hydro-
chloride. The taste-masking effect is too slight to
be completely effective against such intensely
bitter substances but it is useful to mask the
bitterness of the less soluble salts of quinine. The
aromatic syrup is an especially useful vehicle.

Dose, 1 to 4 Gm. (approximately 15 to 60
grains).

ERIODICTYON FLUIDEXTRACT.
N.F.

Yerba Santa Fluidextract, [Fluidextractum Eriodictyi]

Prepare the fluidextract from eriodictyon, in
moderately coarse powder, by Process A (see
under Fluidextracts) , using a menstruum of 4
volumes of alcohol and 1 volume of water.
Macerate the drug during 48 hours, and percolate
at a moderate rate; reserve the first 800 ml. of
percolate. N.F.

Alcohol Content. — From 57 to 62 per cent,
by volume, of C2H5OH. N.F.

Dose, 1 to 4 ml. (approximately 15 to 60
minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

Off. Prep. — Aromatic Eriodictyon Syrup, N.F.

AROMATIC ERIODICTYON SYRUP.

N.F.

Aromatic Yerba Santa Syrup, Syrupus Corrigens,
[Syrupus Eriodictyi Aromaticus]

Dissolve 0.5 ml. of sassafras oil, 0.5 ml. of
lemon oil, and 1 ml. of clove oil in 32 ml. of alco-
hol, add 32 ml. of eriodictyon fluidextract and
65 ml. of compound cardamom tincture, then 25
ml. of potassium hydroxide solution (1 in 20),
and 325 ml. of purified water. Add 5 Gm. of
magnesium carbonate, shake the mixture, allow
it to stand overnight, filter, and add enough puri-
fied water through the filter to make 500 ml.
Pour this liquid upon 800 Gm. of sucrose con-
tained in a bottle, and effect solution by placing
the bottle in hot water, agitating the mixture fre-
quently. Cool the solution, and add enough puri-
fied water to make 1000 ml. N.F.

Alcohol Content. — From 6 to 8 per cent, by
volume, of C2H5OH. N.F.

Uses. — Although eriodictyon has some expec-
torant effect this syrup is more useful as a vehicle
for bitter drugs. Fantus et al. (J. A. Ph. A., 1933,
22, 323) found the syrup to be excellent for dis-
guising the taste of quinine and strychnine (see
also under Uses of Eriodictyon). The syrup is
slightly alkaline in reaction and is incompatible
with acids and acid-reacting salts, these substances
usually precipitating resin from the syrup. Be-
cause it also contains tannin, the syrup is in-
compatible with iron salts.

The N.F. assigns a dose of 8 ml. (approximately
2 fluidrachms).

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." N.F.

ERYTHRITYL TETRANITRATE
TABLETS. N.F.

Erythrol Tetranitrate Tablets, Tetranitrol Tablets,
[Tabellae Erythritylis Tetranitratis]

"Erythrityl Tetranitrate Tablets contain not
less than 93 per cent and not more than 107 per
cent of the labeled amount of erythrityl tetra-
nitrate (C4H6N40i2)."Ar./;'.

The alcohol erythritol or erythrol is tetrahy-
droxybutane, CH2OH.CHOH.CHOH.CH2OH. It
occurs free in the alga Protococcus vulgaris and
in many lichens it occurs as an ester of orsellinic
acid, from which it may be liberated by saponifi-
cation. Erythritol may be synthesized from buta-
diene. Erythrityl tetranitrate may be prepared by
reacting erythritol with concentrated nitric acid,
afterwards adding sulfuric acid. The tetranitrate
is too explosive to handle with any degree of
safety unless it has been mixed with a diluent,
such as lactose.

Erythrityl tetranitrate should not be confused
with the related and similarly employed compound
pentaerythrityl tetranitrate, which is described
under this title in Part II.

Standards and Tests. — Solubility. — The tab-
lets are partially soluble in alcohol and in ether
(erythrityl tetranitrate), and are partially soluble
in water (lactose). Identification. — (1) The resi-
due obtained in the assay melts between 60° and
61°. Caution — The erythrityl tetranitrate used
in this test may explode on percussion. The oper-
ator must be protected by a glass screen while
determining the melting point. (2) A solution of
about 10 mg. of the residue obtained in the assay
in 1 ml. of distilled water and 2 ml. of sulfuric
acid, cooled, then overlaid with 3 ml. of ferrous
sulfate T.S. produces a brown color at the junc-
tion of the two liquids. N.F.

Assay. — A representative sample of tablets,
carefully powdered, equivalent to about 250 mg.
of erythrityl tetranitrate, is extracted with ether,
which dissolves the erythrityl tetranitrate. The
ether extracts are filtered through paper, the fil-
trate evaporated to dryness at a temperature not
above 35°, the residue dried over sulfuric acid in
a vacuum desiccator for 18 hours, and the residue
of erythrityl tetranitrate weighed. N.F.

Incompatibility. — As pure erythrityl tetra-
nitrate explodes on percussion it is advisable not
to triturate it with other substances.

526 Erythrityl Tetranitrate Tablets

Part I

Uses. — Erythrityl tetranitrate does not differ
qualitatively in its physiological action from the
nitrites (see Sodium Nitrite); it is somewhat
less potent in vasodilating action but has decidedly
more prolonged effect. Maximal effect following
oral administration is attained in 20 to 25 min-
utes, too slow to be useful in attacks of angina
pectoris, and lasts upwards of 3 to 4 hours.

Erythrityl tetranitrate is used to lower blood
pressure in various circulatory disturbances when
a constant effect is desired. It is not a very effec-
tive dilator of peripheral vessels. It is sometimes
useful at bedtime to prevent nocturnal attacks
of angina pectoris. Tolerance develops more
rapidly from erythrityl tetranitrate than from
sodium nitrite but more slowly than from glyceryl
trinitrate (Loewenhart, J. Pharmacol., 1931, 41,
103). Erythrityl tetranitrate causes headache in
some cases. Prolonged use may result in methemo-
globinemia. It is commonly administered in tablet
dosage form.

The usual dose of erythrityl tetranitrate is 30
mg. (approximately x/> grain), with a range of 15
to 60 mg., given in tablets every 4 to 6 hours.

Storage. — Preserve "in well-closed contain-
ers." N.F.

Usual Sizes. — % and y2 grain (approximately
15 and 30 mg.).

ERYTHROMYCIN. U.S.P.

"Erythromycin is an antibacterial substance
produced by the growth of Streptomyces erythreus
Waksman. It contains not less than 85 per cent of
ervthromycin. calculated on the anhydrous basis."
UJSJ>.

Erythrocin {Abbott) ; Ilotycin (Lilly).

From cultures of an actinomycete found in a
sample of soil obtained from Iloilo City on the
Island of Panay, in the Philippine Archipelago.
McGuire et al. (Antibiot. Chemother., 1952, 2,
281) isolated a new broad-spectrum antibiotic.
The actinomycete was identified as a strain of
Streptomyces erythreus, so named because, as they
age, the colonies tend to become red; the new
antibiotic was, accordingly, called erythromycin.
The methods of industrial biosynthesis and chemi-
cal recovery from fermented broth cultures are
qualitatively similar to those for most antibiotics
of the Streptomyces group.

Description. — "Erythromycin occurs as white
or slightly yellow crystals or powder. It is odorless
or practically odorless, and is slightly hygroscopic.
Its saturated solution is neutral or slightly alkaline
to litmus. Its solution in alcohol is levorotatory.
One Gm. of Erythromycin dissolves in about
1000 ml. of water. It is soluble in alcohol, in
chloroform, and in ether. Erythromycin melts
somewhat indistinctly between 133° and 148°."
US.P.

Constitution. — The constitution of erythro-
mycin is not yet known in detail. It is a basic
compound, assigned a tentative empirical formula
of C39H73NO13; it readily forms salts with in-
organic and organic acids. The nitrogen in the
molecule is not embodied in a nitro group, and

there is no benzene ring structure in the substance.
Acid degradation yields dimethyl amine and a 3-
dimethylamino-4-desoxy-5-methylaldopentose (see
Clark, Antibiot. Chemother., 1953, 3, 663).

Stability. — Erythromycin is stable in the dry
state. In solution it retains its activity during pro-
longed storage under refrigeration (5°) or when
frozen but progressively loses activity over sev-
eral days at room temperature or higher. Brief
exposure of solutions to a temperature of 60° or
higher results in rapid loss of antibiotic activity.

Erythromycin is adsorbed on bacterial filters so
that there is loss of activity when this means of
sterilization of its solutions is employed. Haight
and Finland (Proc. S. Exp. Biol. Med., 1952, 81,
175) reported that only about 6 per cent of the
original antibacterial activity of erythromycin
solutions (2 and 200 micrograms per ml.) re-
mained after Seitz filtration and that from 50 to
75 per cent of activity was lost during passage
through a Berkfeld filter or sintered glass filter.

Standards and Tests. — Identification. — A
red-brown color is produced when 5 mg. of eryth-
romycin is shaken gently with 2 ml. of sulfuric
acid (bacitracin, neomycin sulfate, and tyrothricin
give colorless or only slightly yellow solutions).
Water. — Not over 10 per cent, when determined
by the Karl Fischer method. U.S.P.

Assay. — Erythromycin is assayed by the offi-
cial microbial assay. U.S.P. For microbiologic
assay procedures see Higgins et al. (Antibiot.
Chemother., 1953, 3, 50). Assays for determining
concentration of erythromycin in serum and other
body fluids have been described by Ziegler and
McGuire (ibid., 1953, 3, 67), and Kirshbaum
et al. (ibid., 1953, 3, 537). Washburn (/. A. Ph. A.,
1954, 43, 48) devised an assay based on infrared
absorption that compares well with microbiologic
assay methods and is specific for erythromycin.

It is noteworthy that erythromycin is more
active antibacterially at pH 8 than in acid media;
for example, four times as high a concentration
is required at pH 7 than at 8 to inhibit Bacillus
cereus (Heilman et al., Proc. Mayo, 1952, 27,
285). Working with different bacterial species
Haight and Finland (loc. cit.) found that the
activity of erythromycin increased approximately
10-fold for a rise of one pH unit.

Action. — Absorption. — Erythromycin is ab-
sorbed readily following oral administration and
is soon present in most tissues (Lee et al.,
Antibiot. Chemother., 1953, 3, 920). It is trans-
mitted through the placental membrane and when
there is a therapeutically effective concentration
in the mother's circulation generally the antibiotic
can be detected in the fetal circulation also. The
drug does not readily pass the blood-brain barrier
and only insignificant amounts enter the cerebro-
spinal fluid when there is no inflammation or
damage of the meninges. After a single oral dose,
maximum blood levels are attained in from one to
two hours. Haight and Finland (loc. cit.) reported
the following maxima and times: 250 mg. dose,
0.2 microgram per ml. after one hour; 500 mg.
dose, 0.6 microgram per ml. after two hours;
1 Gm. dose, 1.2 micrograms per ml. after two
hours. There was much individual variation but,

Part I

Erythromycin 527

in general, the maximum level attained was pro-
portional to the dose. Although differing in abso-
lute values because of differences in dose and
experimental technic, the results reported by Heil-
man et al. (loc. cit.) may be interpreted as pro-
viding confirmatory evidence. Concentrations at-
tained in ascitic fluid are about 30 per cent of
those attained in plasma, following a single dose
of 500 mg. (Grigsby et al., Antibiot. Chemother.,
1953, 3, 1029).

Following multiple doses somewhat higher blood
levels are reached. In general, 400 to 500 mg.
given orally every six hours provides therapeu-
tically satisfactory levels. If gastrointestinal dis-
stress occurs, the individual doses may be reduced
to 300 mg.; such a dosage schedule usually is
bacteriologically adequate, although it does not
provide the measure of security that larger doses
give. Shoemaker and Yow {Antibiotics Annual,
1953-1954, p. 460) found a daily dose of 20 to 25
mg. per Kg. of body weight clinically satisfactory
in treating a variety of infections, including pneu-
mococcal pneumonia, empyema, septicemia, osteo-
myelitis, acute pyelonephritis, and gonorrhea.

There is considerable variation in serum and
tissue levels in different individuals, but there is
more consistency at a given time in the ratio of
tissue concentration to serum concentration (Lee
et al., loc. cit.).

Effect of Dosage Form. — Higher blood levels
are attained and maintained for a longer period of
time when erythromycin is administered in tab-
lets with an acid-resistant coating or when given
with sodium bicarbonate than when given in gela-
tin capsules. Properly formulated tablets contain-
ing 500 mg. of erythromycin given 4 times daily
maintain in the serum a concentration of about
2 micrograms per ml. Kirby et al. {Antibiot.
Chemother., 1953, 3, 473) found 0.5 microgram
to be inhibitory for most species of bacteria, in
vitro.

To achieve best therapeutic effects, it is neces-
sary to protect erythromycin from gastric secre-
tions. If this is not done, or if the drug is given
with or immediately after a meal, it is destroyed
or its absorption is blocked. Special acid-resistant
coating of the dosage form overcomes this, but it
is difficult to regulate the dose with tablets. Sylves-
ter and Josselyn {Antibiot. Chemother., 1953, 3,
930) recommended use of erythromycin stearate,
formed by reacting erythromycin with stearic
acid. The final salt represents 60 per cent erythro-
mycin and 40 per cent stearic acid. The salt is
easily formulated as an oral suspension in an
aqueous vehicle containing carboxymethylcellu-
lose, sweetening agent, and sodium citrate. Even
the relatively insoluble stearate hydrolyzes to a
small extent in water and releases erythromycin
which results in a detectable bitter taste. Murphy
{Antibiotics Annual, 1953-1954, p. 500) and
Stephens {ibid., p. 514) developed several esters
of erythromycin that are equally satisfactory
therapeutically and are essentially tasteless.
Erythromycin stearate is recognized in N.N.R.,
the accepted brand being Erythrocin Stearate
(Abbott), which is supplied as an oral suspension
and as tablets. Erythromycin ethyl carbonate is a

similar compound recognized in N.N.R., the ac-
cepted product being Ilotycin Ethyl Carbonate
(Lilly) ; this is a white, odorless powder, having
a slightly bitter taste, practically insoluble in
water. An oral suspension of the compound is
available.

Under ordinary circumstances, oral administra-
tion of erythromycin for systemic medication is
satisfactory. However, in emergencies, when thera-
peutic levels of the antibiotic should be achieved
in the plasma as rapidly as possible or when pa-
tients cannot accept medication by mouth, a
parenteral form of the drug may be desirable.
Erythromycin glucoheptonate has been studied
as an intravenous dosage form. Maple et al.
{Antibiot. Chemother., 1953, 3, 836) found initial
concentrations in the serum of 23 patients ranged
from 7 to 30 micrograms per ml. when 500 mg.
of the glucoheptonate preparation was infused
intravenously in 200 ml. of saline over a 30-min-
ute period. Thereafter, the concentrations fell
rapidly and ranged from 0.1 to 1 microgram after
6 hours. Administration of 1 Gm. by continuous
intravenous drip over 6 hours maintained thera-
peutic blood levels of 1 to 10 micrograms per ml.
Higher initial levels (approximately 20 to 82
micrograms per ml.) and comparable 2- to 6-hour
levels were obtained by Griffith et al. {Antibiotics
Annual, 1953-1954, p. 496) with smaller doses
(300 mg.) given as a single intravenous injection
over a 4-minute period. Fifteen per cent of the
dose of erythromycin given intravenously as the
glucoheptonate was excreted in the urine during
the 24 hours immediately following injection.
Erythromycin glucoheptonate is recognized in
N.N.R., the accepted product being Ilotycin
Glucoheptonate (Lilly). It occurs as a white,
crystalline powder, freely soluble in water; the
pH of the 2 per cent solution is between 6.0 and
7.5. This salt is supplied in vials containing pow-
der equivalent to 250 mg. of erythromycin. A
similar salt, also recognized in N.N.R., is eryth-
romycin lactobionate, the accepted form of which
is Erythrocin Lactobionate (Abbott) ; it is a white
powder, freely soluble in water, the 2 per cent
solution having a pH between 6.0 and 7.5. It is
supplied in vials containing powder equivalent to
300 mg. and 1 Gm., respectively, of erythromycin.
This salt may be injected intravenously as a 1 per
cent solution, or intramuscularly as a 5 per cent
solution.

Excretion. — The major route of excretion of
erythromycin is renal. Basing judgment on results
of experiments with dogs, it appears that erythro-
mycin is excreted in the urine more rapidly than
either Aureomycin or Terramycin during the first
two hours following an oral dose, but that after
that time excretion of Terramycin is greater. Uri-
nary excretion of erythromycin is several times
that of Aureomycin at all times, following admin-
istration of equal doses. In humans, after single
doses or repeated small doses (300 mg.) the con-
centration in the urine is low, but on continuous
therapy with 500 mg. every 6 to 8 hours, up to
15 per cent of the amount ingested daily can be
demonstrated in active form in the urine and the
concentration may reach 2 mg. per ml. Heilman

528

Erythromycin

Part I

et al. (loc. cit.) emphasized, however, that con-
centration in the urine is not necessarily an index
of the concentration of the antibiotic in the tis-
sues and that the latter may be more important in
effectively treating infections of the urinary tract.

Erythromycin is excreted in the bile also. When
the blood level is 2 micrograms or less per ml.,
comparatively little may be in the bile {e.g., ap-
proximately 0.5 microgram per ml.), but in pa-
tients with serum levels of 4 micrograms or more
of erythromycin per ml., the concentration in the
bile may range from 32 to 256 micrograms per
ml., depending on the duration of therapy and
other factors (Heilman et al., loc. cit.). In duo-
denal fistula dogs, as much as 50 per cent of a
single intravenously injected dose of erythromycin
(10 mg. per Kg.) was recovered in hepatic bile
and in urine in 6 hours; two-thirds of the total
recovered was in the bile.

Uses. — Bacterial Infections. — Erythromycin
may be the antibiotic of choice for treating in-
fections due to penicillin-resistant staphylococci
and enterococci. Eisenberg et al. (Antibiot.
Chemother., 1953, 3, 1026) isolated 592 cultures
and found 42 per cent of them resistant to peni-
cillin, but 90 per cent of them sensitive to eryth-
romycin. Only 75 per cent of these were sensitive
to Aureomycin or to Terramycin. Similar obser-
vations were reported by Finland and Haight
(Arch. Int. Med., 1953, 91, 143).

Erythromycin is indicated also for treating in-
fections due to gram-positive or to coccal organ-
isms in penicillin-sensitive patients or in patients
with a past history of allergy (Grigsby et al.,
Antibiot. Chemother., 1953, 3, 1029).

Results in pneumococcal pneumonia without
complications are generally good (Romansky et
al., Clin. Res. Proc, 1954, 2, 92). Haight and
Finland (New Eng. J. Med., 1952, 247, 227)
observed good response in 11 cases not compli-
cated by bacteremia when total doses ranged from
2.8 to 16.8 Gm. (av. 6.9 Gm.) during 2 to 14 days
(av. 6.5 days). Fever subsided within 48 hours
in all patients and sputum of 9 patients became
negative on or after the first day of treatment
and after the third day of treatment in the others.
Austrian et al. (Am. J. Med. Sc, 1953, 226, 487)
prefer penicillin. Grigsby et al. (loc. cit.) found
that 4 out of 5 patients became afebrile in 24 to
72 hours, but that cases complicated by pneu-
mococcal bacteremia or meningitis responded less
favorably. The same authors reported the drug
ineffective in viral pneumonia and in Friedlander's
pneumonia, but Nasou et al. (Antibiotics Annual,
1953-1954, p. 470) found it curative in a case of
Hemophilus influenzce, type B, pneumonia.

Hemolytic streptococcal infections and staphy-
lococcal septicemia are reported to respond favor-
ably, usually in 24 to 36 hours, to 300 to 500 mg.
of erythromycin given orally every 6 to 8 hours
(Smith et al., J. A.M. A., 1953, 151, 805; Heilman
et al., Proc. Mayo, 1952. 27, 285). Erythromycin
alone, or especially conjointly with streptomycin,
may prove valuable in treating streptococcal or
staphylococcal endocarditis resistant to the usual
regimen of antibiotic therapy (Jones and Yow,
Antibiotics Annual, 1953-1954, p. 480; Haight
(/. Lab. Clin. Med., 1954, 43, 15) found erythro-

mycin or procaine penicillin equally effective in
the treatment of scarlet fever; the incidence of
toxicity was less with the former.

Urinary tract infections caused by gram-posi-
tive organisms respond well, but not those due to
Aerobacter cerogenes, Bacillus proteus, or gram-
negative organisms generally. Other systemic bac-
terial infections treated successfully with eryth-
romycin include empyema, osteomyelitis, and
acute pyelonephritis. Efficacy in meningococcemia
was reported in a child by Anderson (Antibiot.
Chemother., 1953, 3, 1091) and in diphtheria
carriers by Ricci et al. (Aggiornamento Pediatrico,
1953, 4).

Venereal Diseases. — Gonococcal urethritis
and cervicitis have been apparently cleared by a
one or two day dosage schedule of 1 to 2 Gm. of
erythromycin, given in divided doses every 4 to 6
hours (Grigsby et al., loc. cit.; Cordice et al.,
Antibiotics Annual, 1953-1954, p. 480; Haight
and Finland, loc. cit.). However, there have been
relapses. The latter authors consider erythromycin
inferior to penicillin for clearing gonococcal
infections.

Lymphogranuloma venereum in 14 patients was
treated by Banov and Goldberg (Antibiotics
Annual, 1953-1954, p. 475) with erythromycin,
400 to 1600 mg. 4 times daily for from 11 to 25
days. Ten cases had inguinal adenitis and four had
rectal lesions: six of the former cases were cured
with erythromycin and four were equivocal; only
one of the patients with rectal lesions responded
unequivocally. The authors concluded that further
evaluation is necessary to establish the position of
erythromycin in lymphogranuloma venereum.

Cordice et al. (loc. cit.) concluded that eryth-
romycin is useful in treatment of lymphogranu-
loma venereum, gonorrhea, chancroid, and dono-
vanosis. Primary luetic lesions were cleared of
Treponema pallidum in 72 hours on a regimen of
2 Gm. daily in divided doses. Urethral discharge
was cleared of Neisseria gonorrhea in 48 hours,
chancroidal lesions healed in 6 days, lesions of
lymphogranuloma in 15 days, and those of dono-
vanosis in 16 to 33 days. There was no evidence
of toxicity, even under prolonged treatment. How-
ever, they caution that further study is required
to determine optimal dosage and schedules. Rob-
inson and Cohen (/. Invest. Dermat., 1953. 20,
407) reported good results in granuloma inguinale.

Cutaneous Bacterial Infections. — Livingood
et al. (J.A.M.A., 1953. 153, 1266) treated 184
cases of varied infections (impetigo, ecthyma,
folliculitis, furunculosis. paronychia, ulcers, etc.)
with ointments containing 0.5 per cent erythro-
mycin. They concluded that erythromycin is a
very effective topical agent for staphylococcic and
streptococcic primary cutaneous infections but
that it may be less satisfactory in treating sec-
ondary bacterial infections. Three of the patients
had an apparent sensitivity or irritant reaction
to erythromycin and two others responded simi-
larly to erythromycin-neomycin mixtures. Accord-
ing to these authors erythromycin may not be
as well tolerated as other antibiotics by denuded
and eczematized skin. Robinson and Zeligman
(/. Invest. Dermat., 1953, 20, 405) used the 1
per cent ointment effectively in a variety of

Part I

Erythromycin 529

pyodermas, including 25 cases of impetigo con-
tagiosa; Freeman and Scott (/. Pediatr., 1953, 42,
669) treated pyodermas in children successfully.

Amebiasis and Other Non-bacterial Infec-
tions.— In young rats experimentally infected
with Endamceba histolytica, erythromycin was
found to be more effective than Terramycin (Mc-
Cowen et al., Am. J. Trop. Med. Hyg., 1953, 2,
212) and trials in a limited number of human
patients have shown erythromycin to be effective
in acute diarrheal stages of amebic dysentery. In
spite of the in vitro observation that erythromycin
is less inhibitory than Terramycin for Endamceba,
especially in the absence of bacteria (McCowen,
loc. cit.), the drug seems to be a direct-acting
amebicide, since no change in bacterial intestinal
flora is noted in human amebiasis patients treated
with it.

Of particular interest is the effect of erythro-
mycin on trypanosomes, and on Leishmania
donovani. Mice inoculated with Trypanosoma
gambiense (African sleeping sickness) and T.
equiperdum (dourine or mal de coit of horses)
are protected from infection when given oral
doses of erythromycin (40 mg. per mouse) once
a day for 5 days. Neither Aureomycin nor Terra-
mycin is effective at the same dosage.

Erythromycin also has potentialities in treat-
ment of infections due to Spirochceta (Borelia)
novyi (North American relapsing fever), Toxo-
plasma spp. (toxoplasmosis), and Trichomonas
vaginalis. Further research is necessary to un-
equivocally establish the clinical position of eryth-
romycin in such diseases.

Toxicology. — Erythromycin has low toxicity.
Anderson et al. (J. A. Ph. A., 1952, 41, 555; re-
ported the acute LD50 of the free base for the
mouse to be approximately 3000 mg. per Kg. when
given orally and more than 2500 mg. per Kg.
when given subcutaneously; similar figures were
obtained with the rat and the hamster (only oral
determined). The LD50 for guinea pigs injected
intraperitoneally was about 413 mg. per Kg.
Corresponding figures for the hydrochloride ad-
ministered to the mouse were about 2900 mg. per
Kg. (oral), 1849 mg. per Kg. (subcutaneous),
425 mg. per Kg. (intravenous), and 490 mg. per
Kg. (intraperitoneal).

Studies of subacute effects revealed no evidence
of eighth cranial nerve damage in cats or of
pathologic changes in viscera or formed elements
of the blood in rats or dogs receiving the drug
continuously in their diets over a period of a year
(Anderson et al., ibid., 1955, 44, 199). Marrow
constituents and blood and urine analyses were
normal.

In humans, nausea, vomiting, and diarrhea have
been reported occasionally, and Shoemaker and
Yow {Antibiotics Annual, 1953-1954, p. 460) had
to discontinue the drug in one patient (in a series
of 47) because of these effects. But incidence of
such reactions is much less common with eryth-
romycin than with Aureomycin or Terramycin.
The relative lack of gastrointestinal disturbance
may be due to the fact that usually erythromycin
does not interfere with Escherichia coli and other
normal intestinal microflora.

To date, emergence of erythromycin-resistant

pathogens during therapy has not been a serious
clinical problem, although resistance may be in-
duced in vitro. However, Kirby et al. (Arch. Int.
Med., 1953, 92, 464) reported that erythromycin-
resistant organisms developed in one patient with
chronic osteomyelitis of the spine after 6 weeks
of therapy. In soft tissue infections treated for
3 weeks there was no decrease in sensitivity of
the organisms. There is cross-resistance between
erythromycin and carbomycin, but not between
erythromycin and other narrow- or broad-spec-
trum antibiotics. Hobson (Brit. M. J., 1954, 1,
236) found, in vitro, that resistance of staphy-
lococci to erythromycin developed in a stepwise
manner, similar to that to penicillin.

That resistance to erythromycin may become
a problem in hospitals, as it has with penicillin, is
indicated by the report of Lepper et al. (Anti-
biotics Annual, 1953-1954, p. 308). Among hospi-
tal personnel who were carriers, the proportion of
strains of staphylococci not inhibited by 100
micrograms or less per ml. rose from zero to 75
per cent during a period of 5 months when the
drug was being tested extensively on patients and,
during a period of 3 months, incidence of erythro-
mycin-resistant staphylococci infecting the trachea
of tracheotomized patients increased from zero to
95 per cent. When the drug was no longer used in
the hospital, the incidence of resistant strains in
carrier personnel dropped to about 35 per cent.

Summary. — Erythromycin is a relatively broad-
spectrum crystalline antibiotic elaborated by the
actinomycete Streptomyces erythreus.

When dry, erythromycin is stable, but in solu-
tion deteriorates slowly at room temperature
(25°), and rapidly at 60 or higher. At refrigera-
tor temperature (4°) sterile solutions are stable
for at least 8 weeks.

The antibiotic is rapidly absorbed and distrib-
uted to most body tissues and fluids following
ingestion. There is considerable individual varia-
tion in the blood levels attained (maximum usually
in about 2 hours) but the serum/tissue level ratios
are more uniform at any given time. Major excre-
tion of erythromycin is renal and biliary.

Doses of 400 to 500 mg. every 6 hours gen-
erally provide serum levels at least 4 times the
0.5 microgram per ml. required to inhibit most
sensitive organisms in vitro.

Erythromycin is indicated for treatment of all
gram-positive and most coccal infections that are
resistant to penicillin and for treating penicillin-
sensitive infections in patients who react unfavor-
ably to penicillin or who have a past history of
allergy.

Erythromycin has been effective in limited
trials in gonorrhea, syphilis, lymphogranuloma
venereum and other venereal diseases, but prob-
ably is not as effective as penicillin in gonorrhea
or in syphilis. Preliminary trials in acute phases
of amebiasis in man and in experimental relapsing
fever, toxoplasmosis, and African sleeping sick-
ness have yielded promising results.

Bacteria do not readily acquire resistance to
erythromycin in vivo, but when they do, generally
they are resistant to carbomycin also. There seems
to be no significant cross-resistance between eryth-
romycin and other antibiotics except carbomycin.

530 Erythromycin

Part I

Toxicity of erythromycin is low and normally
no serious untoward reactions are seen. There is
a possibility that in some patients eczematized or
infected skin may be sensitive to erythromycin,
but thus far this has been observed only in-
frequently.

Dosage. — The usual dose, for most susceptible
infections, is 300 mg. of erythromycin, orally,
every 6 hours, with a range of dose of 200 to 600
mg. The total daily dose, but not the number of
doses, is proportionately less for children.

When intravenous injection is indicated,
erythromycin glucoheptonate or erythromycin
lactobionate (see above) may be employed.

Erythromycin is incorporated in ointments for
topical use, several of these application forms
being available under the usual trade-marked
names of the antibiotic.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

ERYTHROMYCIN TABLETS. U.S.P.

"Erythromycin Tablets contain not less than
85 per cent of the labeled amount of erythro-
mycin." U.S.P.

Usual Size. — 100 mg. (approximately ll/2
grains).

ESTRADIOL. N.F. (LP.)

Dihydrotheelin, (Estradiol, [Estradiol]

"17-cw-Beta-estradiol." N.F. The LP. defines
Oestradiol as a-3:17-dihydroxyoestratriene-l:3,5.

LP. Oestradiol. Oestradiolum. Dihydroxyestrin. 3.17(a)-
Dihydroxy-^1-3-5<10)-estratriene, Dimenformon (Organon) ;
Ovocylin (Ciba); Progynon (Schering). Sp. Estradiol.

The egg cells of the ovary are contained in a
sort of sac, known as the "primary follicle." When
the animal reaches the age of puberty these folli-
cles begin to grow, seriatim, and when they reach
a stage of maturity constitute the Graafian folli-
cles. This sac contains the ovum floating in a
liquid known as liquor folliculi. In this solution is
the hormone (Allen and Doisy, J.A.M.A., 1923,
81, 819; Zondek, Klin. Wchncshr., 1928, 7, 485)
now known as estradiol. Eventually the Graafian
follicles rupture and discharge their ova, after
which the sac becomes filled with a yellowish
fluid and is known as the corpus luteum. This yel-
low body contains the related, but distinct, hor-
mone progesterone (see under this title and also
Corpus Luteum). For further information on the
physiology of the ovary, see Allen {J. A.M. A.,
1941, 116, 405).

Chemically, estradiol is beta-3,17-dihydroxy-
1,3,5 (lO)-estratriene, or dihydroxyestrin; it may
be considered to be a derivative of cyclopentano-
perhydrophenanthrene (see Sterids, Part II). It
differs from estrone (theelin), the first sex hor-
mone to have been isolated (Doisy et al., J . Biol.
Chem., 1930, 86, 499; Butenandt, Naturwissen-
schaften, 1929, 17, 879), in having a secondary
alcohol group in place of the keto group in theelin,
hence the name dihydrotheelin sometimes given
to estradiol. Its structural formula, in ester form,
is shown under Estradiol Benzoate.

First isolated (MacCorquodale et al., Proc. Soc.
Exp. Biol. Med., 1935, 32, 1182) from sow ovaries

(four tons yielding 11 mg. of crystalline mate-
rial from which the hormone was regenerated),
estradiol is also found in human pregnancy urine
(Smith et al., J. Biol. Chem., 1939, 130, 431) and
in mare pregnancy urine, along with a less potent
stereoisomer.

The more active isomer, usually referred to
merely as estradiol, was originally specifically
called a//>Aa-estradiol while the much less active
isomer was designated fceto-estradiol. Later it was
established that the difference between the two
isomers was in the orientation of the OH group
at carbon atom 17; in the active isomer the OH
group projects to the front while in the less active
isomer this group projects to the rear. Since rules
of nomenclature require that front orientation be
designated beta, and rear orientation alpha, the
isomer originally called ai/>Aa-estradiol is really
17-6era-estradiol, while the original beta-estradiol
is actually 17-a//>Aa-estradiol. This accounts for
the change of nomenclature of these compounds
in the new official compendia.

Estrone (described under this title) and estriol,
the latter differing from estradiol in having an-
other secondary alcohol group (at carbon atom
16), are also found in human pregnancy urine
(Marrian, Biochem. J., 1930, 24, 1021); it is
believed that these substances are metabolic prod-
ucts of estradiol, rather than original hormones.
Pregnant mares' urine is the chief commercial
source of these estrogens and normally all but
1 or 2 per cent of the estrogenic activity of such
urine is attributable to estrone (52 to 90 per cent)
and to estradiol (10 to 47 per cent) ; the remainder
is due chiefly to estriol, equilin, hippulin and
equilenin (for further information concerning
these substances see under Estrone). It is of inter-
est that the estrogens in the urine of. pregnant
women are excreted as water soluble glucuronides
while those in pregnant mares' urine occur as
sulfates; on acid or putrefactive hydrolysis of the
urines the conjugated compounds are converted
to free estrogens. Although a solution of all the
estrogens mentioned here is used in medicine,
only estradiol, estrone and estriol have sufficient
activity to warrant their use individually. When
given by injection, estradiol is the most active of
the three substances; estrone is next in order of
activity and estriol is the least potent. When given
orally, however, estradiol and estrone lose much
of their effectiveness, while estriol is said to be
almost as active as when it is injected. Esterifica-
tion of the phenolic hydroxyl of estradiol as
acetate, benzoate, palmitate or propionate delays
absorption from the site of injection and thereby
apparently enhances the effectiveness of the sub-
stance (see under Estradiol Benzoate).

Estradiol may be readily prepared by the re-
duction, as by hydrogenation, of estrone; indeed,
this had been done before it was isolated from
natural sources (Schwenk and Hildebrandt, Natur-
wissensckaften, 1933, 21, 177). Inasmuch as
estrone has been synthesized from non-steroidal
sources, estradiol also may be thus synthesized.

Description. — "Estradiol occurs as white or
creamy white, small crystals or as a crystalline
powder. It is odorless and is stable in the air.
Estradiol is almost insoluble in water; it is soluble

Part I

Estradiol

531

in alcohol, in acetone, in dioxan, and in solutions
of fixed alkali hydroxides; it is sparingly soluble
in vegetable oils. Estradiol melts between 173°
and 179°." N.F.

Standards and Tests. — Identification. -(1)
A solution of 2 mg. of estradiol in 2 ml. oi sul-
furic acid is greenish yellow and has a green
fluorescence; on dilution with 2 ml. of water the
color of the solution changes to pale orange. If
1 drop of ferric ammonium sulfate T.S. is added
to the sulfuric acid solution before dilution with
water, the green color is markedly intensified, and
after dilution with water the color changes to red.
(2) A deep red color is produced on adding a
potassium hydroxide solution of estradiol to a
solution of diazotized sulfanilic acid. (3) Estradiol
benzoate, prepared by esterifying estradiol with
benzoyl chloride, melts, after recrystallization,
between 190° and 195°. Specific rotation. — Not
less than +76° and not more than +83°, when
determined in a dioxan solution containing 100
mg. of dried estradiol in each 10 ml. Loss on
drying. — Not more than 1 per cent, when dried at
105° for 4 hours. Limit of alpha-estradiol. — An
aliquot portion of a benzene solution of estradiol,
representing 20 micrograms of estradiol, is evapo-
rated to dryness and the residue treated with an
iron-phenol reagent which under the conditions
of this test produces a red color with alpha-
estradiol but not with beta-estradiol (the same
reagent will, however, produce a red color also
with beta-estradiol under the different conditions
specified in the assay of estradiol tablets). Any
color produced in this test is not deeper than that
obtained in a control prepared from 20 micro-
grams of N.F. Estradiol Reference Standard. N.F.

Assay. — No assay is specified for the bulk
forms of such natural estrogens and their deriva-
tives as estrone, estradiol, estradiol benzoate and
estradiol dipropionate ; these substances may be
adequately evaluated by other official specifica-
tions. Assay of the official dosage forms of these
estrogens is, however, provided for and these
assays are explained in the respective monographs
of such dosage forms.

Prior to the general availability of relatively
pure individual estrogens and to the development
of chemical methods of assay of such substances
a biological method of assay was used in stand-
ardizing estrogenic preparations; indeed, such a
method is still useful and is often employed. The
following is a discussion of one of these biological
procedures; some of the problems associated with
such a method are presented. The method is based
on observation of the series of changes produced
in the cellular contents of the vaginal secretion
of adult female rats from which the ovaries have
been completely removed in comparison with
similar effects produced by the same type of prep-
aration made with either estrone, estradiol, or
estradiol benzoate as the reference standard. The
method is patterned after that suggested by the
League of Nations Health Organization some
years ago, in connection with which that body
established two international reference standards:
estrone and estradiol benzoate.

The first standard established by the Organiza-
tion, in 1933, was a composite sample of estrone,

the international unit of which was defined as the
specific estrus-producing activity in 0.1 gamma
(0.0001 mg.) of the standard. Because it was
later found that estrone was not a suitable stand-
ard for the assay of the esterified forms of estrus-
producing hormones, the Organization in 1935
established a composite sample of estradiol mono-
benzoate (estradiol benzoate) as the second inter-
national standard, and defined the international
unit of that substance as the specific estrus-pro-
ducing activity in 0.1 gamma. While the two units
are identical in terms of weight of the respective
standards, they are quite different in biological
activity. The estradiol monobenzoate unit is more
potent than the estrone unit, but the exact rela-
tionship cannot be stated with certainty. Some of
the reasons for the uncertainty, not only in the
inter-relationship of the two standards, but often
also in the potencies of any two products of the
same composition, are evident in the statement
appearing in the Organization's memorandum to
the effect that the results "... may have a varying
value, in accordance with the choice of mice or
rats for the tests, with the method of solution,
division and spacing of dosage, etc." It is further
recommended, in the same memorandum, that
". . . with a view of greater uniformity of dosage
in practice and to more accurate interpretation
of effects recorded in the literature, such addi-
tional data concerning the details of the test de-
termining the indicated unitage should be given
in some document accompanying each package of
such preparation." An appreciation of the order
of accuracy inherent in tests of this nature is indi-
cated in the statement that "a method (of assay)
should be chosen which has been proved, in the
hands of the particular investigator, to be capable
of determining such quality or activity with an
error not greater than plus or minus 20 per cent."

An even greater degree of uncertainty of the
significance of such assays is found in the case
of solutions of estrogenic substances, which are
mixtures of estrogens usually from the urine of
pregnant mares. Normally up to 95 per cent of
the activity of such material may be contributed
by estrone, but evidence indicates that in some
instances at least the less active estrone has by
hydrogenation been converted to the more active
estradiol — the response of which is sufficiently
different that a separate standard of potency was
considered advisable. Moreover, it is said that in
some other instances the solution of estrogens
has been prepared from the mother liquor of
urine remaining after the estrone in it has been
crystallized out; this liquid contains the hormones
equilin, equilenin and hippulin which, while estrus-
producing, are not normal constituents of the
human body and have not been adequately investi-
gated as to their actions and fate in the human.

Uses. — Estrogens, including estradiol, are used
principally for the following: to provide sympto-
matic relief of menopausal and related symptoms
of ovarian deficiency, for this purpose usually
being administered in minimally effective doses
for short periods (several weeks) ; to inhibit
lactation; to palliate inoperable cancer of the
prostate or, after the menopause, of the breast;
to stop functional uterine bleeding; to treat

532

Estradiol

Part I

threatened or habitual abortion; to treat osteo-
porosis, and also certain other conditions. They
are capable of causing great harm as well as much
good; prolonged use causes endometrial hyper-
plasia, abnormal bleeding, and gynecomastia.

The function of estradiol in the normal female
physiology is to prepare the genitalia for the re-
ception of the fertilized ovum. It causes hyper-
trophy of the mucous membrane of both the
uterus and the vagina. In the endometrium there
is not only thickening of the mucous membrane
but also increased development of the uterine
glands; in the vagina there is a tendency towards
keratinization of the epithelium. There is also
some hypertrophy of the uterine muscle. The
same tendency towards increased growth of the
reproductive organs extends to the mammary
glands, especially the ducts, and the ureters. Large
doses inhibit the gonadotropic secretion of the
anterior lobe of the pituitary bodies as well as
other endocrine secretions; Zondek (J. A.M. A.,
1940, 114, 1850) reported that with sufficient
quantities it was possible to inhibit completely
the normal ovarian cycle. Studies on animals and
humans led Brown et al. {Am. J. Obst. Gyn.,
1953, 65, 733) to conclude that estrogenic mate-
rials stimulate the release of gonadotropin from
the anterior pituitary gland within 48 to 96 hours;
continued administration suppresses further gon-
adotropin release. In addition to these actions
estradiol is connected with the production of sec-
ondary sex characteristics, such as contour of the
body and distribution of hair, and with bone for-
mation. For further information concerning the
physiological functions of estradiol and other
estrogenic substances, see Doisy (J.A.M.A., 1941,
116, 501). In the following the actions and uses
of estrogenic substances, because they are similar,
are considered together.

Metabolism. — Following oral administration,
all estrogenic substances are absorbed to varying
degrees from the gastrointestinal tract and in part
excreted in the urine as such and in part in the
form of partly metabolized products, some of
which have physiological activity (see also under
Estrone). The rates of absorption, inactivation
and excretion of the several estrogenic substances
differ. Knowledge regarding their metabolism is
incomplete but the failure to produce physio-
logical effects by oral administration, or only with
much larger doses than are required parenterally.
appears to be due as much to rapid inactivation
and or excretion as to lack of absorption. In the
body estradiol seems to be converted to estrone
and the weak estrogen estriol (Stimmel, J. Clin.
Endocrinol., 1947. 7, 364). However, injection
of estrone, but not of estriol. increases excretion
of estradiol in the urine. In vitro, estradiol and
other estrogenic substances are inactivated (Tag-
non et al., J. Clin. Inv., 1952, 31, 346) by liver
"brei" and also in the heart-lung-liver animal cir-
cuit, by which test only small percentages of
estrogenic activity can be recovered from the
tissues or the excreta (Doisy, loc. cit.). As already
noted, it is believed that urinary estrogens are
formed in the fiver but Lipschutz et al. (Science,
1945, 101, 410) claimed, on the basis of im-
plantation of urinary estrogens in the spleen of

animals, that urinary estrogens are not the ulti-
mate product of metabolism in the liver. Physio-
logically inactive forms have been recognized in
the urine. However, Cantarow et al. (Science,

1945, 101, 558) observed that estradiol was ex-
creted in large quantity by the bile and concluded
that biliary excretion rather than fiver inactivation
was the important factor. Whatever the mech-
anism may be, patients with impaired liver func-
tion often present gynecomastia and other mani-
festations of excess estrogens in the body (Glass.
Endocrinology, 1940, 27, 749). Deficiencies in the
vitamin B complex result in failure of animals
to excrete or inactivate estrogens implanted in
the spleen. Biskind et al. (Surg. Gynec. Obst.,
1944, 78, 49) assembled clinical evidence which
points to the importance of mild nutritional de-
ficiency (vitamin B complex — see Ershoff and
Deuel," Am. J. Phyiol., 1946, 145, 465) in the
etiology of metro-menorrhagia. cystic mastitis and
premenstrual tension; Ayre and Bauld (Science,

1946, 103, 441) called attention to a correlation
between thiamine deficiency and the high estro-
gen findings in uterine cancer. About two-thirds
of the estrogens in the blood are said to be loosely
bound to protein, the remainder being in the form
of sodium salts or glucuronates (Szego and Rob-
erts. Fed. Proc, 1946. 5, 103). Estradiol, estrone,
diethylstilbestrol and hexestrol are not stored in
the fat depots of the body, as is the case with
tri-p-anisylchloroethylene (Greenblatt and Brown.
Am. J. Obst. Gyn., 1952. 63, 1361 >.

During the menstrual cycle, elimination of es-
trogens in the urine, which presumably reflects the
blood levels, varies from 5 to 100 rat units per 24
hours; two peaks, one at the mid-period at the
time of ovulation and the other just before the
onset of the menstrual flow, are evident. During
pregnancy, the urinary excretion increases fairly
progressively to a peak of about 100.000 rat units
in 24 hours just before delivery; early in gesta-
tion estriol accounts for about one-third of the
output but in the last trimester estradiol is the
principal form present in the urine. A prelabor
decrease in urinary excretion of estrogen from
the high levels attained during the last trimester
of pregnancy does not occur with sufficient regu-
larity to be employed to predict the onset of labor
(Bradshaw and Jessop. /. Endocrinol., 1953,
9, 427).

Relative Activities. — Considering the diffi-
culties in relating the activities of the several
estrogens in animal assays to therapeutic use
(Freed. J.A.M.A., 1941. 117, 1175; see also under
Assay), it is fortunate that many estrogenic sub-
stances are available in chemically pure form;
clinical experience has determined appropriate
dosages in terms of weight of the substance. Allen
(South. M. J., 1944. 37, 270) determined the
average number of milligrams required per week
for three weeks to cause withdrawal bleeding in
50 per cent of a group of castrated women. With
oral administration, the following dosages in milli-
grams per week were required: ethinyl estradiol
0.4. diethylstilbestrol 3.0, estradiol 13.4, sodium
estrone sulfate 17.5, estrone 31.5; with intramus-
cular administration, the results were: estradiol
dipropionate 0.86, estradiol monobenzoate 1.06,

Part I

Estradiol

533

estradiol mono propionate 1.75, estrone 3. Although
individuals may vary widely in their response,
these figures illustrate the general order of magni-
tude of the potencies of the estrogenic substances.
Differences in rates of absorption, inactivation
and excretion are marked and such individual
factors as slight impairment of liver function
seem important. The dosage form is also an im-
portant factor; Ferin (/. Clin. Endocrinol., 1952,
12, 28) found the duration of action of estradiol-
3-benzoate to be 7 to 10 days when administered
in oil solution, 28 to 34 days in an aqueous
emulsion, and 30 to 79 days in a microcrystalline
suspension.

Therapeutic Uses. — Clinical applications of
estrogens have been many and varied. In general
the endocrine applications fall into three groups:
developmental action on the reproductive organs,
inhibition of pituitary hormones, and constitu-
tional effects.

Menopause. — The most widespread use of estro-
gens is for the relief of the menopausal symptoms
— flushing, palpitation, headache, giddiness and
malaise (Rakoff, Med. Clin. N. Am., Jan. 1945,
269). These symptoms do not occur in all women,
but they are common and often particularly
severe following castration (Buxton, J. Clin.
Endocrinol., 1944, 4, 591). In many patients seda-
tives and psychotherapy suffice and estrogenic
therapy should not be employed unless it is
needed. Prolonged administration is undesirable
and appears at times to prolong this period of re-
adjustment. Sufficient doses to relieve the symp-
toms should be given and then discontinued
(Sevringhaus, /. Clin. Endocrinol., 1944, 4, 597);
if symptoms recur, administration should be re-
peated employing smaller doses. In the severe
condition following castration, an intense and
continuous effect, such as may be obtained with
5 mg. of estradiol dipropionate intramuscularly
weekly for three weeks, is indicated.

Monroe {New Eng. J. Med., Aug. 13, 1953)
deplored indiscriminate use of estrogens, observ-
ing that while thyroid as well as ovarian or tes-
ticular function is deficient in old age it is not
common practice to administer desiccated thyroid
to all aged persons. Greenblatt et al. (J. Clin.
Endocrinol., 1950, 10, 1547), and Glass and
Shapiro (GP, 1951, 3, 39) found that combined
estrogen and androgen therapy, such as 0.25 mg.
of diethylstilbestrol and 5 mg. of methyltestos-
terone three times daily by mouth, relieved meno-
pausal discomforts with fewer side effects than
when effective doses of either component was
given by itself. Juster and Guiard (Presse mid.,
1953, 61, 365) reported good results following
intramuscular injection of 1 ml. of solution con-
taining 3 mg. of estradiol, 20 mg. of progesterone,
and 25 mg. of testosterone propionate, adminis-
tered once or twice weekly at the start and then
at less frequent intervals, the frequency being
determined by appearance of symptoms. Steroids
with minimal androgenic action, such as methyl-
androstenediol or methylandrostane-3-on-17-ol,
antagonize the endometrial hyperplasia caused by
estrogens (Ferin, Ann. endocrinol., 1951, 12,
1082). In menopausal patients who have survived
carcinoma of the breast, steroid therapy should

be avoided, if possible; if symptoms are severe
administration of an estrogen-androgen combina-
tion for a short time may be effective and safe
(J.A.M.A., 1953, 153, 456).

In castrated women, Heller et al. {J. Clin. En-
docrinol., 1944, 4, 109) reported that small doses
relieved the symptoms, caused cornification of the
vagina and increased the amount of luteinizing
gonadotropin in the urine, whereas large doses
caused suppression of urinary gonadotropins. At
present, neither the disappearance or diminution
of estrogens nor the increase of gonadotropins can
be accepted as the cause of the menopausal syn-
drome (Fluhmann, /. Clin. Endocrinol., 1944, 4,
586). These symptoms are related to overactivity
of the sympathetic nervous system which seems to
be in part a result of deprivation of the ovarian
hormones but also a result of the anxiety which
is commonly experienced at this epoch (Hoskins,
/. Clin. Endocrinol., 1944, 4, 605).

Certain associated menopausal phenomena may
be effectively managed with estrogenic substances.
Chief among these is senile or post-menopausal
vaginitis, which is manifested by vaginal discharge
and slight bleeding, severe pruritus, dysuria and
dyspareunia. The use of vaginal suppositories of
estrogens is usually effective within a few days'
time and may be repeated whenever symptoms
recur. Application of an ointment containing
estrogens on the external genitalia and adjacent
skin is indicated in some instances. Involutional
melancholia associated with estrogen deficiency
responds well to estrogenic therapy (Danziger,
Arch. Neurol. Psychiat., 1944, 51, 462); in the
absence of estrogen deficiency results have been
disappointing. In certain cases of migraine, essen-
tial hypertension, and mixed arthritis associated
with the menopause, estrogenic therapy has
seemed beneficial. Estrogenic substances are
potent therapeutic agents and promiscuous use
is not without danger; it is particularly important
that apparent benefit from such therapy should
not delay the recognition of neoplasm or other
serious conditions (Scheffey et al., J.A.M.A.,
1945, 127, 76; Stoddard, ibid., 1945, 129, 508).

Gonorrheal Vulvovaginitis of Infants and Chil-
dren.— Prior to the advent of penicillin estrogenic
therapy was generally used in doses sufficient to
convert the thin, immature, juvenile vaginal epi-
thelium into the more resistant, cornified type
characteristic of the estrogenic phase of the
menstrual cycle. With daily use of suppositories
of estrogenic material, the discharge disappeared
after 1 to 2 weeks and gonococci disappeared by
the end of the second week. By comparison, with
sulfadiazine therapy discharge ceased after 2 to
3 days although gonococci persisted through the
first and second weeks (Compton et al., J. A.M. A.,
1945, 127, 6). Temporary swelling of the breasts
and labia was observed in half of Compton's
cases and occasionally nausea, slight vaginal
bleeding and growth of pubic hair appeared. Be-
cause of the greater potential toxicity of the
sulfonamides, estrogenic therapy was preferred.
However, Hac et al. {Am. J. Obst. Gyn., 1945,
50, 88) reported 89 per cent cure with sulfa-
thiazole and employed estrogenic therapy only for
the 11 per cent of failures. Compton reported

534

Estradiol

Part I

better results with diethylstilbestrol than with the
natural estrogens. Such patients may be treated
at home but they must be isolated day and night
and careful instructions must be given regarding
clothing, towels and the commode. The estrogenic
therapy is effective when administered orally.
Penicillin, however, offers the least toxic form of
treatment.

Ovarian Deficiency. — Female hypogonadism
would seem to be an obvious indication for
estrogenic therapy but this is a complex condition
of several different types which are difficult to
appraise accurately. Klinefelter et al. (J. Clin.
Endocrinol., 1943, 3, 529) classified female
hypogonadism into three categories: Primary or
ovarian insufficiency in which the urinary excre-
tion of estrogenic substance is decreased with
an increased excretion of gonadotropin (follicle
stimulating) ; gonadotropin insufficiency in which
both estrogen and gonadotropin excretion are
decreased; and luteinizing insufficiency in which
the urinary estrogefis are decreased but the ex-
cretion of follicle-stimulating gonadotropin is
normal. The complex interrelationships of the
gonads, the pituitary, the adrenals and the other
endocrine glands remain to be adequately un-
raveled.

In instances of estrogenic deficiency, estrogenic
therapy will usually induce vaginal bleeding but
this is an accomplishment of questionable merit.
Of greater value constitutionally and psychologi-
cally is the development of the genital organs
and of the secondary sexual characteristics which
may be induced by estrogenic therapy. In the
primary type and in the group with deficiency
of the follicle-stimulating factor treatment with
estrogens is substitution therapy, the benefits of
which persist only as long as treatment is con-
tinued. However, the serious import of this
situation and the minimal toxicity of estrogenic
therapy in this group of young women justifies
endocrine therapy after the best possible evalu-
ation of the nature of the abnormality. Cyclic
bleeding may be produced by cyclic therapy —
estrogens during the first two weeks followed
by progesterone, with subsequent alternation of
the use of these substances (Hamblen et al.,
J. Clin. Endocrinol., 1941, 1, 211). In some in-
stances the use of gonadotropins is also indicated.
Davis et al. (J. Clin. Endocrinol., 1945, 5, 138)
reported intense pigmentation of the nipples,
linea alba, etc., in these cases which was not
observed in the treatment of menopausal patients.
An 18-year-old girl who had been castrated by
roentgen irradiation at the age of 15 months
associated with surgical excision of a tumor
which proved to be a neuroblastoma failed to ma-
ture but showed rapid response in secondary
sexual characteristics and bone age after treat-
ment with diethylstilbestrol and progesterone
(Portmann and McCullagh, J.A.M.A., 1953, 151,
736).

Primary dysmenorrhea, when due to estrogenic
deficiency and associated with a hypoplastic
uterus, may be benefited, temporarily at least,
by estrogenic therapy (Patton, Am. J. Obst.
Gyn., 1945, 50, 417). However, in such patients
a normally developed uterus is more frequently

found and estrogens, which increase the irritabil-
ity of the uterine muscle, may aggravate rather
than alleviate the complaints; progesterone pro-
vides a more frequently beneficial form of symp-
tomatic therapy. Dysmenorrhea is relieved by
causing withdrawal bleeding, i.e., anovulatory
menstruation; this is usually effective in relieving
discomfort for 3 to 4 months, but ovulation
eventually occurs and symptoms recur (Bishop
and Orti, Proc. Roy. Soc. Med., 1952, 45, 803).
For this purpose estrogens are administered dur-
ing the first half of the menstrual interval.
Endometriosis can be controlled by the same
mechanism (Hurxthal and Smith, New Eng. J.
Med., 1952, 247, 339) but long-term therapy
is not feasible because of the side effects of the
large doses of estrogens required. Among 68 pa-
tients with amenorrhea or delayed menstruation
given estrogen and progesterone orally for 5
days, Soule (Obst. & Gynec, 1953, 1, 38) found
no effect on 15 who proved to be pregnant while
79 per cent of the 53 non-pregnant cases showed
vaginal bleeding an average of 3.37 days after
discontinuing the therapy. Sterility, oligomenor-
rhea or frigidity, if associated with an estrogenic
deficiency, may be benefited. Therapeutic results
in hirsutism have been poor.

Lactation Inhibition. — Lactation can be inhib-
ited by estrogens. If estrogenic therapy is com-
menced before lactation is established, pain,
engorgement and erythema are prevented (Walsh
and Stromme, Am. J. Obst. Gyn., 1944, 47, 593).
Although lactation may recur in about a week
after treatment is discontinued, it will again
respond to treatment. Such therapy may have a
beneficial effect on uterine involution (Con-
nally, Am. J. Obst. Gyn., 1943, 46, 125). Testos-
terone is also effective and is perhaps preferable
since it avoids the untoward effects of estrogen
administration; the action is presumably one of
inhibition of the lactogenic hormone of the pitui-
tary gland. Estrogenic treatment is valuable in
the management of acute mastitis. Periodic
mastalgia, painful engorgement of the breasts in
the premenstrual period, has been relieved by
estrogenic therapy. On the other hand, implanta-
tion of large amounts of diethylstilbestrol in
cows, which had failed to get in calf, produced
lactation in commercially useful quantities (see
J.A.M.A., 1945, 127, 399). Estrogen-containing
creams have been promoted as enlarging small
breasts for cosmetic purposes. It is certain that
estrogens are absorbed percutaneously and that
large doses of estrogens orally or parenterally
cause engorgement of breasts and pigmentation
of nipples but breast development is dependent
on factors other than estrogens (Miiller, Schweiz.
med. Wchnschr., 1953, 83, 81); the doses ab-
sorbed from cosmetic creams may be sufficient
to cause endometrial hyperplasia and abnormal
bleeding without any definite effect on the size
or contour of the breast other than that resulting
from incidental massage.

Cancer of Prostate. — In inoperable carcinoma
of the prostate gland, estrogenic therapy has
effected astonishing and gratifying relief of pain
(Huggins and Hodges, Cancer Res., 1941, 1,
293; Herbst, J. A.M. A., 1945, 127, 57). This is

Part I

Estradiol

535

one of the conditions in which availability of
cheap synthetic estrogenic substances has made
therapy practicable (see under Diethylstilbestrol) .
In one study about 60 per cent of cases re-
sponded, with rapid relief of pain and actual
regression of the primary tumor and of the me-
tastases for about 18 months, or in some
instances longer (Huggins, Science, 1943, 97,
541). This treatment is simpler and less objec-
tionable than castration, which produces similar
results (Nesbit et al., J. Urol., 1944, 52, 570);
if estrogens fail or symptoms recur, castration
may be performed. Painful engorgement of the
breasts is the untoward effect of estrogenic
therapy of cancer of the prostate (Moore et al.,
J.A.M.A., 1945, 127, 60). Remarkable changes
in the size and cytology of the tumor have been
reported (Kahle et al., J. Urol., 1943, 50, 711),
although the regressive changes are incomplete
and temporary (Fergusson and Franks, Brit. J.
Surg., 1953, 40, 422). The American statistics
(see under Diethylstilbestrol) find their counter-
part in Europe; Holder (Arch. klin. Chir., 1953,
275, 178) reported that 56 cases treated only by
palliative surgery were all dead within 1 year;
16 cases treated with estrogens alone were all
dead within 3 years; of 67 cases treated with
orchiectomy and estrogens during the period of
1943 to 1951, 39 were still alive at the time of
the report with 17 of the survivors having bone
metastases. Implantation of 100 mg. of diethyl-
stilbestrol into each testis was reported by Darget
et al. (Bordeaux Chir., 1952, 4 supplement, 101)
to cause complete atrophy of seminiferous and
interstitial tissue, a complete disappearance of
17-ketosteroids from the urine, and good clinical
results. Studies in animals by Nicol and Abou-
Zikry (Brit. M. J., 1953, 1, 133) demonstrated
that either castration or estradiol therapy stimu-
lated the reticuloendothelial system and fibro-
blastic proliferation, which resists the spread of
carcinoma; the combination of operative and
therapeutic procedures was more effective than
either by itself. Klein and Newman (Arch. Surg.,
1944, 48, 381) reported benefit from estrogens
in cases of benign prostatic hypertrophy, but this
has not become generally accepted therapy.

Carcinoma of the Breast. — Castration or tes-
tosterone therapy (q.v.) in women has proven
beneficial; strangely, so also has estrogenic
therapy in inoperable cases who have passed
the menopause at least five years. Lewison and
Chambers (New Eng. J. Med., 1952, 256, 1)
reported good responses in both primary tumor
sites and metastases in 21 of 40 cases receiving
estrogenic therapy. Early reports of failure, or
actual aggravation with estrogenic therapy (Ellis
et al., Proc. Roy. Soc. Med., 1944, 37, 731;
Henry, Can. Med. Assoc. J., 1945, 53, 31), seem
to have been in patients prior to or within 5
years of the menopause (Huseby, Ann. Surg.,
1954, 20, 112). Studies of urinary estrogen ex-
cretion in women with carcinoma of the breast,
by Huggins and Dao (J.A.M.A., 1953, 151,
1388), demonstrated high levels in both premeno-
pausal and postmenopausal cases. As much as 63
units (international) of estrogenic activity daily
was observed, whereas the average normal pre-

menopausal excretion was S3 units and post-
menopausal excretion was 4.7 units. After bi-
lateral adrenalectomy in castrated cases, the
urinary estrogen excretion decreased to zero and
the tumor in patients with papillary carcinoma
or adenocarcinoma regressed; duct carcinoma
rarely regressed and undifferentiated cell types
of breast carcinoma never regressed. It was
recommended that postmenopausal cases with
papillary carcinoma or adenocarcinoma and high
urinary estrogen excretion in spite of castration
be subjected to bilateral adrenalectomy. Injection
of aqueous solution of estrogenic materials locally
into epithelioma of the skin caused incomplete
degeneration of the cancer and stimulation of
the fibroblastic reaction (Agostini, Arch. Ital.
Derm. Si}. Vener., 1953, 25, 397).

Menorrhagia. — Estrogenic substances are em-
ployed to produce hemostasis (Cuyler et al.,
J. Clin. Endocrinol., 1942, 2, 1942; Karnaky,
ibid., 1945, 5, 279). Diagnostic efforts to ascer-
tain the cause of the bleeding must be conducted.
Large doses are indicated and have been employed
safely for periods as long as several months. On
discontinuation of therapy withdrawal bleeding
may occur for a short time. Patients in this cate-
gory who have hypothyroidism respond much
better to thyroid therapy.

Abortion. — In habitual abortion, Vaux and
Rakoff (Am. J. Obst. Gyn., 1945, 50, 353) re-
ported much better results when estrogenic sub-
stance was added to the usual regimen (including
progesterone) until the period of fetal viability.
Large doses of estrogens had no deleterious effect
on pregnancy (Belonoschkin and Bragulla, Klin.
Wchnschr., 1942, 21, 583) although restlessness,
vertigo, nausea, abdominal pain and urinary
urgency were induced. Estrogens do, however,
sensitize the uterine muscle to the action of
oxytocic drugs and have been administered the
day preceding the attempt to induce labor with
posterior pituitary injection. The Friedman test
for pregnancy is not affected by the administra-
tion of estrogens to the woman because the hemor-
rhagic follicles in the rabbit ovary are produced
by chorionic gonadotropin in the urine of preg-
nancy. Estrogens increase the peristaltic activity
of the human ureter (Hundley and Diehl,
J.A.M.A., 1945, 127, 572).

Calcium Metabolism. — Hills and Weinberg
(Bull. Johns Hopkins Hosp., 1941, 48, 328) used
estrogens to induce calcification in ununited frac-
tures. In senile (postmenopausal) osteoporosis,
Albright et al. (Trans. Asso. Am. Phys., 1940, 55,
298), Howard (Can. Med. Assoc. J., 1950, 63,
258) and others found that estrogens would con-
vert the negative into a positive calcium balance
and result in remineralization of the skeleton.
Fewer fractures were observed in the treated one
of twins with fragilitas ossium during medication
with estradiol and testosterone (Hernberg, Acta
med. Scandinav., 1952, 141, 309) but estrogen
may be undesirable in the young because of its
dwarfing effect from epiphyseal closure. As men-
tioned under Citric Acid, Shorr (/. Urol., 1945,
53, 507) reported that estrogens, by increasing
excretion of citrates in urine and thereby in-
creasing solubility of calcium in urine, were of

536

Estradiol

Part I

value in the prevention of stone formation in
patients with recurrent renal lithiasis of the cal-
cium carbonate and/or phosphate, and/ or mag-
nesium ammonium phosphate types.

Miscellaneous. — Estrogenic substances have
been used in the treatment of a miscellaneous
group of conditions. Following up the discredited
reports of the use of ovarian extracts for the
coagulation defect in hemophilia, Chassagne
(Progrds vied., 1945, 73, 282) reported restora-
tion of normal coagulation time over a period
of several days with 0.5 to 5 mg. of diethylstil-
bestrol daily intramuscularly. The fortunately
rare but often tragic syndrome of hereditary,
hemorrhagic telangiectasia, for which no therapy
has been successful, responded to ethinyl estra-
diol in a case reported by Shapiro (South African
M. J., 1953, 27, 885).

Improvement following oral estrogenic therapy
was described by Holbrook (Wisconsin M. J.,
1953, 52, 425) in 18 of 25 cases of adolescent
acne vulgaris in boys but the side effects (gyne-
comastia, testicular atrophy and early epiphyseal
fusion of the skeleton) were undesirable. Topical
application of 0.625 mg. of Premarin daily, in
an aqueous vehicle, in 1 to 3 divided doses was
effective in 9 of 12 cases. Topical application
of 1 to 2.5 mg. of estrogen per ml. of 70 per cent
alcohol or per Gm. of vanishing cream base to
acne vulgaris lesions, in a total quantity of 4 ml.
or 4 Gm. daily, produced excellent or marked
improvement in 25 of 42 women and 16 of 28
men (Shapiro, J. Clin. Endocrinol., 1952, 12,
751); however, gynecomastia, abnormal uterine
bleeding and pruritus occurred in a few cases.
Topical application of estradiol, estrone or tes-
tosterone to atrophic senile skin caused histo-
logical regeneration of the epithelium (Gold-
zieher et al., Arch. Derm. Syph., 1952, 66, 304).

Vaginal suppositories of estrogens corrected
vaginitis due to Trichomonas vaginalis (Candiani,
Rivista Ostet. Gin., 1953, 8, 281).

Law (Med. Press, 1943, 1, 351) reported clear-
ing of ringworm of the scalp, which had resisted
other measures, with 0.5 mg. of diethylstilbestrol
daily by mouth. Harder (N. Carolina M. J., 1946,
7, 20) used an 0.13 per cent diethylstilbestrol
ointment effectively for epidermophytosis and
other mycotic infections. Solutions of estrogenic
substances have been employed with some suc-
cess as a spray in atrophic rhinitis or stomatitis
and otosclerosis (Mortimer et al., Canad. Med.
Assoc. J., 1937, 37, 445 and 1939, 40, 17). Con-
firming results reported under diethylstilbestrol.
Crosnier (Presse med., 1952. 60, 1398) reported
effective prophylaxis of orchitis in cases of mumps
with 2 to 3 mg. diethylstilbestrol, 2 to 3 mg.
hexestrol, or 1 to 2 mg. dienestrol daily for 10
days, commencing as soon as mumps is diagnosed;
for treatment of orchitis double this dose was
used daily.

In acromegaly, McCullagh et al. (Cleveland
Clin. Quart., 1952, 19, 121) reported correction
of the diabetic state with large doses of estrogens
(up to 1 mg. daily of ethinyl estradiol). In dia-
betes mellitus complicated by pregnancy admin-
istration of diethylstilbestrol (q.v.), alone or
with progesterone, throughout the pregnancy

(White et al., Med. Clin. North America, 1953,
37, 1481) has been reported to improve fetal
survival rate from 16 per cent to 61 per cent in
cases without proliferative retinitis and to 50
per cent in the presence of retinitis; in cases with
nephritis the survival rate increased from about
8 to 66 per cent. The dose of estrogen was 25
mg. of diethylstilbestrol daily during the first
16 weeks of pregnancy, increasing to 125 to 250
mg. daily from the 34th week to delivery.
However, others believe that this improvement
in fetal mortality depends on the careful man-
agement of the diabetes during the pregnancy
rather than the ovarian hormone therapy (Pedo-
witz and Shlevin, Bull. N. Y. Acad. Med., 1952,
28, 440). Infertility in some women has been
ascribed to an abnormality of the mucus secreted
by the cervix of the uterus which the sperm is
unable to penetrate; Campes de Paz (Fertility &
Sterility, 1953, 4, 137) reported that intramus-
cular injection of 5 mg. of estradiol benzoate
on the 5th and 10th days after menstruation cor-
rected this abnormal mucus. McGrath and Herr-
mann (Ann. Surg., 1944, 120, 607) reported
marked improvement with estrogenic therapy in
peripheral vascular disturbances in which there
was a significant component of vasomotor imbal-
ance; their group of cases comprised Raynaud's
syndrome, thromboangiitis obliterans, arterio-
sclerosis obliterans, acute arterial occlusion, and
chronic phlebitis. Less certain value has been
reported for angina pectoris and for attacks of
migraine occurring at the time of the menstrual
flow.

For a discussion of the action of estrogens in
hypercholesterolemia and atheromatosis see under
Diethylstilbestrol.

Toxicology. — In general the toxic effects of
estrogens are exaggerations of their physiological
actions which may be induced by very large doses
or prolonged administration. With therapeutic
doses over short periods of time, untoward effects
are rare (Novak, J.A.M.A., 1944, 125, 98). With
some of the substances nausea, vomiting, abdom-
inal pain, skin rashes, and diarrhea may develop
after either oral or parenteral administration.
Sometimes allergic responses to the oil used as
a vehicle for the injection have occurred. Large
doses may inhibit the functions of the pituitary
and other glands of internal secretion and cause
sufficient calcification to produce a myelophthisic
anemia (Chevalier and Umdenstock, Sang,
1942-3, 15, 528). Although large doses have been
employed to stop functional uterine bleeding,
estrogens may cause uterine bleeding; also,
bleeding results with great frequency when estro-
gens are discontinued. During the first two weeks
of the menstrual interval, estrogens prevent ovu-
lation and postpone the next menstrual flow and
during the last half of the cycle they depress
corpus luteum formation. Gonadotropins, not
estrogens, are indicated to stimulate ovarian func-
tion.

Carcinogenic Hazard. — The cases of breast
or uterine carcinoma which have followed pro-
longed use of estrogenic substances (see under
Diethylstilbestrol) demand caution in the use
of these drugs. Finkler (/. A. M. Women's A.,

Part I

Estradiol Injection, Aqueous 537

1954, 9, 7), however, reported that no cases of
uterine carcinoma were seen in her 25 years
of careful use of estrogenic therapy where indi-
cated; her policy includes avoidance in women
with a family history of cancer, the use of mini-
mal doses in interrupted courses, and periodic
examination of the breasts and pelvis during
treatment. White (Ann. Surg., 1954, 139, 9)
pointed out that carcinoma of the breast is rare
during pregnancy (endogenous estrogens) and
that pregnancy after treatment of breast cancer
does not alter the prognosis for survival from
the cancer. Nevertheless, estrogens seem to play
a role in carcinoma of the breast (Huggins and
Dao, loc. cit.) and Jensen (Ugesk. f. laeger.,
1953, 115, 1950) found in an analysis of the
history of patients with carcinoma of the fundus
of the uterus in postmenopausal cases that
greater endogenous and exogenous estrogen action
had been present. Novak (J.A.M.A., 1954, 154,
217) summarized the situation as follows: post-
menopausal endometrial hyperplasia is associated
with and related to carcinoma of the uterine
fundus; estrogenic therapy causes hyperplasia of
the endometrium; but it cannot be concluded
that estrogenic therapy causes cancer because an
undefined genetic predisposition seems to be es-
sential.

Caution should be exercised with persons with
impaired liver function (Bennett et al., Am. J.
Clin. Path., 1950, 20, 814). In hamsters, Kirk-
man and Bacon (/. Nat. Cancer Inst., 1952, 13,
745) reported appearance of renal cortical tumors
after more than 150 days of diethylstilbestrol
therapy. Bleeding in patients with endometriosis
was caused by estrogens following castration
(Faulkner and Riemenschneider, Am. J. Obst.
Gyn., 1945, 50, 560). Abnormal bleeding in the
menopausal patient demands careful and re-
peated examination but biopsy may be post-
poned if it seems probable that estrogenic therapy
is responsible for the bleeding. In female children
a diagnosis of ovarian tumor should not be enter-
tained because of vaginal bleeding, gynecomastia,
etc., until the accidental or erroneous ingestion
of estrogens has been excluded (Cook et al.,
New Eng. J. Med., 1953, 248, 671). Estrogenic
therapy is probably contraindicated in cases of
disseminated lupus erythematosis (Ellis and
Bereston, Arch. Derm. Syph., 1952, 65, 170).

Allergy to steroid hormones occurs. Intracu-
taneous testing with the hormone preparation
compared with a similar injection of the vehicle
alone will demonstrate the causative agent and
desensitization can be carried out, if indicated,
by the usual method of subcutaneous injections
of progressively increasing doses. So far there is
no evidence that cosmetics containing estrogens
exert any beneficial influence on the changes of
aging in the skin or that such changes are related
to an estrogen deficiency (see J.A.M.A., 1945,
128, 515).

Dose. — The usual dose of estradiol by mouth
is 0.2 mg. (approximately %oo grain) but a dose
of 0.05 mg. (approximately 1/i2oo grain) daily is
given to infants with vulvovaginitis and one of
0.5 mg. (approximately Vi2o grain) and more
three times daily for mild menopausal symptoms.

Estradiol is well absorbed sublingually from a
solution in alcohol and propylene glycol contain-
ing 0.5 mg. per ml. (Hall, /. Clin. Endocrinol.,
1942, 2, 26) or as a tablet (Joel, ibid., 1942, 2,
639). Perloff (Am. J. Obst. Gyn., 1950, 59, 223)
found that the dose as buccal tablets was the
same as that of estradiol benzoate intramuscu-
larly and about one-fifth of the dose of estradiol
required by mouth. In the form of a gelatin-
glycerin vaginal suppository 0.4 mg. (approxi-
mately Aso grain) of estradiol for senile vaginitis
or 0.04 mg. (approximately Vi6oo grain) for in-
fantile vulvovaginitis is used each night. As an
ointment, 0.15 mg. (approximately 14oo grain)
or less of estradiol in 1 Gm. of ointment is rubbed
into the skin once or twice daily for senile
vaginitis. An oily nasal spray containing 0.013
mg. of estradiol per ml. is used in doses of 1 to
1.5 ml. twice daily for atrophic rhinitis. For paren-
teral administration estradiol benzoate or estra-
diol dipropionate is used (q.v.), although a solu-
tion of estradiol in propylene glycol has been
given intravenously well diluted (Kurzrok and
Streim, Am. J. Surg., 1952, 83, 117).

Pellets of estradiol, the amount depending on
the needs and metabolism of the individual, have
been placed in fatty subcutaneous tissues to pro-
duce a prolonged and continuous estrogenic effect.
Aqueous suspensions have been employed simi-
larly. Foreign body reaction induced by crystals
may result in fibrosis which may prevent complete
absorption of the estradiol (Walters et al., Proc.
Soc. Exp. Biol. Med., 1940, 44, 314); Deanesly
and Parkes (Lancet, 1943, 2, 500) observed that
protein was rapidly deposited on such crystals
but that there seemed to be no interference with
absorption.

Storage. — Preserve "in well-closed, light-re-
sistant containers." N.F.

AQUEOUS ESTRADIOL INJECTION.
N.F.

"Aqueous Estradiol Injection is a sterile sus-
pension of estradiol in water for injection. It
contains not less than 90 per cent and not more
than 110 per cent of the labeled amount of
C18H24O2." N.F.

The commercially available injections of this
type are variously prepared, as by precipitation
of estradiol from solution by addition of water
in the presence of suitable stabilizing agents, or
by subdivision dispersion of relatively large
crystals by appropriate mechanical methods, in-
cluding use of ultrasonic dispersion technics. The
products differ in the particle size of the sus-
pended estradiol; some contain relatively large
particles, others contain small particles, and still
others contain a mixture of large and small par-
ticles. It is to be expected that the intensity and
duration of action will vary to some extent at
least with variation of particle size; it is not pos-
sible to say what the optimum particle size should
be and it is probable that this will depend on the
particular need of the patient.

Uses. — Intramuscular injection of an aqueous
suspension of estradiol produces a somewhat
more prolonged effect than follows the injection

538 Estradiol Injection, Aqueous

Part I

of a solution of estradiol in oil. In non-menstru-
ating women, Vogel et al. (Am. J. Obst. Gyn.,
1949, 58, 147) reported that the character of
vaginal smears changed in 108 hours following
injection of 1 mg. of estradiol in oil, the change
persisting for 36 hours, whereas after the same
dose in aqueous suspension the change appeared
slightly more rapidly (90 hours) but persisted
for 109 hours. In general initial absorption and
excretion are perhaps more rapid after injection
of oil solutions than when suspensions are ad-
ministered. However, both types of injections
are generally used in the same dosage.

The N.F. gives the usual dose of estradiol, in
this dosage form, as 0.25 mg.

Storage. — Preserve "in single-dose or mul-
tiple-dose containers, preferably of Type I glass."
N.F.

Usual Sizes. — 0.25 and 1 mg. in 1 ml.

ESTRADIOL PELLETS. N.F.

"Estradiol Pellets consist of estradiol com-
pressed in the form of pellets, without the pres-
ence of any binder, diluent, or excipient." N.F.

These pellets, to be used by implantation,
must not contain any other material than
estradiol; the N.F. requires, as evidence of ab-
sence of foreign material, that a solution of
tablets representing 25 mg. of estradiol, in 1 ml.
of chloroform, shall be clear and practically free
from insoluble residue. It is required also that
the pellets shall be sterile.

Uses. — Estradiol pellets are used when a
small, continuous estrogenic effect is desired over
a period of several months. They have been
particularly useful in preventing severe meno-
pausal symptoms following hysterectomy and
bilateral ovariectomy in young women. It is a
relatively simple matter to implant three pellets
of 25 mg. each under the sheath of the rectus
abdominus muscle at the time the incision is
being closed following the operation (Delaplaine
et al., Surg. Gynec. Obst., 1952, 94, 323). Estro-
genic action persists for 9 to 15 months after
this procedure, and acute menopausal symptoms
are not experienced in the postoperative period;
by the end of a year endocrine readjustment has
occurred. Implantation of pellets in the mesen-
tery fails to produce effective estrogenic action
(Kirgis and Rothchild, Endocrinology, 1952, 50,
269). Subcutaneous implantation of pellets with
a Ream's or similar trocar of suitable dimensions
is a simple office procedure which may be per-
formed under local anesthesia and with a small
incision in the skin to admit the trocar.

Estradiol pellets commonly contain 10 mg. or
25 mg. of estradiol; the dosage varies from 10 mg.
to 75 mg. (see above), according to the needs
of the patient.

Storage. — Preserve "in tight containers hold-
ing one pellet each." N.F.

ESTRADIOL TABLETS. N.F. (LP.)

[Tabellae Estradiolis]

"Estradiol Tablets contain not less than 90
per cent and not more than 115 per cent of the

labeled amount of C18H24O2." N.F. The LP.
limits are the same.

I. P. Tablets of Oestradiol ; Compressi Oestradioli.

Assay. — The official assay is based on the
Kober reaction (Biochem. Ztschr., 1931, 239,
209) of estradiol with a solution of redistilled
phenol in sulfuric acid (phenolsulfonic acid),
modified to include some ferric ion, to produce
a red solution. Inclusion of iron in the Rober
reagent intensifies the color obtained with beta-
estradiol to approximately 2l/z times that ob-
tained without iron (private communication, F.
H. Wiley, Food and Drug Administration,
Washington, D. C). In the test, an aliquot
portion of a benzine solution of the estradiol
from the tablets, equivalent to 20 micrograms
of estradiol, is heated in a boiling water bath
for 35 minutes to develop the color fully; if the
mixture were not heated, only alpha-estradiol,
which may be present as an impurity, would
produce a color and this would be of an intensity
considerably greater than that given by an iden-
tical weight of beta-estradiol when the latter is
heated in order to develop its color fully. Also,
by heating the assay reaction mixture for the
prescribed period, the intensity of color pro-
duced by any alpha-estradiol present is reduced
considerably, an observation first made and util-
ized by Carol and Molitor (/. A. Ph. A., 1947,
36, 208). The optical density of the solution is
determined at 525 m(A, at which wave length
the colored derivative of the estradiol exhibits
maximum absorption; an optical density determi-
nation is also made at 420 mn, at which wave
length absorption due to non-estrogenic compo-
nents may be estimated. From the latter
observation the absorption due to non-estrogenic
components at 525 m\i is calculated by dividing
the E420 reading by 2, it having been established
that the ratio of E525 to E420 for such compo-
nents is 0.5. The difference between the two
optical densities at 525 mn is proportional to
the amount of estradiol present; this difference
is compared with the corresponding difference
observed for a 20-microgram portion of N.F.
Estradiol Reference Standard similarly treated.
N.F. The LP. uses the same assay.

Storage. — Preserve "in well-closed contain-
ers." N.F.

Usual Sizes. — 0.1 and 0.2 mg. (approximately
Yeoo and %oo grain).

ESTRADIOL BENZOATE.

U.S.P. (B.P., LP.)

Beta-estradiol Benzoate, (Estradiol Monobenzoate,
[Estradiolis Benzoas]

"Estradiol Benzoate is the benzoyl ester of
the beta isomer of estradiol (3,17p-diol-l,3,5-

Part I

Ethanolamine Oleate, Injection of 539

estratriene)." U.S. P. The B.P. defines Oestradiol
Monobenzoate as 3-benzoyloxy-17-hydroxy-l:3:5-
(lO)-oestratriene, stating that it may be prepared
by reduction of cestrone and benzoylation of the
3-oestradiol produced. The LP. defines it as
a-3-benzoyloxy-l 7-hydroxyoestratriene-l : 3 : 5.

B.P. (Estradiol Monobenzoate; CEstradiolis Monoben-
zoas. I. P. Oestradiol Benzoate; Oestradioli Benzoas.
Dihydroxyestrin Monobenzoate. Diogyn-B {Pfizer) ; Ovocylin
Benzoate (Ciba); Dimenformon Benzoate (Organon);
Progynon-B (Schering). Sp. Benzoato de Estradiol.

The presence of two hydroxy! groups in estra-
diol, at positions 3 and 17, permits of esterifica-
tion of one or both groups. The official ester, more
specifically designated as the 3-monobenzoate, is
esterified at the phenolic hydroxyl group of
position 3.

Description. — "Estradiol Benzoate occurs as
a white or creamy white, crystalline powder. It
is odorless, and is stable in air. Estradiol Benzoate
is almost insoluble in water. It is soluble in
alcohol, in acetone, and in dioxane. It is slightly
soluble in ether, and sparingly soluble in vege-
table oils. Estradiol Benzoate melts between
190° and 195°." U.S.P. The LP. melting range
is 191° to 196°.

Standards and Tests. — Identification. — (1)
A solution of 2 mg. of estradiol benzoate in 2 ml.
of sulfuric acid is greenish yellow and has a blue
fluorescence; on dilution with 2 ml. of water
the color changes to pale orange. (2) Estradiol
obtained by saponification of the benzoate melts
between 173° and 179°. (3) Estradiol obtained
in the preceding test, coupled with diazotized sul-
fanilic acid, has a deep red color. (4) Benzoic
acid, obtained in identification test (2), melts
between 120° and 122°. Specific rotation. — Not
less than +58° and not more than +63°, when
determined in a dioxane solution containing 100
mg. of dried estradiol benzoate in 10 ml. Limit
of alpha-estradiol.— -The corresponding test under
estradiol is used. Residue on ignition. — The resi-
due from 100 mg. is negligible. Completeness and
reaction of solution. — 100 mg. of estradiol ben-
zoate dissolves completely in 5 ml. of warm
alcohol and the solution, after cooling, is only
slightly acid to litmus paper. U.S.P.

The B.P. provides two tests for the estradiol
obtained by saponification of the benzoate. In
one of these 0.05 mg. is heated with 1 ml. of a
2.5 per cent w/w solution of 3-naphthol in sul-
furic acid for 2 minutes at 100° ; on adding 1 ml.
of water to the cooled solution an orange-yellow
color, changing to red when the solution is heated
at 100° for 90 seconds, is produced. In the second
test a red color or precipitate is produced on
adding 2 or 3 drops of mercury nitrate solution
(Millon's reagent) to 5 ml. of a saturated aque-
ous solution of estradiol. A test for limit of
estrone consists in dissolving 2.5 mg. in 0.5 ml.
of 1 N potassium hydroxide in dehydrated alcohol,
adding 0.2 ml. of a 2 per cent w/v solution of
dinitrobenzene in dehydrated alcohol and, after
keeping the mixture at 25° for an hour in a place
protected from bright light and then adding
10 ml. of dehydrated alcohol, the resultant color,
showing an absorption band in the green, is less

intense that that produced in a similar test per-
formed with 0.1 mg. of estrone.

Uses. — Estradiol benzoate is an intramuscu-
lar dosage form of estradiol; it has the actions
and uses of other estrogenic substances (see
under Estradiol). Parenterally administered, it is
approximately three times as active as estrone.
Estradiol benzoate is less rapidly destroyed in
the body than is free estradiol; it is likewise less
rapidly absorbed and excreted, and thereby is
more effective in clinical use. [v]

The usual dose is 1 mg. (approximately Vm
grain) daily, given intramuscularly, with a range
of 0.1 to 5 mg. ; the maximum safe dose seldom
exceeds 5 mg. daily. In the menopause, from
0.33 to 3>.3>3 mg. weekly is given in single or
divided dose. Similar doses are used for other
conditions which are treated with estrogens. For
suppression of lactation, 1.66 mg. has been given
on each of 2 successive days.

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S.P.

INJECTION OF ETHANOLAMINE
OLEATE. B.P.

Injectio .ffithanolaminae Oleatis

Injection of Ethanolamine Oleate contains
ethanolamine oleate equivalent to not less than
3.9 per cent w/v and not more than 4.3 per cent
w/v of oleic acid, C17H33COOH, and not less
than 0.85 per cent w/v and not more than 0.93
per cent w/v of ethanolamine, C2H7ON. B.P.

The injection may be prepared by gradually
adding 0.91 Gm. of ethanolamine to a dispersion
of 4.23 Gm. of oleic acid in 50 ml. of water for
injection, shaking thoroughly to insure conver-
sion of the reactants to ethanolamine oleate,
which is soluble in water. After the reaction is
complete 2.0 ml. of benzyl alcohol is added and,
after agitating thoroughly, sufficient water for
injection to make the final volume 100 ml. The
injection is sterilized by heating in an autoclave.
The pH of the injection is required to be between
8.0 and 9.2. B.P.

Assay. — For oleic acid. — The oleic acid in 10
ml. of the injection is liberated with 20 ml. of
0.1 N sulfuric acid and extracted with three por-
tions, each of 25 ml. of chloroform. After wash-
ing each chloroform extract with the same 10 ml.
portion of water, the combined chloroform solu-
tion is evaporated to dryness, the residue of oleic
acid dissolved in alcohol previously neutralized
to phenolphthalein, and the solution titrated
with 0.1 N sodium hydroxide, using phenolphtha-
lein as indicator. Each ml. of 0.1 N sodium hy-
droxide represents 28.24 mg. of C17H33COOH.
For ethanolamine. — The excess of acid in the
combined acid layer and washings obtained in
the preceding assay is titrated with 0.1 N sodium
hydroxide, using methyl orange as indicator.
Each ml. of 0.1 N sulfuric acid required to neu-
tralize the ethanolamine represents 6.108 mg. of
C2H7ON. B.P.

Uses. — This injection is offered as a substitute
for the troublesome injection of sodium morrhu-
ate, which is a variable substance and subject to
precipitation during storage; the ethanolamine

540 Ethanolamine Oleate, Injection of

Part I

oleate injection, on the other hand, is more defi-
nite in composition and remains clear. The benzyl
alcohol in the injection serves as an analgesic.

The injection prepared by the above method
contains 5 per cent w/v of ethanolamine oleate.
An injection of this concentration, containing also
the benzyl alcohol, is available in 5 ml. ampuls
under the name Monolate (Abbott).

Ethanolamine oleate injection is employed as
a sclerosing agent for the obliteration of varicose
veins. Several investigators have reported it to
be the most satisfactory of the sclerosing agents
(see Biegeleisen, Ann. Surg., 1937, 105, 610; also
Rogers, Brit. M. J., 1939, 2, 385). It is only
slightly irritant to perivenous tissue and ulcera-
tion is not likely to occur if some of the solution
escapes out of the vein.

The dose is 1 to 2 ml, injected into the lumen
of the varicosity, with not more than a total of
5 ml. given at one time; the dose is repeated at
weekly intervals.

Storage. — Protect the injection from exposure
to light.

ESTRADIOL BENZOATE
INJECTION. U.S.P. (B.P.) (LP.)

[Injectio Estradiolis Benzoatis]

"Estradiol Benzoate Injection is a sterile solu-
tion of estradiol benzoate in oil. It contains not
less than 90 per cent and not more than 115 per
cent of the labeled amount of C25H28O3." U.S.P.
Under the title Injection of (Estradiol Mono-
benzoate the B.P. recognizes a sterile solution of
oestradiol monobenzoate in ethyl oleate or a suit-
able fixed oil. When the volume in each container
does not exceed 30 ml., the containers are heated
at 150° for one hour to effect sterilization; when
the volume exceeds 30 ml., the containers are
heated for a sufficient time to ensure that the
whole of the solution in each container is main-
tained at 150° for one hour; no assay rubric is
provided. B.P. The LP. title for this preparation
is Injection of Oestradiol Benzoate (Injectio
Oestradioli Benzoatis); it is a sterile solution in
ethyl oleate or a suitable oil and is required to
contain not less than 90.0 per cent and not more
than 115.0 per cent of the labeled content of
oestradiol benzoate.

Assay. — An iso-octane solution of an accu-
rately measured volume of the injection is pre-
pared and an aliquot portion, equivalent to 1.0
mg. of estradiol benzoate, is taken for the analy-
sis. This is diluted with iso-octane, and the result-
ing solution extracted with several portions of 70
per cent alcohol, which removes the estradiol
benzoate. The combined alcohol solutions are
evaporated in the presence of sodium carbonate
T.S., which hydrolyzes estradiol benzoate to
estradiol and sodium benzoate. The estradiol,
being phenolic, is converted to water-soluble form
by addition of sodium hydroxide solution; this
solution is extracted with iso-octane to remove
any non-phenolic impurity. The alkaline solutions
are acidified and the estradiol is extracted with
benzene; the benzoic acid which is also extracted
by the benzene is subsequently separated by shak-
ing the benzene with sodium carbonate T.S. After

washing the benzene solution with water, and
drying it with anhydrous sodium sulfate, it is
diluted to a definite volume and an aliquot portion
is submitted to the assay described under Estradiol
Tablets. A portion of Estradiol Benzoate Refer-
ence Standard is treated in the same manner as
the estradiol benzoate injection in order to have
a basis for quantitative evaluation of the observa-
tions made on the injection. U.S.P.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass."
U.S.P.

Usual Sizes. — 0.166, 0.333, 1, and 1.66 mg.
(approximately ]/4oo, Vl'oo, %o, and Vm grain) in
1 ml.; 1.66 and 3.33 mg. (approximately lio and
V20 grain) in 10 ml.

ESTRADIOL DIPROPIONATE. U.S.P.

0-C0CH2CH3

CH3CH20C-0

"Estradiol Dipropionate is the dipropionyl ester
of the beta isomer of estradiol." U.S.P.

Dimenformon Dipropionate (Orr/anon) ; Ovocylin Dipro-
pionate (Ciba) ; Progynon-DP (Schering).

Whereas estradiol benzoate is esterified at only
one of the two hydroxyl groups of estradiol,
namely, at the hydroxyl group attached to carbon
atom number 3, estradiol is esterified at the
hydroxyls of both carbon atoms number 3 and
number 17.

Description. — "Estradiol Dipropionate occurs
as small, white or slightly off-white crystals or
crystalline powder. Estradiol Dipropionate is
practically insoluble in water. It is soluble in
acetone and in alcohol, and is sparingly soluble
in vegetable oils. Estradiol Dipropionate melts
between 104° and 109°." U.S.P.

Standards and Tests. — Identification. — (1)
Estradiol obtained by saponification of the di-
propionate melts between 173° and 179°. (2) A
solution in 2 ml. of sulfuric acid of 2 mg. of
estradiol obtained in the preceding test is greenish
yellow and exhibits a green fluorescence; on add-
ing 1 drop of ferric ammonium sulfate T.S. the
green color is strongly intensified and on dilution
with water it changes to red or orange-red. Spe-
cific rotation. — Not less than +37° and not more
than +41°, when determined in a dioxane solu-
tion containing 100 mg. of dried estradiol dipro-
pionate in 10 ml. Loss on drying. — Not over 0.5
per cent, when dried in vacuum over sulfuric acid
for 4 hours. Completeness and reaction of solu-
tion.— 100 mg. of estradiol dipropionate dissolves
completely in 5 ml. of warm alcohol and the solu-
tion, after cooling, is only slightly acid to litmus
paper. U.S.P.

Uses. — Estradiol dipropionate exerts a more
prolonged estrogenic effect than does estradiol
benzoate, and reputedly also provides a slightly

Part I

Estrone

541

greater therapeutic effect (Allen, South. M. J.,
1944, 37, 270).

The U.S. P. gives the category and dose as being
the same as for estradiol benzoate. Estradiol di-
propionate is supplied in oil solution in concentra-
tions of 0.1, 0.2, 0.5, 1, 2.5 and 5 mg. per ml.

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S.P.

ESTRONE. U.S.P. (LP.)

(Estrone, Theelin, [Estronum]

The LP. defines Oestrone as 3-hydroxy-17-
keto-oestratriene-1 :3 :5.

LP. Oestrone; Oestronum. Folliculin; Ketohydroxyestrin,
Folliculinura. Fr. Folliculine ; (Estrone; CEstrine; Theeline.
Sp. Estrona.

After its absorption into the blood stream
estradiol (see under this title) is partly eliminated
as such through the urine but a considerable pro-
portion of it undergoes chemical change before
excretion. Certain of its decomposition products
also have estrogenic activity which, however, is
inferior to that of estradiol. One of the decom-
position products is the keto derivative, estrone,
which is of historical interest as being the first of
the estrogens isolated in chemically pure form;
this was accomplished in 1929 by Doisy, who
called the substance Theelin.

Chemically, estrone is a derivative of cyclo-
pentanoperhydrophenanthrene, being 3-hydroxy-
17-keto-l,3,5(10)-estratriene. In addition to its
occurrence in human pregnancy urine it is also
found in mare pregnancy urine, stallion urine,
male human urine, placenta and palm kernel oil.
Details of the isolation of estrone from pregnancy
urine are provided in U. S. Patents 1,967,350 and
1,967,351. Estrone is also obtained through partial
synthesis from steroids such as cholesterol, ergos-
terol (see U. S. Patent 2,202,704), and from
steroidal components of the Mexican yam Dios-
corea. Its complete synthesis from non-steroidal
sources has been accomplished by Anner and
Miescher (Experientia, 1948, 4, 25), who used a
derivative of an octahydro-2-phenanthrenecar-
boxylic acid as the starting compound, and by
Johnson and Christiansen (J.A. C.S., 1951, 73,
5511), who started with anisole and built up the
rings of the steroid in a relatively short synthesis.
The estrogenic activity of 0.1 microgram of crys-
talline estrone constitutes the international unit,
corresponding to 10 million such units per gram
of estrone.

Estrone is an oxidation product of estradiol in
which the secondary alcohol group of the latter
has been oxidized to a keto group. Estrone is
also closely related to estriol (see in Part II)
or theelol, the second estrogenic hormone to have
been isolated from human pregnancy urine and

now also thought to be a metabolic product of
estradiol, as well as of estrone. Chemically, estriol
is 3,16,17-trihydroxy-l,3,5-estratriene or trihy-
droxyestrin and differs from estrone in the sub-
stitution of a secondary alcohol group for the
ketonic structure of carbon atom 17 and also in
having another secondary alcohol group in the 16
position. Another compound closely related to
estrone is equilin, chemically 3-hydroxy-17-keto-
1,3,5,7-estratetraene, an estrogenic hormone de-
rived from the urine of pregnant mares and differ-
ing from estrone only in having one additional
double bond in its structure. Hippulin, isomeric
with equilin, has also been isolated from pregnant
mares' urine. Equilenin, another hormone isolated
from pregnant mares' urine, differs from estrone
in containing two additional double bonds; chem-
ically it has the formula of 3-hydroxy-17-keto-
1,3,5,6,8-estrapentaene. Equilenin has been syn-
thesized (J.A.C.S., 1940, 62, 824); of the four
optically active isomers of this compound which
are possible, only the naturally occurring d-equi-
lenin possesses appreciable estrogenic activity.

Description. — "Estrone occurs as small, white
crystals, or as a white to creamy white crystalline
powder. It is odorless, and is stable in air. Estrone
is slightly soluble in water. It is soluble in alcohol,
in acetone, in dioxane, and in solutions of fixed
alkali hydroxides. Estrone melts between 256°
and 262°. U.S.P.

Standards and Tests. — Specific rotation. —
Not less than +158° and not more than +165°,
when determined in a dioxane solution containing
100 mg. of estrone in each 10 ml. Residue on igni-
tion.— The residue from 100 mg. is negligible.
Equilenin and equilin. — A solution representing
1 mg. of estrone produces with dibromoquinone-
chloroimide no more red color, under the condi-
tions of the test, than that produced by 20 meg.
of equilenin used as a control. U.S.P. The LP.
gives the absorptivity (1%, 1 cm.) in fluorescence-
free dehydrated alcohol, at 280 mn, as between
80 and 90.

Estrogenic Substances. — In addition to the
official crystalline estrone there are also on the
market many preparations of highly concentrated
estrogens, generally consisting mainly (up to 95
per cent) of estrone (see Assay under Estradiol),
the remainder being made up of the other estro-
genic substances found in the urine of pregnant
mares or other natural source from which these
preparations are made. For a summary of a
method of extracting the substances from mare's
urine, see N.N.R. 1950. These mixed estrogens
are either dissolved in oil or prepared in the form
of an aqueous suspension for use by intramuscu-
lar injection; the common potencies are 2000,
5000, 10,000, 20,000 and 50,000 international
units per ml. The international unit referred to
here is the estrus-producing activity represented
in 0.1 microgram (0.0001 mg.) of the interna-
tional standard estrone; thus a solution containing
10,000 units is assumed to be equivalent, in estrus-
producing activity, to 1 mg. of pure estrone.
Capsules, tablets, vaginal suppositories and prep-
arations for local application containing the mixed
estrogens are also available. Some manufacturers
and distributors simply call such products cap-

542

Estrone

Part I

sules, tablets, solution, etc., of Estrogenic Sub-
stances or of Estrogens; others have adopted
distinctive names.

Conjugated Estrogens. — Another type of
preparation of estrogenic substances, in amor-
phous form, is that obtained by extracting the
naturally occurring, water-soluble, conjugated
forms of the mixed estrogens in the urine of preg-
nant mares; such conjugated estrogenic sub-
stances, as they are called, consist principally of
sodium estrone sulfate and the potency is com-
monly expressed in terms of the equivalent weight
of this compound. For a method of extraction
see N.N.R. 1952. The commercial preparations
recognized by N.N.R, are Amnestrogen (Squibb),
Conestron (Wyeth), Estrijol (Premo), Hortnes-
teral (Miller), Konogen (Lilly), and Premarin
(Ayerst). Tablets containing 0.3 mg., 0.62 mg.,
1.25 mg., and 2.5 mg. are available, also Liquid
Premarin, which contains 0.16 mg. per ml.; all
preparations are for oral use. For control of
menopausal symptoms a dose of 1.25 mg. daily is
usually sufficient but may be increased if neces-
sary; for treatment of senile vaginitis, kraurosis
vulvae and pruritus vulvae the daily dose usually
varies between 1.25 and 3.75 mg.; for palliation
of mammary cancer a daily oral dose of 30 mg.
is recommended.

A purified preparation of natural estrone sul-
fate, combined with piperazine to form a mono-
piperazine salt and known as piperazine estrone
sulfate, has recently become available, under the
trade-marked name Sulestrex Piperazine (Ab-
bott) ; the product is recognized in N.N.R. , and
is supplied in tablets containing 0.75 mg., 1.5 mg.
and 3 mg., also an elixir containing 0.3 mg. per
ml. The piperazine, which is pharmacologically
inert, acts as a buffer to increase the stability of
estrone sulfate; in the body the compound is
rapidly hydrolyzed to estrone. For control of
menopausal symptoms the daily dose is 1.5 mg.,
administered orally. For senile vaginitis, kraurosis
vulvae and pruritus vulvae 1.5 to 4.5 mg. should
be adequate. For postpartum breast engorgement
4.5 mg. is administered at 4-hour intervals for
5 doses.

Uses. — Action. — The physiological action of
estrone is similar to that of estradiol. Statements
as to the relative potency of these compounds
are quite divergent, not only when the compari-
son is made in different animal species but even
when different investigators employ the same spe-
cies of test animal (see Freed, J.A.M.A., 1941,
117, 1175). In the human it appears that estrone,
when injected intramuscularly, has about one-
third the potency of estradiol benzoate (see
Uses of Estradiol). When assayed by observation
of withdrawal bleeding in patients with amenor-
rhea estrone was found to have one-twentieth the
potency of diethyls tilbestrol (Bishop et al., Lancet,
1951, 1, 818).

The available knowledge of the metabolism of
estrone has been discussed in part above. Incuba-
tion of estrone with human red cell and serum
mixtures results in increased biological activity
while incubation with serum alone does not change
activity (Bischoff et al., Am. J. Physiol., 1951,
164, 774); the activity of estradiol or estriol is

not changed by incubation with the red cell and
serum mixture. Since injection of estrone is fol-
lowed by an increase of estradiol in the urine
(Stimmel, J. Clin. Endocrinol, 1947, 7, 364) it
appears that in the body estrone is partly con-
verted to estradiol and estriol.

A simple pregnancy test based on observation
of the increase in concentration of estrone in
blood, reported by Richardson {Am. J. Obst.
Gyn., 1951, 61, 1317) to be highly accurate, has
been found to give both false positive and false
negative results (Halpern et al., Proc. S. Exp.
Biol. Med., 1952, 80, 182; Horwitt and Segaloff,
J.A.M.A., 1953, 151, 406).

Therapeutic Uses. — Estrone has the uses of
other estrogenic substances: in menopause, senile
vaginitis, gonorrheal vaginitis, female hypogonad-
ism, carcinoma of the prostate, etc. (see under
Estradiol for discussion). In management of
amenorrhea, Finkler {Acta Endocrinol., 1951, 7,
122) advocated a single injection of an aqueous
suspension of 5 mg. of estrone with 25 to 50 mg.
of progesterone, or of 10 mg. of estrone with 50
mg. of progesterone; he reported satisfactory
menstrual flow in 22 of 24 patients thus treated.
For functional uterine bleeding a mixture of 6
mg. of estrone, 50 mg. of progesterone, and 25 mg.
of testosterone, in an aqueous suspension, or of a
mixture of 1.67 mg. of estradiol benzoate, 25 mg.
of progesterone, and 25 mg. of testosterone pro-
pionate, in oil solution, injected intramuscularly
daily for 3 to 5 days has been advocated by
Greenblatt and Barfield {Am. J. Obst. Gyn., 1952,
63, 153). They reported that bleeding ceased in
5 to 24 hours in 19 of 20 cases, and in 72 hours
in the other case; withdrawal bleeding simulating
normal menstrual behavior followed discontinu-
ance of the injections within 24 to 72 hours in 15
of the 20 cases. Twenty days after the withdrawal
bleeding progestational therapy is advocated to
induce menstruation; this procedure may be re-
peated cyclically to establish a normal rhythm.
Histological examination of specimens showed a
progestational change superimposed on the cystic
glandular hyperplasia usually present in these
cases as well as in those treated with estrogens
only to stop menorrhagia. Some believe that
estrogens are not required in the mixture, since
an excess of estrogen action is already present in
this condition; thus a mixture of 25 mg. each of
progesterone and testosterone is employed daily
for 4 or 5 days for "medical curettage."

Dose. — The usual dose of estrone, adminis-
tered intramuscularly, varies from 0.2 to 1 mg.
(approximately ^oo to Veo grain) ; the maximum
safe dose is usually 5 mg., and this quantity is
seldom exceeded in 24 hours. Estrone may be in-
jected as an oil solution or, more commonly, as
an aqueous suspension. In the menopause, 0.2 to
1 mg. is injected one or more times a week,
according to the response of the patient; the
smallest effective dose should be employed, and
administration should be discontinued as soon as
relief is obtained. As much as 5 mg. weekly may
be required in some instances of postmenopausal
vaginitis and other conditions. Glycerogelatin sup-
positories containing 0.2 mg. of estrone are of
value in senile as well as in gonorrheal vaginitis.

Part I

Ether

543

Estrone is effective by mouth if given in suffi-
ciently large doses ; the dose must be at least five
times that by injection. It has also been adminis-
tered by implantation of tablets; approximately
3 months is required for absorption of 30 mg.
of estrone.

Estrone dosage is sometimes stated in inter-
national units; 1 mg. of estrone is equivalent to
10,000 such units. As a rough approximation,
1 rat unit corresponds to about 3 international
units. The potency of preparations known as
estrogenic substances (see above) are commonly
expressed in such units ; their dosage may be esti-
mated from the equivalent given. For doses of
conjugated estrogenic substances see elsewhere in
this monograph.

Storage. — Preserve "in tight, light-resistant
containers." U.S. P.

ESTRONE INJECTION. U.S.P. (LP.)

[Injectio Estroni]

"Estrone Injection is a sterile solution of
estrone in oil. It contains not less than 90 per
cent and not more than 115 per cent of the labeled
amount of C18H22O2." U.S.P. The LP. definition
and rubric are the same.

I. P. Injection of Oestrone ; Injectio Oestroni.

Assay. — Originally proposed by Carol and
Rotondaro (/. A. Ph. A., 1946, 35, 176), the
official assay is based on the following principal
steps: (1) Extraction of estrone and any other
phenolic steroids present first into sodium hydrox-
ide solution, then into ether following acidification
of the alkaline solution, followed by solution in
chloroform and evaporation of the latter; (2)
separation of estrone, together with any other
phenolic ketosteroids present, from non-ketonic
steroids by complexing the former with Girard's
Reagent T (trimethylacethydrazide ammonium
chloride); (3) decomposition of the estrone com-
plex with acid, extraction of the liberated estrone
into chloroform, followed by evaporation of the
chloroform and drying of the residue of estrone
in a vacuum desiccator to constant weight. U.S.P.
For a colorimetric method of determining estrone,
equilin and equilenin in mixtures, utilizing di-
bromoquinonechloroimide in conjunction with a
modified Kober solution, see Banes (/. A. Ph. A.,
1950, 39, 37). The LP. uses the same assay
method as the U.S.P.

Uses. — Aqueous suspensions of crystals of
estrone, and also of other steroid hormones, have
become more popular than solutions in oil, for
two reasons: (1) the tissues of some patients are
adversely affected by oil; (2) the crystals of a
suspension are more slowly absorbed from the
injection site and hence have more prolonged
action. A comparison of the duration of action
of crystals of estrone of different size, as observed
by changes in the vaginal smears of ovariec-
tomized rats following intramuscular injection of
5000 international units, indicated that crystals
with a length of 10 microns or less produced
estrogenic effect for 10 days; crystals of 25 to 30
microns were active 17 days, and crystals of 50
to 150 microns were active 24 days (Simond

et al., J. A. Ph. A., 1950, 39, 52). The duration of
action of the smallest crystals was slightly longer
than that of the same dose in oil solution, and
also longer than that of an aqueous suspension of
estradiol crystals or of an oil solution of estradiol
benzoate.

In clinical use aqueous suspensions of estrone
provided smooth, continuous estrogenic action
(Freed and Greenhill, J. Clin. Endocrinol., 1941,
1, 983). Maximum urinary excretion (as estrone,
estradiol, and estriol), amounting to 6.1 per cent
of the injected dose, occurred during the first 3
days following injection of an oil solution of
estrone, while with an aqueous solution urinary
excretion amounted to only 3.5 per cent during
the first 3 days and was fairly steady for 7 days
(Stimmel, ibid., 1947, 7, 364).

The usual dose of estrone in aqueous suspen-
sion is the same as when it is administered in oil
solution (see statement of dose under Estrone)
except that injections may not be required as fre-
quently. Injections should be given deep into a
large muscle to avoid discomfort from the crys-
tals, which represent a foreign body in the tissues
until they are dissolved. An occasional patient
may manifest hypersensitivity to the pure steroid
hormone.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass."
U.S.P.

Usual Sizes. — 0.1, 0.2, 0.5 and 1 mg. in 1 ml.

ETHER. U.S.P. (B.P., LP.)

Ethyl Ether, Diethyl Ether, [.ffither]
(C2H5)20

"Ether contains from 96 per cent to 98 per
cent of C4H10O, the remainder consisting of
alcohol and water. Caution. — Ether is highly
flammable. Do not use where it may be ignited.
Ether to be used for anesthesia must be preserved
in tight containers of not more than 3 Kg. capacity
and is not to be used for anesthesia if it has been
removed from the original container longer than
24 hours. Ether to be used for anesthesia may,
however, be shipped in larger containers for
repackaging in containers as directed above, pro-
vided the ether at the time of repackaging meets
the requirements of the tests of this Pharmaco-
peia." U.S.P.

Anaesthetic Ether is the title by which both
the B.P. and the LP. recognize this grade of
ether; it is defined as purified diethyl ether to
which may be added a suitable stabilizer in a
proportion not greater than 0.002 per cent w/v.

B.P. Anaesthetic Ether; .ffither Anaestheticus. LP.
Aether Anaesthesicus. Purified Ether; Sulfuric Ether;
Ethyl (Diethyl) Oxide, .^ther /Ethylicus; .(Ether Purifica-
tus; Either pro Narcosi. Fr. fither ethylique; £ther officinal;
fether anesthesique; £ther pur. Ger. Ather; Narkoseather.
It. Etere etilico; Etere. Sp. Eter.

It is to be noted that two grades of ethyl ether,
one suitable for use as an anesthetic and the other
not, are recognized by the U.S.P. and B.P. ; the
LP. recognizes only the anesthetic grade. While
the B.P. and the LP. titles clearly indicate the
distinction between the two grades of ether, the
B.P. using the title Solvent Ether for the less pure

544

Ether

Part I

grade, the U.S. P. calls the anesthetic grade simply
Ether and the solvent grade Ethyl Oxide, which
terminology may be confusing.

While aldehydes, which are among the more
objectionable of impurities to be found in ether,
are apparently excluded from both grades of
ether according to U.S. P. specifications, the test
for this impurity in Ethyl Oxide is less sensitive
than the test applied to Ether (U.S. P.). Mal-
linckrodt reported (J.A.C.S., 1927, 49, 2655)
that the order of sensitivity of the former test
is approximately 5 parts in 10,000, while the
latter is sensitive to 1 part in 1,000.000 if the
mercuric iodide test solution is prepared as di-
rected in U.S. P.

Ether is commonly prepared from alcohol by
the action of sulfuric acid, according to the
following reaction:

C2H5OH + SO2OH.OH -> SO2OH.OC2H5 + HOH

that is. alcohol reacting with sulfuric acid yields
ethylsulfuric acid (sulfovinic acid) and water.
In the presence of an excess of alcohol and at
the proper temperature, the ethylsulfuric acid
subsequently reacts with another molecule of
alcohol, as follows:

C2H5OH + SO2OH.OC2H5-*

C2H5OC2H5 + SO2OH.OH

whereby ethyl oxide (ether) is formed, and sul-
furic acid is regenerated. These reactions take
place best at a temperature of about 140°, and
if the mixture in the still is kept at this tempera-
ture a steady stream of alcohol can be converted
into ether, until the efficiency of the sulfuric acid
is too far reduced by dilution or by-product
formation. At higher temperatures ethylene is
produced from the same reactants; indeed some
is produced also when ether is manufactured but
it remains dissolved in the sulfuric acid (see
Ethylene).

The B.P. and LP. permit addition of a suitable
stabilizer in a proportion not exceeding 0.002
per cent w/v. Among the substances used as
stabilizers, according to the British Pharmaceu-
tical Codex, are hydroquinone and propyl gallate.

Description. — "Ether is a transparent, color-
less, mobile liquid, having a characteristic odor,
and a burning, sweetish taste. It is slowly oxi-
dized by the action of air. moisture, and light,
with the formation of peroxides. Ether boils at
about 35°; it is highly volatile and flammable.
Its vapor, when mixed with air and ignited, may
explode violently. Ether dissolves in about 12
times its volume of water with slight contraction
of volume. It is miscible with alcohol, benzene,
chloroform, petroleum benzin. and with fixed and
volatile oils. The specific gravity of Ether is not
less than 0.713 and not more than 0.716 (indi-
cating 96 to 98 per cent of C4H10O)." U.S.P.

Ether dissolves, at room temperature, approxi-
mately 1.5 per cent of water (see Rowlev and
Reed, J.A.C.S., 1951, 73, 2960), which presents
a problem in those procedures of synthesis or
analysis where anhydrous ether is required. Such
anhydrous or absolute ether may be prepared
by drying ether over sulfuric acid, solid sodium

hydroxide, calcium chloride, metallic sodium, or
a mixture of calcium chloride and sodium; de-
pending on which substance is used, more or less
of the alcohol present is also removed.

Ether volatilizes very rapidly in air, with ab-
sorption of considerable heat. It is extremely
flammable, and care should be taken not to bring
it in the vicinity of a flame or electric spark;
ether vapors may ignite from a flame several feet
away from the ether. Salzer (J.A.M.A., 1929, 92,
2096) reported that 2 per cent of ether vapor
in the air is flammable, or explosive if confined.
On exposure to air ether undergoes decomposi-
tion, and is converted in part into aldehyde,
acetic acid and organic peroxides.

Ether dissolves iodine and bromine freely, and
sulfur and phosphorus sparingly. Its solvent
power for mercury bichloride makes it useful
in detecting that poison. Ether is also a solvent
of volatile and fixed oils, many resins and bal-
sams, tannic acid, caoutchouc, and most of the
vegetable alkaloids. It does not dissolve potassium
or sodium hydroxide, in which respect it differs
from alcohol.

Standards and Tests. — Acidity. — Not more
than 0.4 ml. of 0.02 A' sodium hydroxide is re-
quired to neutralize 25 ml. of ether mixed with
10 ml. of 80 per cent alcohol previously neutral-
ized with the same alkali, using phenolphthalein
T.S. as indicator. Non-volatile residue. — Not over
1 mg. from 50 ml. of ether, evaporated spon-
taneously, the residue being dried at 105° for
1 hour. Foreign odor. — No foreign odor is per-
ceptible on evaporating ether spontaneously from
a volume of 10 ml. to 1 ml. or when this residue
is transferred to absorbent paper and the last
traces of ether have evaporated. Aldehyde. — No
turbidity is apparent in the water layer of a
mixture of 20 ml. of ether and 7 ml. of a mixture
of 1 ml. of alkaline mercuric-potassium iodide
T.S. with 17 ml. of a saturated solution of re-
agent sodium chloride, after shaking vigorously
for 10 seconds in a glass-stoppered cylinder, then
setting aside for 1 minute. Peroxide.— When
viewed transversely, no color is seen in either
liquid of a mixture of 10 ml. of ether and 1 ml.
of a freshly prepared solution of potassium iodide
which has been shaken occasionally during 1 hour
in a 25-ml. glass-stoppered cylinder, protected
from light. U.S.P.

The B.P. and I. P. tests for anesthetic ether
are similar to those of the U.S.P. for ether but
the B.P. includes also a test for the presence of
methyl alcohol.

Stability. — It is generally believed that the
danger 'of postoperative inflammations of the
lungs is greatly augmented by the use of ether
containing products of oxidation. While there is
some uncertainty as to how these substances are
so deleterious the experiments of Mendenhall
and Connelly (/. Phartnacol., 1931. 43, 315)
indicated that they have a harmful effect on the
ciliated epithelium lining the respiratory passages.
In order to prevent oxidative changes the ether
should be stored in opaque containers, as light
hastens oxidation. Bicknese (Pharm. Zentr.,
1927, 68, 439) found that the presence of a
small amount of powdered iron will protect ether

Part I

Ether

545

against oxidation and even cause the disappear-
ance of peroxides, after some months, in ether
that has already begun to deteriorate. Nitardy
and Billheimer (/. A. Ph. A., 1932, 21, 112)
claimed that the best method for the preserva-
tion of the anesthetic is to keep it in copper-
lined cans. Reimer (Quart. J. P., 1946, 19, 172),
however, found that in the presence of light
both iron and copper acted as autocatalysts for
the decomposition of ether. In contravention to
the opinion held by many, Hediger and Gold
(J. A.M. A., 1940, 114, 1424) offered further
evidence confirming their earlier report that bulk
ether can be safely used for surgical purposes
for at least one month after the drum container
is opened. Their experiments showed also that
ether stored in amber bottles remains of U.S. P.
quality for more than two weeks, even when
exposed to sunlight. Stored in clear glass bottles
under comparable conditions, however, impurities
developed by the second day. Storage of an-
esthetic ether in bottles wrapped in black paper
has also been found satisfactory. Clarke (Am.
Prof. Pharm., 1942, 8, 97) has described the
technic employed in The New York Hospital for
dispensing anesthetic ether from 30-pound drums
in 1-pound copper containers.

The addition of certain organic chemicals has
the effect of stabilizing ether; the B.P. and LP.
both permit up to 0.002 per cent w/v of a suitable
stabilizer to be added to anesthetic ether. The
British Pharmaceutical Codex indicates that hy-
droquinone and propyl gallate are among such
stabilizers currently in use.

The choice of a stopper for a bottle or other
containers for ether may have a bearing on the
usefulness of ether. Cork and rubber stoppers
both contain ether-soluble constituents. Lindgren
and Vesterberg (Chem. Abs., 1943, 37, 4532)
reported that cork may contain 5 to 6 per cent
of ether-soluble constituents; as this material is
almost nonvolatile and nontoxic they claim that
its presence in anesthetic ether seems not to be
objectionable. When such impurities are present
in ether used in certain chemical tests and assays,
however, the results may be unreliable.

Uses. — Ether continues to be the most widely
used inhalation anesthetic. As early as 1805, in-
halations of ether were recommended by Warren,
of Boston, to relieve pulmonary distress in ad-
vanced phthisis, and in 1812 ether intoxication by
inhalation is said to have been frequently prac-
ticed. It seems to have been first used as an anes-
thetic by Dr. C. W. Long, of Georgia, in 1842,
but it was not until October, 1846, that Warren,
at the instance of W. T. G. Morton, of Boston,
used ether as a surgical anesthetic at the Massa-
chusetts General Hospital and made its value
public knowledge. A few days subsequently, C. T.
Jackson, of Boston, claimed to have first made
known to Morton the use of ether for the preven-
tion of pain in dental operations.

Action. — Locally, ether is a violent irritant. It
is absorbed through the lungs with very great
rapidity, and less quickly, but with equal cer-
tainty, through the mucous membrane of the
gastrointestinal tract, and is eliminated through
the lungs.

Ether is predominantly a paralyzant to the
central nervous system affecting first the cerebral
centers, then the spinal cord, and at last the vital
centers in the medulla. The condition of surgical
anesthesia is really one of advanced poisoning
which is made reasonably safe only by the fact
that the vital centers are involved so late and
that the volatility of the ether allows it to be
rapidly eliminated through the lungs. Although
eventually both sensory and motor apparatus are
paralyzed, the effect occurs much earlier in the
sensory side of the organism than in the motor.
Ether causes uniform depolarization of the spinal
neurone (Van Harreveld and Feigen, Am. J.
Physiol, 1950, 160, 451). Ether is inferior to
chloroform in being distinctly slower in action,
more disagreeable to the patient by producing
greater excitement and in being more apt to cause
prolonged nausea and vomiting after its use. How-
ever, the proportion of deaths due to chloro-
formization has been four to five times greater
than after etherization.

It is impossible in the space which can be
allotted to the subject in the present work to dis-
cuss fully the subject of surgical etherization;
there are many books devoted to this subject
exclusively, such as: Lundy, Clinical Anesthesia,
Saunders, 1942 ; Guedel, Inhalation Anesthesia,
Macmillan, 1937; Flagg, The Art of Anesthesia,
Lippincott, 1944; National Research Council,
Fundamentals of Anesthesia, 3rd ed., American
Medical Association, 1953; Keys, The History
of Surgical Anesthesia, Schuman's, 1945; Adriani,
The Chemistry of Anesthesia, Springfield, 111.,
1946; Adriani, Pharmacology of Anesthetic
Drugs: A Syllabus for Students and Clinicians,
3rd ed., Thomas, 1953; Macintosh and Bannister,
Essentials of General Anesthesia, 5th ed., Thomas,
1952; Collins, Principles and Practice of Anes-
thesiology, Lea & Febiger, 1952.

General Anesthesia. — Ether is probably the
most generally used anesthetic. Deep anesthesia
can be accomplished without any anoxia and,
although it is usually desirable, a preanesthetic
sedative is not necessary, as is the case with cer-
tain anesthetics, to produce complete relaxation.
All planes of surgical anesthesia can be produced
with ether. The stages of general anesthesia pro-
duced by ether and other anesthetics are classified
as follows: I. Stage of Analgesia; II. Stage of
Excitement; III. Stage of Surgical Anesthesia,
which is divided into four planes; IV. Stage of
Medullary Paralysis.

The first stage ends when consciousness is lost.
Ether has an unpleasant odor and causes a sensa-
tion of suffocation and smarting of the naso-
pharynx with an excessive secretion of mucus.
Unless the ether has been introduced gradually
and carefully the patient struggles and breathes
irregularly; this discomfort and delay in induc-
tion may be minimized by instructing the patient
to breathe deeply as the anesthetist counts. The
patient feels a generalized sensation of warmth
and thinking becomes blurred as analgesia de-
velops. Hallucinations are frequent. Consciousness
remains during this stage and induction of anes-
thesia may be made more difficult by ill-chosen
conversation or the use of forceful restraints. The

546

Ether

Part I

face becomes flushed. The pupils are normal in
size. Slight tachycardia and increase in blood
pressure are common.

The second stage arrives as consciousness is
lost. The eyes close and muscular tone increases
generally. Reflexes are increased; spasmodic re-
spiratory irragularities occur and shouting, thrash-
ing about or actual delirium, especially in alco-
holics, may occur. It is desirable to hurry the
patient through this period but, if apnea occurs,
the ether should not be forced because the even-
tual deep breath might suddenly increase the con-
centration in the blood to dangerous heights.
Most anesthetic deaths occur in stage II. Vomit-
ing may occur during this stage; if the patient
swallows frequently, lower the head and turn it
to one side to minimize the danger of aspirating
vomitus into the lungs. The stomach should be
empty (by fasting or gastric lavage) before ether
is used. Analgesia is present but spinal reflexes
remain and the general irritability (excitement)
demands a minimum of stimuli of all sorts during
this stage. The pupils are dilated. The skin is red.
The pulse rate and blood pressure are elevated.
Preanesthetic sedation, rapid induction and re-
straint of the patient minimize the difficulties of
the second stage.

The onset of surgical anesthesia (stage III) is
indicated by: regular respirations which are both
abdominal and thoracic, constricted pupils which
do not react to fight, roving movements of the
eyes and the failure of a sudden increase in the
concentration of ether vapor to cause swallowing
and breath holding. Plane 1 refers to the condi-
tion at the onset of surgical anesthesia (stage III)
and is satisfactory for such procedures as the
repair of inguinal hernia, the setting of fractured
bones, obstetrical delivery and many procedures
on the head, neck and extremities. As the concen-
tration of ether increases, plane 2 arrives and may
be recognized by cessation of the roving move-
ments of the eyeballs; this depth of anesthesia is
satisfactory for operations on the pharynx and for
most abdominal surgery. Plane 3 is indicated by
increased abdominal and delayed thoracic breath-
ing as diaphragmatic motion compensates for be-
ginning paralysis of the intercostal muscles. The
increased motion of the abdomen may be trouble-
some in abdominal operations but plane 3 anes-
thesia may be necessary in the presence of peri-
tonitis to abolish reflex effects from traction on
the peritoneum, such as contraction of the ab-
dominal wall or adduction of the vocal c^rds
with crowing respiration which may require an
endotracheal tube. Other signs of plane 3 anes-
thesia are dilated pupils which do not react to
light, fixation of the eyeballs in a converged posi-
tion, an increasing pulse rate and a falling blood
pressure. All reflexes (corneal, conjunctival, pha-
ryngeal, cutaneous, peritoneal, etc.), are abolished
in this plane of anesthesia. A patient should never
be carried beyond plane 3, for plane 4 is charac-
terized by complete paralysis of the intercostal
muscles, a thready, rapid pulse and a low blood
pressure.

Stage IV is that of complete paralysis of the
centers in the medulla; the abdominal breathing

of plane 4 ceases, sphincter muscles relax and the
bowel and bladder may empty, the skin is cold,
gray and clammy, the eyes are fixed and staring
with widely dilated and paralyzed pupils, and the
pulse and blood pressure are unobtainable. Since
the heart continues to beat for a few minutes
after respiration ceases, immediate artificial res-
piration will excrete sufficient ether to restore
function to the medullary centers. The warning
signs of approaching stage IV are: abdominal
breathing, dilated pupils (even though morphine
has been employed), tachycardia and cyanosis;
these signs indicate the withdrawal of ether and
the use of oxygen or air.

Recovery of consciousness occurs in J^ to 2
hours; hyperpnea induced by inhalation of carbon
dioxide hastens excretion and recovery. During
recovery swallowing movements appear and
vomiting occurs in about half of the cases. Fol-
lowing recovery the patient usually goes to sleep.
For the induction of anesthesia a concentration
of ether in air of 5 to 7 volumes per cent is re-
quired while 3 to 5 suffice for the maintenance
of surgical anesthesia. The concentration of ether
in the blood for stage III is as follows: plane 1,
110 mg. per cent; plane 2, 120; plane 3, 130;
plane 4, 140.

Ether is an irritant to the respiratory mucous
membrane; the increased bronchial secretion is
minimized by the use of atropine; salivation
ceases during stage III. Respiration is stimulated
during early stage III with the deep and often
stertorous breathing of an increased volume of
air; toward the end of stage III respiration is de-
pressed and the sensitivity of the respiratory cen-
ter to carbon dioxide and other metabolites is
impaired. In the absence of anoxia, this depres-
sion is counteracted by reflex nervous stimuli from
the lungs and extremities (Schmidt, Anesthesi-
ology, 1945, 6, 113). The pulse rate and blood
pressure are increased during the induction period,
due to stimulation of the adrenals to secrete epi-
nephrine, but return to normal again until plane 3
is reached, when blood pressure falls due to loss of
tone by both smooth and skeletal muscles. Ether
causes peripheral vasodilatation due to both cen-
tral and peripheral action with an increased flow
of blood; pressure in the cerebrospinal fluid in-
creases. There is no depression of the heart in
anesthetic concentrations although conduction dis-
turbances may be observed by electrocardiography
(in contrast chloroform has marked action on the
heart). Nausea and vomiting are due to central
action and is more frequent with ether during
induction and recovery than with other anes-
thetics. Intestinal tone and peristalsis are inhibited
during stage III; this effect is partially counter-
acted by morphine but the atropine so commonly
used interferes with this action of morphine. After
anesthesia, the colon recovers in a few hours and
often becomes spastic whereas the small intestines
are slow to recover and postoperative abdominal
distention is frequently encountered. The flow of
urine, glomerular filtration, renal blood flow and
tubular reabsorption of glucose are decreased dur-
ing plane 3 anesthesia but not in plane 1 and re-
covery is rapid (Am. J. Physiol., 1945, 143, 108;

Part I

Ether

547

Ann. Surg., 1943, 118, 717). Postoperative reten-
tion of urine is not infrequent. Plane 1 anesthesia
does not interfere with the progress of obstetrical
delivery and does not cause any serious anesthesia
of the fetus (the same blood concentration of
ether as in the mother). Ether does not act rapidly
enough to alleviate the pains of labor unless the
pains are anticipated. Ether anesthesia causes
some acidosis (decrease in carbon dioxide com-
bining power and increase in hydrogen ion concen-
tration of the blood), although Beecher et al.
(J. Pharmacol., 1950, 98, 38) found insignificant
changes if adequate oxygen was supplied; a de-
crease in plasma volume with an increased vis-
cosity of the blood also occurs. A neutrophilic
leucocytosis occurs. Hyperglycemia and depletion
of liver glycogen are associated with the increased
epinephrine action of the induction period.

Contraindications. — The main contraindica-
tions to ether anesthesia are acute and chronic
respiratory diseases and advanced renal disease.
However, Beecher and Adams (J.A.M.A., 1942,
118, 1204) reviewed the evidence and found no
basis for the fear of ether in pulmonary tubercu-
losis, and Murphy (Am. Rev. Tuberc, 1944, 49,
251) reports 150 thoracoplasty operations with-
out untoward effects. It is often difficult to anes-
thetize chronic alcoholics and morphine addicts
and patients with hyperthyroidism or markedly
increased metabolism due to fever but adequate
preanesthetic management is helpful.

Administration by Inhalation. — Ether anes-
thesia may be accomplished by the open, semi-
open or closed methods. The open method con-
sists of dropping ether on a wire-mesh mask
covered with several layers of gauze. Using a
wick of cotton in the orifice of the ether container,
the approximate number of drops per minute is
as follows: first minute, 12 drops; second, 25;
third, 50; fourth, 100 and thereafter for about
15 minutes; second quarter-hour, 50 drops per
minute; third quarter-hour, 25 drops per minute;
fourth quarter-hour and thereafter, 12 to 25 drops
per minute. This method wastes a great deal of
ether; about 400 Gm. of ether is used in an hour
in contrast to about 50 Gm. which is sufficient in
the closed method. In hot climates ether evapo-
rates before the drops reach the mask. Storni
and Lundy (Anesth., 1944, 5, 380) describe an
effective method for the use of ether, instead of
the more toxic chloroform, in the tropics with-
out the elaborate equipment required for the
closed method. They cooled the can of ether in
water before opening it, then placed a rubber
tube on the neck of the can with a pinch-cock on
the rubber tube and placed the open end of the
tube under the mask. The amount of ether inhaled
could easily be controlled by the pinch-cock. The
semi-open method employs a towel wrapped
around the patient's face and the mask; this
diminishes the loss of ether vapor and retains a
little carbon dioxide and water vapor. The closed
method employs an apparatus which provides for
the administration of oxygen and carbon dioxide
as well as ether and other anesthetic gases and
for the absorption of the exhaled moisture and

carbon dioxide, a rebreathing bag and a tight-
fitting mask.

Explosion Hazard. — An open flame should
not be used during the open administration of
ether. If unavoidable, the flame should be as far
from the mask as possible, at least 2 feet, and
always 1 to 2 feet higher than the ether mask.
The closed method of administration is safer but
the combination of oxygen with ether increases
the explosiveness. A cautery must not be used on
the head or neck or, in fact, anywhere on the
body unless the site is higher than the head. Ex-
plosive concentrations may develop in body cavi-
ties and the breath remains inflammable for 10
minutes or more after anesthesia is discontinued.
Elaborate precautions and eternal vigilance are
essential but unfortunately will not eliminate the
hazard of explosions. Even minor flashes may
travel down the trachea and fatally burn the lungs.
(See also Anesth., 1941, 2, 580, 689; Quart. Nat.
Fire Protection Asso., 1944, 37, 74).

Untoward Effects. — Respiratory arrest dur-
ing the induction period sometimes presents a
serious problem. An overdose of ether following
a period of breath-holding may be responsible;
this may be avoided by decreasing the amount of
ether in the mask during a period of apnea. De-
pression of the respiratory center due to morphine,
associated with hyperventilation during the in-
duction period, especially with the open drop
method, may result in insufficient respiratory
stimulation and apnea. Artificial respiration should
be instituted and in the latter situation the ad-
ministration of carbon dioxide is most beneficial.
Rarely a vascular accident may be associated with
the hypertension of the induction period. Hypo-
tension is due largely to hemorrhage and surgical
shock but the peripheral vasodilatation induced
by ether contributes to the patient's susceptibility
(Brit. M. J., 1944, 2, 683) ; the use of the shortest
possible period of anesthesia and the use of plane
1 anesthesia as much as possible minimize this
danger. Convulsions occur rarely and usually in
children due to a combination of factors (Lundy,
Surgery, 1937, 1, 666) and may be controlled by
the intravenous administration of one of the
short-acting barbiturates such as 2.5 to 5 per cent
thiopental sodium (Brit. M. J., 1944, 1, 447).
Massive collapse of the lung may occur due to
blocking of the bronchus with mucus; this is in-
frequent until the postoperative period and may
be avoided by the insistence on deep breathing
and the use of carbon dioxide, if necessary, to
increase respiration.

Rectal Administration. — Rectal administra-
tion of ether (Gwathmey, JAMA., 1929, 93,
447) has been widely employed. McCormick
(South. M. J., 1939, 32, 19) successfully em-
ployed a modification of this method in obstetrics.
At the onset of labor, a cleansing enema of 1000
ml. of 5 per cent sodium bicarbonate is given and
when pains become uncomfortable from 100 to
300 mg. pentobarbital sodium is administered by
mouth and may be repeated if labor is prolonged
without impending delivery. As dilatation of the
cervix progresses and the pains again become
uncomfortable the patient is placed on her left

548

Ether

Part I

side with both thighs flexed and a catheter, well-
lubricated with tragacanth, is inserted into the
rectum between uterine contractions with the
guidance of a gloved finger. Then a mixture of
75 ml. of ether and 45 ml. of olive oil or mineral
oil is instilled into the rectum by means of air
pressure from a rubber bulb. To increase the
action of this mixture, 8 ml. of paraldehyde may
be added. The effect of this medication reaches a
maximum in about 40 minutes and persists for
2 to 6 hours. The instillation may be repeated
when necessary, even as soon as 1 hour. The
analgesia may be augmented during the second
stage of labor and while forceps are applied or
surgery carried out by the inhalation of small
amounts of ether or nitrous oxide. This pro-
cedure has proved effective, cheap, safe and
simple of use under varied circumstances. This
ether-oil mixture may be effective in cases of
status asthmaticus when all other methods fail.
Jefferson (/. Nat. M. A., 1945, 37, 114) used
2 to 3 ml. of equal parts of ether and mineral oil
intramuscularly for asthma or croup. Anesthesia
employing the intravenous injection of 5 per cent
ether in an isotonic blood serum solution has
been accomplished successfully (Hudon and Para-
dis, Laval mid., 1945, 10, 633) ; thrombosis of
the vein resulted in a quarter of the patients.

Other Uses. — In the form of compound ether
spirit, ether may be used in nausea dependent on
gastric depression and flatulent colic. In 1919
Andrain recommended intramuscular injection of
1 to 2 ml. of ether, according to age, once daily
in the management of whooping cough. McGee
(J.A.M.A., Sept. 26, 1931) gave the ether by
rectum and Milton (Brit. M. J., 1938, 1, 919)
gave it orally. Gall stones remaining in the com-
mon bile duct following cholecystectomy have
been dissolved successfully in many cases by in-
jection of ether through the "T" tube into the
common duct. The stones must be composed of
cholesterol, at least in part. From a few drops
several times daily to 5 ml. once daily for 3 days
has been employed. The injection of a little min-
eral oil may facilitate discharge of the fragments
(Lancet, 1939, 1, 1311; J. A.M. A., 1940, 114,
2372). Intravenously 0.15 ml. of ether, mixed
with an equal amount of saline solution, is com-
monly used as a test of circulation time (arm to
lung time). Normally, 3 to 8 seconds elapse be-
tween rapid injection into the antecubital vein
and perception of the odor of ether by the patient.
This time is prolonged in instances of right-dded
heart failure. Intravenously a 2.5 to 7.5 per cent
solution in isotonic sodium chloride solution and
5 per cent dextrose solution for injection has been
employed, in a dose of 1000 ml. or less, to quiet
manic patients (Ferraro et al., J. Nerv. Mental
Dis., 1950, 111, 271). S

For the non-medicinal uses of ether, see under
Ethyl Oxide.

The usual dose, by inhalation, is that quantity
which produces the depth of anesthesia required
(v.s.). By mouth the usual dose is 1 to 4 ml.
(approximately 15 to 60 minims), well diluted.

Storage. — "Preserve Ether in partly filled,
tight, light-resistant containers, remote from fire.

It is recommended that Ether be kept at a tem-
perature not exceeding 25°." U.S. P.

SPIRIT OF ETHER. B.P.

Spiritus iEtheris

Ether Spirit. Hoffmann's Drops. Spiritus .<Ethereus;
.■Ether ^Ethylicus Alcoholisatus; ./Ether Alcoolisatus; /Ether
cum Spiritu. Fr. £ther alcoolise ; Liqueur d'Hoffmann.
Ger. Atherweingeist ; Hoffmannstropfen. It. Etere etilico
con alcool; Liquore amodino di Hoffmann. Sp. Eter etilico
alcoholizado ; Licor anodino mineral de Hoffmann.

Dilute 330 ml. of anesthetic ether with sufficient
90 per cent alcohol to make 1000 ml. B.P. The
N.F. IX directed 325 ml. of ethyl oxide to be
diluted with enough alcohol (U.S. P.) to make
1000 ml.

Description. — "Ether Spirit is a transparent,
colorless liquid having an ether odor and a burn-
ing, sweetish taste. It is affected by light. The
color of moistened blue litmus paper is not
changed to red when the paper is immersed in
Ether Spirit for 10 minutes. Ten cc. of Ether
Spirit mixed with 10 cc. of water yields a clear
solution." N.F. IX.

Alcohol Content. — From 60 to 65 per cent,
by volume, of C2H5OH. N.F. IX.

The N.F. IX recognized also Compound Ether
Spirit, popularly known as Hoffmann's Anodyne;
this was prepared by mixing 325 ml. of ethyl
oxide with 650 ml. of alcohol and 25 ml. of
ethereal oil.

Both ether spirit and compound ether spirit
were once popular as carminative preparations
for treating gastric flatulence and milder forms
of gastralgia. lYl

The dose range of both preparations was 1 to 8
ml. (approximately 15 minims to 2 fluidrachms).

Storage. — Preserve "in tight, light-resistant
containers." N.F. IX.

ETHINYL ESTRADIOL.

(B.P., LP.)

Ethynylestradiol

U.S.P.

CSCH

The B.P. and LP. define Ethinyloestradiol as 17-
ethynyl-3:17-dihydroxy-l:3:5-cestratriene; none
of the pharmacopeias provides an assay rubric.

B.P. Ethinyloestradiol; .ffithinylcestradiol. LP. Ethinyl-
oestradiol ; Aethinyloestradiolum. Diogyn-E (.Pfizer) ;
Estinyl (Schering). Lynoral (Organon) ; Orestralyn (Mc-
Neil).

This compound is a derivative of estradiol in
which the hydrogen atom attached to carbon
atom number 17 is replaced by the ethynyl
( — CiCH) group. It may be prepared by the
action of potassium acetylide on estrone in liquid
ammonia; after interaction the ammonia is evapo-
rated and the resulting potassium derivative con-
verted to ethinyl estradiol by treatment with acid.
For further information see U.S. Patents 2,243,887
(1941); 2,251,939 (1941); 2,256,976 (1942).

Part I

Ethinyl Estradiol 549

Description. — "Ethinyl Estradiol occurs as a
white to creamy white, odorless, crystalline pow-
der. In dioxane solution it exhibits a slight dextro-
rotation. Ethinyl Estradiol is insoluble in water.
It is soluble in alcohol, in chloroform, in ether and
in vegetable oils, and also in solutions of the fixed
alkali hydroxides. Ethinyl Estradiol melts between
142° and 146°. It may also exist in a polymorphic
modification, melting between 180° and 186°."
U.S.P. The B.P. gives the melting point as be-
tween 178° and 184° for one form and 141° and
146° for the other. The corresponding LP. melt-
ing ranges are 182° to 184° and 144° to 146°.

Standards and Tests. — Identification. — (1)
A solution of 2 mg. of ethinyl estradiol in 2 ml.
of sulfuric acid appears orange-red by transmitted
light and shows a yellow-green fluorescence by
reflected light. (2) On adding a drop of ferric
ammonium sulfate T.S. to half of the solution in
the preceding test, followed by 2 ml. of water, a
reddish brown, flocculent precipitate forms. On
adding 2 ml. of water to the other portion a rose-
red, flocculent precipitate is formed. (3) The
benzoyl derivative of ethinyl estradiol melts be-
tween 200° and 202°. Absorptivity.— The ab-
sorptivity (1%, 1 cm.), determined at 281 mp, in
an alcohol solution containing 0.05 mg. in each
ml., is between 69 and 73. Loss on drying. — Not
over 0.5 per cent, when dried in vacuum over
sulfuric acid for 4 hours. Completeness of solu-
tion.— A solution of 100 mg. of ethinyl estradiol
in 5 ml. of alcohol is clear and free of undissolved
particles. U.S.P.

Uses. — This derivative of estradiol is used
for all the therapeutic purposes to which estro-
genic substances have been applied (see under
Estradiol). It is one of the most active estrogenic
compounds, particularly on oral administration
(Thompson, /. Clin. Endocrinol., 1948, 8, 1088)
by which route the effect approaches that pro-
duced by injection. The potency of ethinyl
estradiol in clinical use has been estimated as
from 6 (Kearns. /. Urol, 1942, 47, 587) to 8
(Allen, South. M. J., 1944, 37, 270) to even 20
(Dubrow et al., N. Y. State J. Med., 1949, 49,
1828) times that of diethylstilbestrol. The ethinyl
radical appears to delay decomposition of the
estrogen in the gastrointestinal tract and the liver
(Stimmel and May, J. Clin. Endocrinol., 1951,
11, 408). As is the case with other estrogens,
exact comparison of activities by various routes
of administration and on various species or vari-
ous conditions is not feasible. On vaginal smears
of the ovariectomized rat, Harmer and Broom
(Lancet, 1950, 1, 850) found ethinyl estradiol to
have an activity of 18 orally and 233 subcutane-
ously in comparison with diethylstilbestrol as-
signed an activity of 100. On oral administration
in humans, Soule (Am. J. Obst. Gyn., 1943, 45,
315) found it to be several times as active as
estradiol.

In the menopause the total findings of 9 reports
revealed symptomatic improvement in 92.5 per
cent of 428 cases (Salmon et al., J. Clin. Endo-
crinol., 1941, 1, 556; Watson, ibid., 1942, 2, 447;
Groper and Biskind, ibid., 703; Soule, Am. J.
Obst. Gyn., 1943. 45, 315; Lyon, ibid., 1944, 47,
532; Harding, ibid., 48, 181; Wiesbader and

Filler, ibid., 1946, 51, 75; Birnberg et al., ibid.,
1947, 54, 855; Perloff, ibid., 1949, 58, 684).
Symptoms were relieved within 3 to 6 days and
the small doses required seldom gave rise to un-
toward effects (Parsons and Tenney, Med. Clin.
North America, 1950, 34, 1537) although nausea
and vomiting and other side effects of estrogenic
therapy appeared with large doses (Kennedy and
Nathanson, J. A.M. A., 1953, 152, 1140). Senile
vaginitis or gonorrheal vaginitis in children re-
sponded well. The dosage range was 0.02 to 0.15
mg. daily for these purposes.

For functional uterine bleeding (menometror-
rhagia) this estrogen has proved effective in the
control of bleeding and in cyclic therapy (Bickers,
Am. J. Obst. Gyn., 1946, 51, 100). As soon as
the diagnosis of functional bleeding is made, 0.5
mg. is given orally one or two times daily until
bleeding ceases, then 0.05 mg. is prescribed 1 to 3
times daily for 20 days, during the last 5 days of
which 5 mg. of progesterone is also given intra-
muscularly. Withdrawal bleeding occurs on about
the twenty-fifth day; on the thirty-first day the
cyclic administration of ethinyl estradiol and pro-
gesterone is started again. This cycle should be
repeated 3 or perhaps even 6 times (Rock, Med.
Clin. North America, 1948, 32, 1171). About a
third of these patients return to ovulatory men-
struation after 3 months. In 82 pregnancies in 75
women (with histories of 1 to 5 previous abor-
tions) sufficient desiccated thyroid to maintain a
normal basal metabolic rate (about 1 grain daily)
and ethinyl estradiol (commencing with 0.05 mg.
daily and increasing this by 0.05 mg. daily at
monthly intervals to a maximum dose of 0.3 mg.
daily) resulted in 74 full-term live births, 2 pre-
mature live births and 6 abortions (Brimberg
et al., N. Y. State J. Med., 1951, 51, 623). Birn-
berg et al. (Am. J. Obst. Gyn., 1952, 63, 1151)
reported prophylactic value in complicated preg-
nancies, including cases of habitual abortion, dia-
betes mellitus and previous toxemias. A dose of
0.05 mg. every 4 hours for 5 doses prevented
engorgement of the breasts immediately post-
partum (Gershenfeld and Perlmutter, /. Clin.
Endocrinol, 1948, 8, 875). With a total dose of
0.75 to 1.3 mg. spread over 7 days, Jeffcoate et al.
(Brit. M. J., 1948, 2, 809) reported satisfactory
suppression of lactation and noted that a dose of
40 to 50 mg. of diethylstilbestrol was required to
produce a similar effect. In a later paper (ibid.,
1949, 1, 664), they reported inferior results if
0.55 to 1 mg. was given in a period of 12 hours
or given half on the first and half on the fourth
day. In some cases of essential dysmenorrhea,
Schuck (Am. J. Obst. Gyn., 1951, 62, 559) re-
ported relief from the administration of 0.05 mg.
daily during the first 10 to 12 days of the men-
strual interval.

For inoperable carcinoma of the prostate
(Creevy, J.A.M.A., 1948, 138, 412) or breast in
women past the menopause from 0.15 to 3 mg.
daily has been used effectively and is sometimes
tolerated by patients unable to take adequate
doses of other estrogens.

The hypercholesterolemia in cases with coronary
artery disease was decreased by as much as 41 per
cent during use of 0.2 mg. daily increased ac-

550 Ethinyl Estradiol

Part I

cording to tolerance (Oliver and Boyd, Am.
Heart J., 1954, 47, 348); the blood phospho-
lipids remained unchanged. Benefit has been re-
ported in cases of acne vulgaris (Steigrad, Praxis,
1950, 39, 820).

Estrogen-Androgen Therapy. — Combined es-
trogen-androgen therapy has become popular in
the menopause, in post-menopausal osteoporosis
and in other geriatric conditions because it pro-
vides symptomatic relief of menopausal symp-
toms and provides the anabolic stimulus of the
androgens in a dose which does not cause un-
desirable masculinization. In the menopause tes-
tosterone gives symptomatic relief (Wandall,
JAM. A., 1948, 136, 809) and in osteoporosis
androgens are needed to fully restore the osteo-
blastic function of providing bone matrix for
calcification (Albright, Ann. Int. Med., 1947, 27,
861). The constructive stimulus to protein me-
tabolism of androgens is often valuable in aged
persons (Kountz, ifrid., 1951, 35, 1055). In a
controlled study involving 5 identical tablets of
different composition, de Watteville and Lunen-
feld (Schweiz. med. Wchnschr., 1953, 83, 14)
found that a combination of 0.01 mg. of ethinyl
estradiol and 5 mg. of methyltestosterone daily
during 15 days of each month produced relief of
symptoms without pathological proliferation of
the endometrium or mammary tissue. One such
tablet daily is usually sufficient but as many as
4 tablets may be used and in osteoporosis two
tablets daily are indicated.

Toxicology. — The untoward side effects and
contraindications are the same as with other estro-
gens (see under Estradiol).

The usual dose of ethinyl estradiol is 0.05 mg.
(approximately V&oo grain) orally 1 to 3 times
daily with a range of 0.02 to 0.05 mg. The maxi-
mum safe dose is usually 3 mg. in cases of car-
cinoma and this dose is seldom exceeded in a
24-hour period.

Storage. — Preserve "in well-closed, fight-re-
sistant containers." U.S.P.

ETHISTERONE. U.S.P., B.P., LP.

Anhydrohydroxyprogesterone, Pregneninolone,
[Ethisteronum]

C=CH

The B.P. defines ethisterone as 1 7-ethynyl-4-
androsten-17-ol-3-one; the LP. defines it as 17-
ethynyl-17-hydroxy-3-ketoandrostene-4.

I. P. Aethisteronum. A*-Pregnen-17-ine-17[a]-ol-3-one. 17-
Ethynvltestosterone. 17-Ethinyltestosterone. Lutocylol (Ciba),
Ora'-Lutin {Parke, Davis), Pranone (Schering), Progestoral
(Organon), Trosinone {Abbott). Sp. Anhidrohidroxi-
progesterone.

Ethisterone, formerly official as anhydrohy-
droxyprogesterone, represents progesterone from
which a molecule of water has been eliminated
and a hydroxyl group introduced — in the side
chain attached at carbon atom 17 (compare the

structural formulas of ethisterone and proges-
terone). Ethisterone is also properly called 17-
ethynyltestosterone, since it differs from testos-
terone in having an ethynyl (HC:C — ) group in
the 17 position. According to the B.P. ethisterone
may be obtained by the addition of acetylene to
the ketonic group at position 17 in dehydro-
e/>/androsterone, obtained as a product of the
degradative oxidation of sterols such as choles-
terol, followed by oxidation. For further informa-
tion see Schwenk, in the A.A.A.S. volume on The
Chemistry and Physiology of Hormones (1944).

Description. — "Ethisterone occurs as white
or slightly yellow crystals or as a crystalline pow-
der. It is odorless and is stable in air. It is affected
by fight. Ethisterone is practically insoluble in
water; it is slightly soluble in alcohol, in chloro-
form, in ether, and in vegetable oils. Ethisterone
melts between 267° and 275°, with some decom-
position." U.S.P. The B.P. and LP. give the melt-
ing point as between 269° and 275°.

Standards and Tests. — Identification. — (1)
Ethisterone oxime melts between 225° and 232°.
(2) The absorptivity (1%, 1 cm.) in methanol
at 241 mu is between 500 and 530. Specific rota-
tion.— Not less than +28° and not more than
+33° when determined in a pyridine solution con-
taining 100 mg. of dried ethisterone in each 10 ml.
Loss on drying. — Not more than 0.5 per cent,
when dried in vacuum over sulfuric acid for 4
hours. U.S.P.

Uses. — (See also discussion of Uses of Pro-
gesterone and Corpus Luteum). The therapeutic
uses of ethisterone are in general the same as
those of progesterone, except that the former is
administered orally. The structure of ethisterone
is similar to that of progesterone and it resembles
also that of testosterone; in animals, ethisterone
shows progestin, metrotrophic, androgenic and
estrogenic properties (Salmon, Proc. S. Exp. Biol.
Med., 1940, 43, 709). In humans, however, it
does not cause untoward symptoms of pituitary
inhibition although it overcomes the symptoms of
an excess of estrogens. In the rabbit the effective
oral dose is only twice the effective parenteral
dose (Hohlweg and Inhoffen, Klin. Wchnschr.,
1939, 18, 77); with progesterone the oral dose
is 60 times the parenteral dose. Since progesterone
has twice the activity of ethisterone, the latter is
15 times as active, by mouth, as progesterone.
After a priming dose of estrogens, 35 to 60 mg.
of ethisterone by mouth daily produces a proges-
tational effect on the endometrium (Salmon et al.,
Proc. S. Exp. Biol. Med., 1939, 40, 252).

In dysmenorrhea and the premenstrual tension
syndrome, doses of 5 mg. one to three times daily
during the last 7 to 10 days of the menstrual
interval produced 50 per cent or better improve-
ment in 60 of Harding's 82 patients {Am. J. Obst.
Gyn., 1945, 50, 56); most patients were relieved
only during the month in which therapy was used,
although a few did not experience a return of
svmptoms when treatment was discontinued.
Cohen and Stein (ibid., 1940, 40, 713), using
doses of 15 to 30 mg. daily, and also Greenblatt
(J. Clin. Endocrinol., 1944, 4, 321) reported simi-
lar favorable results; Burge and Halloway (Am.
J. Obst. Gyn., 1941, 41, 873), however, were not

Part I

Ethyl Acetate 551

favorably impressed with this form of therapy.

Ethisterone has been less beneficial in func-
tional uterine bleeding than progesterone (Bickers,
/. Clin. Endocrinol., 1949, 9, 736; Greenblatt
et at., ibid., 1950, 10, 886). Successful use, in an
oral dose of 30 mg. daily for 7 days, has been
reported by Jones and TeLinde (Am. J. Obst.
Gyn., 1949, 57, 854). In amenorrhea, Bickers
(Virginia Med. Monthly, 1952, 79, 620) pre-
scribed effectively a combination of 10 mg. of
ethisterone and 0.01 mg. of ethinyl estradiol 5
times daily, by mouth, for 5 days each month to
cause medical curettage; 44 per cent of his pa-
tients bled after the first use and all bled after
the third use. In threatened abortion the gravity
of the situation usually results in administration
of progesterone by injection, but Ingram (Am. J.
Obst. Gyn., 1945, 50, 154) emphasized the im-
portance of immediate treatment at the onset of
cramps or bleeding and prescribed ethisterone for
the patient to carry with her for this purpose.
Absorption sublingually is perhaps more effective
than from the intestine (Greenblatt, loc. cit.).

Toxicology. — Untoward effects from use of
ethisterone have been both infrequent and mild,
and of the type associated with injections of
progesterone.

Dose. — The usual dose is 10 mg. (approxi-
mately V6 grain), up to 4 times daily, by mouth,
with a range of 5 to 75 mg.

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S. P.

ETHISTERONE TABLETS.
U.S.P. (B.P., LP.)

[Tabellae Ethisteroni]

"Ethisterone Tablets contain not less than 90
per cent and not more than 110 per cent of the
labeled amount of C21H28O2." U.S.P. The B.P.
has no assay rubric; the LP. rubric is the
same as that of the U.S.P.

B.P. Tablets of Ethisterone; Tabellae ^Ethisteroni ;
LP. Compressi Aethisteroni. Sp. Tableta de Anhidro-
hydroxiprogesterona.

Assay. — A portion of powdered tablets, equiva-
lent to about 50 mg. of ethisterone, is extracted
with petroleum benzin to remove lubricants, after
which it is extracted with chloroform to remove
ethisterone. The chloroform is evaporated and the
residue of ethisterone is dried at 105° for 2 hours
and weighed. U.S.P., LP.

Usual Sizes. — 5, 10 and 25 mg.

ETHOHEXADIOL. U.S.P.

Ethyl Hexanediol, 2-Ethylhexane-l,3-diol, [Ethohexadiol]

CH3.CH2.CH2.CHOH.CH(C2H5) .CH2OH

"Ethohexadiol contains not less than 97 per cent
of CsHisGV' U.S.P.

Rutgers 612.

Ethohexadiol may be prepared by condensing
3 molecules of butyraldehyde, using as a catalyst
certain metallic ethoxides (see Villani and Nord,
J.A.C.S., 1947, 69, 2605), to form 2-ethyl-l,3-
hexanediol butyrate, the ester being saponified by
alcoholic alkali to produce the alcohol.

Description. — "Ethohexadiol is a clear, color-
less, oily liquid. It is odorless or has only a slight
odor. One ml. of Ethohexadiol dissolves in about
50 ml. of water. It is miscible with alcohol, with
chloroform and with ether. The specific gravity
of Ethohexadiol is between 0.936 and 0.940."
U.S.P.

Standards and Tests. — Distilling range. —
Ethohexadiol distils almost completely between
240° and 250°. Refractive index. — Between 1.4465
and 1.4515. Acidity. — Not over 0.02 per cent,
expressed as acetic acid. U.S.P.

Assay. — Ethohexadiol is assayed by the acet-
ylation-saponification procedure explained under
Benzyl Alcohol, the methods differing only in
details. U.S.P.

This substance has found considerable use as
an insect repellent and toxicant, but for general
use it is especially effective when combined with
butopyronoxyl and dimethyl phthalate, and in the
official Compound Dimethyl Phthalate Solution.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Compound Dimethyl Phthalate
Solution, U.S.P.

ETHYL ACETATE. N.F.
CH3COOC2H5

Acetic Ether, [.ffithylis Acetas]

"Ethyl Acetate contains not less than 99 per
cent of C4H8O2, the remainder consisting chiefly
of alcohol and water." N.F.

.Either Aceticus; ^Ethylium Aceticum. Fr. Acetate
d'ethyle; fither acetique. Ger. Essigather; Essigester.
/*. Etere acetico. Sp. Eter acetico.

Ethyl acetate may be produced by any of the
many methods used in the preparation of esters.
The most common of these is direct esterification
of the appropriate alcohol and acid, as by mixing
ethyl alcohol, acetic acid and sulfuric acid, the
latter serving as a dehydrating agent essential for
esterification. The ethyl acetate is obtained on
distilling the reaction mixture and may be puri-
fied by treatment with potassium carbonate fol-
lowed by redistillation. Other general methods
for the production of esters of this type include:
(1) The reaction of an acid chloride and an alco-
hol (acetyl chloride and ethyl alcohol being used
to produce ethyl acetate); (2) reaction between
an acid anhydride and an alcohol; (3) the inter-
action of alkyl halides and the silver salt of the
acid.

Description. — "Ethyl Acetate is a transpar-
ent, colorless liquid, with a fragrant, refreshing,
slightly acetous odor, and a peculiar, acetous,
burning taste. One ml. of Ethyl Acetate is misci-
ble with about 10 ml. of water. It is miscible with
alcohol, ether, fixed oils, or volatile oils. The
specific gravity of Ethyl Acetate is not less than
0.894 and not more than 0.898. Ethyl Acetate
distills between 76° and 77.5°." N.F.

Standards and Tests. — Identification. — Ethyl
acetate is readily volatilized even at low tempera-
tures; it is flammable and when burned shows a
yellow flame and emits an acetous odor. Non-
volatile residue. — Not over 0.02 per cent, the
residue being dried at 105° for 1 hour. Readily

552 Ethyl Acetate

Part I

carbonizable substances. — No dark zone develops
within 15 minutes when 2 ml. of ethyl acetate is
superimposed on 10 ml. of sulfuric acid. Acidity.
— Not more than 0.1 ml. of 0.1 N sodium hydrox-
ide is required to neutralize a mixture of 2 ml. of
ethyl acetate, 10 ml. of neutralized alcohol, and
2 drops of phenolphthalein T.S. Butylic or amylic
derivatives. — No odor resembling pineapple or
banana is apparent when 10 ml. of ethyl acetate
is spontaneously evaporated from blotting-paper.
Methyl compounds. — Ethyl acetate, saponified to
ethyl alcohol by sodium hydroxide and the mix-
ture distilled, meets the requirements of the test
for methanol under whisky. N.F.

Assay. — About 1.5 Gm. is saponified by heat-
ing with 50 ml. of 0.5 N sodium hydroxide for
1 hour; the excess of alkali is titrated with 0.5 N
hydrochloric acid, using phenolphthalein T.S. as
indicator. A residual blank titration is performed.
Each ml. of 0.5 N sodium hydroxide represents
44.06 mg. of C-1H8O2. N.F.

Uses. — Ethyl acetate is occasionally used in-
ternally as a carminative and antispasmodic. Its
action upon the system is probably very similar
to that of ether; but, as it is less volatile, it is
less rapidly absorbed and eliminated, and conse-
quently is much less prompt and fugacious in its
influence. H. C. Wood found it to be too slow in
action to serve as a practical anesthetic.

Ethyl acetate is sometimes employed externally,
by friction, as a resolvent, and for rheumatic
pains. It is locally irritating. In air a concentra-
tion of 150 parts per million or more causes in-
flammation of the conjunctiva (J.A.M.A., 1945,
127, 56). It may be used internally as a stimulant
in syncope. A fairly frequent use is that of im-
parting its odor to pharmaceutical preparations.
It is an important industrial solvent and enters
into many processes of organic synthesis.

Dose, 1 to 2 ml. (approximately 15 to 30
minims).

Storage. — Preserve "in tight containers and
avoid excessive heat." N.F.

Off. Prep. — Glycerinated Gentian Elixir, N.F.

ETHYL AMINOBENZOATE.

N.F. (B.P.) LP.

Benzocaine, [iEthylis Aminobenzoas]
H2N-/ V-C00C2H5

The B.P. defines this substance as ethyl
p-aminobenzoate, the LP. as ethyl 4-amino-
benzoate.

B.P. Benzocaine; Benzocaina. LP. Aethylis Amino-
benzoas. Ansesthesin (IVinthrop); Anesthesin (Abbott).
/Ethyli Amynobenzoas. Ger. Anasthesin. Sp. Aminoben-
zoato de etilo; Anesthesina.

Ethyl aminobenzoate, which is the ethyl ester
of £ara-aminobenzoic acid, may be prepared by
reducing />-nitrobenzoic acid to />-aminobenzoic
acid and esterifying the latter acid by heating
with ethyl alcohol in the presence of sulfuric acid.
It may also be prepared by first esterifying
^-nitrobenzoic acid (which may be obtained by

oxidizing />-nitrotoluene) with ethyl alcohol, then
reducing the resulting ethyl />-nitrobenzoate to
ethyl />-aminobenzoate.

Description. — "Ethyl Aminobenzoate occurs
as small, white crystals, or as a white, crystalline
powder. It is odorless, and is stable in air. Ethyl
Aminobenzoate exhibits local anesthetic proper-
ties when placed upon the tongue. One Gm. of
Ethyl Aminobenzoate dissolves in about 2500 ml.
of water, in 5 ml. of alcohol, in 2 ml. of chloro-
form, in about 4 ml. of ether, and in 30 to 50 ml.
of expressed almond oil or olive oil. It dissolves
in dilute acids. Ethyl Aminobenzoate melts be-
tween 88° and 90°." N.F.

Standards and Tests. — Identification. — (1)
Alcohol is formed when ethyl aminobenzoate is
boiled with an alkali hydroxide solution. (2) An
orange-red precipitate results when to a solution
of 20 mg. of ethyl aminobenzoate in 10 ml. of
water containing a few drops of diluted hydro-
chloric acid are added 5 drops of a 1 in 10 solution
of sodium nitrite and 2 ml. of a 1 in 50 solution of
betanaphthol in sodium hydroxide T.S. (3) A
precipitate is produced on adding iodine T.S. to a
1 in 50 solution of ethyl aminobenzoate prepared
with the aid of diluted hydrochloric acid. Acidity.
— A solution of 1 Gm. of ethyl aminobenzoate
in 10 ml. of neutralized alcohol is clear; when this
is diluted with 10 ml. of water. 2 drops of phenol-
phthalein T.S. and 1 drop of 0.1 N sodium hy-
droxide added, a red color is produced. Loss on
drying. — Not over 1 per cent, when dried over
sulfuric acid for 3 hours. Residue on ignition. —
Not over 0.1 per cent. Chloride. — No immediate
turbidity results on adding silver nitrate T.S. to
a 1 in 25 solution of ethyl aminobenzoate in alco-
hol, previously acidified with diluted nitric acid.
Readily carbonizable substances. — 500- mg. dis-
solved in 5 ml. of sulfuric acid has no more color
than matching fluid A. Heavy metals. — The limit
is 10 parts per million. N.F.

To distinguish this substance from orthocaine
it is required by the B.P. and LP. that a precipi-
tate be produced when solution of iodine is added
to a 2 per cent solution of benzocaine previously
slightly acidified with hydrochloric acid. To dis-
tinguish it from procaine hydrochloride a solution
of benzocaine should not yield a precipitate with
solution of potassium mercuri-iodide.

Incompatibilities. — Ethyl aminobenzoate is
hydrolyzed on boiling with water, especially in the
presence of alkali. It produces a semiliquid or
liquid mixture with camphor, menthol and re-
sorcinol.

Uses. — Ethyl aminobenzoate is a local anes-
thetic of wide usage. It belongs to the class of
anesthetics which are slightly soluble in water ; it
is comparatively non-irritant, non-toxic, and is
poorly absorbed.

Action. — The anesthetic effect of ethyl amino-
benzoate is almost entirely on nerve terminals; as
compared with cocaine it has very little effect on
nerve trunks. Notwithstanding its slight solu-
bility in water, it is capable of passing through
mucous membranes to a sufficient degree to lessen
sensation. Sollmann (/. Pharmacol., 1919, 13,
429) found that a dusting powder containing 5

Part I

Ethyl Biscoumacetate 553

per cent of ethyl aminobenzoate caused almost
complete loss of sensation when applied to the
gums of human subjects (see also Tainter et al.,
J. A. Dent. A., 1937, 24, 1480). Beutner and
Beutner (Proc. Soc. Exp. Biol. Med., 1940, 45,
337) reported that in fine aqueous dispersion it
was more effective as a topical anesthetic than
when applied in oil solution or as powder; it was,
in fact, more effective than procaine.

Topical Uses. — In concentrations of 5 to 20
per cent ethyl aminobenzoate is employed in oint-
ments or dusting powders as a local anesthetic
application to open wounds, burns, or ulcers on
the skin or mucous membranes. Morel found its
bactericidal powers to be very low. In tuberculous
laryngitis a powder may be insufflated or used in
the form of lozenges, each containing from 20 to
40 mg. (approximately M to % grain) of ethyl
aminobenzoate. Dentists have found it useful in
lessening after-pains of various dental operations,
as of extraction of teeth. Use of a lozenge contain-
ing ethyl aminobenzoate, before meals, often
makes it possible for patients with Vincent's
stomatitis, or other painful lesions of the mouth
or throat, to eat sufficient food to maintain nutri-
tion (Pelner, Am. J. Digest. Dis., 1944, 11, 63).

Externally, ointments containing 5 to 10 per
cent of ethyl aminobenzoate have been used to
relieve various types of itching, as the pruritus
of diabetes, or of skin diseases. In painful hemor-
rhoids, suppositories containing 200 to 300 mg.
(approximately 3 to 5 grains) in cacao butter are
often of much value. Dulhot reported excellent
results in painful cystitis following injection of a
solution of ethyl aminobenzoate in sweet almond
oil into the bladder (see Humphreys, /. Urol.,
1937, 37, 715), but care is necessary to avoid
poisoning (J. A.M. A., 1939, 112, 1256).

Systemic Uses. — In gastric ulcer and gastritis
ethyl aminobenzoate will generally give complete
relief from pain, but it is not popular for this
use. Reiss (Ther. Geg., 1905) recommended oral
administration to relieve vomiting due to gastric
irritation; he also found it to counteract the
emetic effect of antimony but not that of apo-
morphine, indicating that the antiemetic effect
of ethyl aminobenzoate is not central. It is often
ineffective, however, and may aggravate gastric
irritation. Seff (Ven. Dis. Inform., 1945, 26, 57)
was able to prevent vomiting induced by the odor
and taste following injection of neoarsphenamine
by dissolving 33 mg. (l/2 grain) of ethyl amino-
benzoate on the tongue.

Subcutaneous Uses. — Weekly subcutaneous
injections of a solution containing 3 Gm. of ethyl
aminobenzoate, 5 ml. of benzyl alcohol, 10 ml. of
ether, and sufficient sterile olive oil to make 100
ml., administered in doses up to 2.5 ml. in each
of two to four areas, have been found effective
in relieving the discomfort and sometimes effect-
ing cure in pruritus ani (Gabriel, Brit. M. J.,
1929, 1, 1071), pruritus vulvae (Bourne, Pract.,
1933, 2, 441; Kennedy, Edinburgh M. J., 1933,
125), and anal fissure (Riddock, Lancet, 1936,
2, 1150).

Sunburn Protection. — Bird reported (/. A.
Ph. A., 1942, 31, 151) that various derivatives of

^-aminobenzoic acid, including ethyl aminoben-
zoate, strongly absorb those ultraviolet rays which
produce sunburn, and recommended use of the de-
rivatives in burn-preventive preparations.

Toxicology. — From experiments on guinea
pigs, injected hypodermically with an oil solution
of ethyl aminobenzoate, Closson (/. Michigan M.
Soc, 1914, 13, 587) concluded that this compound
has about one-twentieth the toxicity of cocaine.
Kennel (Klin. Wchnschr., December, 1902) re-
ported that 2.6 Gm. (40 grains) had been ad-
ministered to a patient without apparent ill-effect.
Ethyl aminobenzoate is almost free of local irri-
tant action, although sensitization may develop.
If dermatitis, stomatitis, proctitis, etc., develop
the drug should be discontinued. The soluble salts
that ethyl aminobenzoate forms with acids are,
however, quite irritant; Binz found that the hy-
drochloride, which is soluble in 100 parts of water,
is of very low toxicity but much too irritant to be
of value as a local anesthetic.

Dose, oral, from 200 to 500 mg. (approximately
3 to 7 J/2 grains).

Storage. — Preserve "in well-closed contain-
ers." N.F.

Off. Prep. — Ethyl Aminobenzoate Ointment,
N.F.

ETHYL AMINOBENZOATE
OINTMENT. N.F.

Benzocaine Ointment, Unguentum .ffithylis
Aminobenzoatis

Sp. Ungiiento de Aminobcnzoato de Etilo.

Levigate 50 Gm. of ethyl aminobenzoate, in
very fine powder, with some white ointment until
a smooth mixture is obtained, then incorporate
enough of the same base to make the weight of
the product up to 1000 Gm.

For uses of this ointment see the preceding
article.

Storage. — Preserve "in tight containers and
avoid prolonged exposure to temperatures above
30°." N.F.

ETHYL BISCOUMACETATE. B.P.

The B.P. defines Ethyl Biscoumacetate as ethyl
4:4'-dihydroxydicoumarin-3 :3'-ylacetate, requiring
it to contain not less than 97.0 per cent of
C22H16O8, calculated with reference to the sub-
stance dried to constant weight at 105°.

Tromexan (Geigy); Tromexan Ethyl Acetate (N.N.R.).
Pelentan. BOEA.

This anticoagulant, also known as ethyl bis (4-
hydroxycoumarinyl) acetate and 3,3'-carboxy-
methylene bis-(4-hydroxycoumarin) ethyl ester,
was synthesized to provide a substance which
would not have the disadvantage of bishydroxy-
coumarin of delayed action. It differs from the
latter compound only in that the two hydroxy-
coumarin groups are joined by — CH(COOC2H.5) —
instead of the — CH2 — (methylene) bridge pres-
ent in bishydroxycoumarin. The B.P. states that
ethyl biscoumacetate may be prepared by esteri-
fication of 4:4'-dihydroxydicoumarin-3:3'-ylacetic
acid; for further information see U. S. Patents
2,482,510-2 (1949).

554 Ethyl Biscoumacetate

Part I

Description. — The B.P. describes ethyl bis-
coumacetate as a white to yellowish-white, fine,
crystalline powder; it is odorless and has a bitter
and persistent taste. It is almost insoluble in
water, is readily soluble in aqueous solutions of
alkali hydroxides, and is soluble in 20 parts of
acetone. One form of it melts at about 154°, the
other at about 179°.

Standards and Tests. — Identification. — (1)
A reddish-brown color is produced on adding
ferric chloride T.S. to a solution of ethyl bis-
coumacetate in alcohol. (2) Sulfuric acid pro-
duces a yellow color (distinction from bishydroxy-
coumarin) when a few drops are added to about
100 mg.; on adding the solution to 10 ml. of
water a flocculent white precipitate is produced.
(3) On fusing 200 mg. of ethyl biscoumacetate
with 200 mg. of potassium hydroxide, extracting
with water and acidifying the solution, a pre-
cipitate of salicylic acid is obtained. (4) The
diacetate derivative melts at about 295°. Sulfated
ash. — Not over 0.2 per cent. Loss on drying. —
Not over 0.5 per cent, when dried to constant
weight at 105°. B.P.

Assay. — About 400 mg. of ethyl biscoumace-
tate is dissolved in 25 ml. of acetone, the solu-
tion diluted with 20 ml. of water, and titrated
with 0.1 N sodium hydroxide, using bromophenol
blue as indicator. A blank titration is performed
on the acetone-water solvent mixture. Each ml.
of the difference in the titrations represents 40.83
mg. of C22H16O8. In this assay one hydroxyl group
of ethyl biscoumacetate is neutralized by sodium
hydroxide. B.P.

Uses. — Ethyl biscoumacetate is an anticoagu-
lant drug derived from bishydroxycoumarin. Its
action in blocking synthesis of prothrombin in the
liver, thus prolonging prothrombin time, and the
indications and contraindications for its use are
the same as those fcr bishydroxycoumarin (q.v.).
Assuming that the delay in action of bishydroxy-
coumarin was due to difficulty in splitting this
molecule Rosicky (Cos. Lek. cesk., 1944, 83,
1200) weakened the methylene linkage between
the two coumarin components of bishydroxy-
coumarin by introducing the carboxyl group; the
ethyl ester of the new compound is ethyl bis-
coumacetate. This ethyl ester, while having about
one-fourth the activity of bishydroxycoumarin on
an equal weight basis, is more rapidly absorbed,
more rapidly excreted, and generally appears to
be safer than bishydroxycoumarin. Von Kaulla
and Pulver (Schweiz. med. Wchnschr., 1948, 78,
806, 956) observed maximum concentration of
the drug in serum 3 to 6 hours after ingestion but
could find none 24 hours after administration;
bishydroxycoumarin. by contrast, was detected
for as long as 7 days. Further information on the
metabolic fate of ethyl biscoumacetate in man is
provided bv Burns et al. (J. Pharmacol., 1952,
106, 453).'

Solomon et al. (J. Lab. Clin. Med., 1950, 36,
19) found that the initial dosage required to pro-
duce a therapeutic prothrombin time of 25 sec-
onds is 1.2 to 1.8 Gm.; significant prolongation
of prothrombin time is reached within 24 hours,
usually in 16 to 18 hours. They further found
that the dose to be given daily to maintain a

therapeutic level is from 300 to 900 mg. To avoid
wide fluctuations in effect during a 24-hour period
they divided the daily dose into three parts, given
every 8 hours. They often observed an increase
in prothrombin time on the fourth day of treat-
ment; regarding this as evidence of a cumulative
effect, they reduced dosage on the third day. Con-
sistent prolongation of prothrombin time 18 to
24 hours after administration has been confirmed
by Burke and Wright (Circulation, 1951, 3, 164).
who found the duration of the anticoagulant
action to be about one-half to one-fourth that of
bishydroxycoumarin, with return of the pro-
thrombin time to normal 48 to 60 hours after a
single initial dose.

It is generally agreed that in active therapy
with this drug the clinician should attempt to
maintain the prothrombin time (expressed in sec-
onds) at a figure two to two and one-half times
that of the control. Bronstein and Witkind (Am.
J. Med. Sc, 1951, 222, 677) indicated the de-
sirability of reporting prothrombin time in terms
of seconds rather than on a percentage basis.
They, too, noted transitory cumulative effects at
some time during therapy and pointed out that
there is no correlation between required dosage
and body weight in adults. Barker et al. (J. A.M. A.,
1952, 148, 2 74) advised that for prophylaxis two-
thirds the usual initial therapeutic dose suffices.
Others emphasized that ambulatory individuals
are more sensitive to its action and, therefore,
should receive smaller doses than bed patients.

Myocardial Infarction". — Administration of
ethyl biscoumacetate during the first four weeks
following coronary thrombosis reduced the mor-
tality to half that of a control series treated with-
out anticoagulants, in the experience of Tulloch
and Gilchrist (Am. Heart J., 1951, 42,. 864), and
there was five-fold reduction in the incidence of
thromboembolic complications. They administered
heparin in addition during the first 36 to 48 hours
until the prothrombin time had been doubled by
ethyl biscoumacetate. It is established that during
combined therapy with the two drugs the coagu-
lation time is not increased beyond that which
can be predicted for heparin alone. Illingworth
(Brit. M. J., 1951, 2, 646) obtained satisfactory
results in cases of cardiac infarction and in pa-
tients with extracardiac thromboses when the
prothrombin time was maintained at 10 to 30 per
cent of normal. Two of their patients bled from
unsuspected peptic ulcers, but in both instances
withdrawal of the drug stopped the hemorrhage
without resort to vitamin K or transfusion. Olivier
(Presse med., 1951, 59, 82) stated that in treating
recent phlebitis prothrombin time levels under
30 per cent of normal are needed only at the
outset of treatment even in the event of pulmo-
nary embolism.

Congestive Heart Failure. — In the treatment
of congestive heart failure Griffith et al. (Ann.
Int. Med., 1952, 37, 867) found heparin, bis-
hydroxycoumarin and ethyl biscoumacetate to be
equally beneficial in prevention and treatment of
thromboembolism. However, they believed ethyl
biscoumacetate to be safer than bishydroxycou-
marin because of the rapid reversibility of its
action. They agreed with others as to the difficulty

Part I

Ethyl Chloride 555

in maintaining a stable prothrombin time, but
were largely able to overcome this disadvantage
by dividing the daily dose in two. Morning and
afternoon prothrombin time determinations were
made daily to provide information as to whether
the level was rising or falling. Dosage was adjusted
accordingly, the first dose for the day being ad-
ministered in the afternoon and the second dose
12 hours later.

Toxicology. — As with the other anticoagu-
lants, hemorrhage is the chief complication of
therapy (see Gripe, New Eng. J. Med., 1951, 245,
803). The most common manifestation is micro-
scopic hematuria, but it apparently occurs less
frequently than with bishydroxycoumarin. Ecchy-
mosis at the site of venipuncture may represent
toxicity. Major contraindications to the use of
ethyl biscoumacetate include the hemorrhagic dis-
eases, impaired liver function, renal failure and
insufficiency, bacterial endocarditis, and ulcer-
ating or granulomatous lesions. Caution must be
observed in the presence of cachexia, severe vita-
min deficiency, toxic-infectious syndromes and
menstruation. Administration of salicylates may
enhance the drug action. Safety of the drug is
such that in event of markedly prolonged pro-
thrombin times following overdosage and un-
attended by hemorrhage, withholding the day's
dose is sufficient to restore the level to or near
normal within 24 hours. In some instances of
minor bleeding no additional treatment is re-
quired. For significant bleeding full doses of
menadione sodium bisulfite or phytonadione are
indicated and in some instances infusions of fresh
citrated blood or plasma are needed as well.

Dose. — The average initial adult dose (oral)
for the first 24 hours is 1.5 Gm. Subsequently the
usual daily maintenance dose required to prolong
the prothrombin time two to two and one-half
times the normal value varies from 600 to 900 mg.
As expressed in terms of percentage a prothrombin
level between 30 and 50 per cent of normal is
satisfactory. Values below 10 or 15 per cent are
considered dangerous. The desired therapeutic
prothrombin time is usually considered to be 35
seconds. During the first days of treatment, daily
prothrombin time estimations are essential; later
a determination on alternate days may suffice.
The B.P. gives the range of dose as 150 mg. to
1 Gm. daily, according to the prothrombin activity
of the blood.

ETHYL CHLORIDE. U.S.P., B.P., I.P.

[iEthylis Chloridum]
CH3.CH2CI

"Caution. — Ethyl Chloride is highly flammable.
Do not use it where it may be ignited." U.S.P.
The B.P. requires that ethyl chloride contain not
less than the equivalent of 99.5 per cent w/w of
C2H5CI. As it may be prepared by action of
hydrogen chloride on industrial methylated spirit,
as well as on ethyl alcohol, the B.P. states that
ethyl chloride may contain a small quantity of
methyl chloride if the former has been used. The
I.P. purity rubric is the same as that of the B.P.

Chlorethyl; Monochlorethane; Kelene {Merck). Ethylium
Chlorhydricum; Mther Chloratus; Ethylium Chloratum;

.dEthyli Chlorurum. Fr. Chlorure d'ethyle; Ester ethyl-
chlorhydrique. Ger. Athylchlorid ; Chlorathyl. It. Cloruro di
etilo. Sp. Cloruro de etilo; Cloretilo; Eter etilclorhidrico.

Ethyl chloride was discovered by Rouelle, and
made by him in 1759 by action of sulfur chloride
or metallic chlorides upon ethyl alcohol. Basse
prepared it in larger quantities in 1801 by the
interaction of hydrochloric acid and ethyl alcohol.
This process is one of the two in commercial use
today, the other being based on addition, in pres-
ence of a catalyst, of a molecule of hydrogen
chloride gas to one of ethylene. Enormous quan-
tities of ethyl chloride are produced in making
tetraethyl lead (by reaction with an alloy of lead
and sodium) for high-octane gasolines.

Description. — "At low temperatures or under
pressure, Ethyl Chloride is a colorless, mobile,
very volatile liquid. It boils between 12° and 13°.
Its specific gravity is about 0.921 at 0°. It has a
characteristic, ethereal odor, and a burning taste.
When Ethyl Chloride is liberated at ordinary
room temperature from its sealed container, it
vaporizes at once. It burns with a smoky, green-
ish flame, producing hydrogen chloride. Ethyl
Chloride is slightly soluble in water, and dissolves
freely in alcohol and in ether." U.S.P.

Standards and Tests. — Acidity. — When 10
ml. of ethyl chloride is shaken with 10 ml. of dis-
tilled water, both at 0°, and the former volatilized
spontaneously, the water phase is neutral to litmus
paper. Non-volatile residue and odor. — Evapora-
tion of 5 ml. of ethyl chloride leaves a negligible
residue, with no foreign odor noticeable as the
last portion evaporates. Chloride. — No turbidity
is produced at once when 0.5 ml. of ethyl chloride
is added to 10 ml. of alcohol containing a few
drops of silver nitrate T.S., both liquids cooled
to 0°. Alcohol. — No odor of acetaldehyde, and no
greenish or purplish color, is apparent on adding
potassium dichromate T.S. and diluted sulfuric
acid to the liquid remaining in the test for acidity,
and boiling. U.S.P.

In the B.P. test for limit of ethyl alcohol the
iodoform reaction is applied instead of the di-
chromate oxidation test of the U.S.P. The B.P.
assay consists in saponifying the sample with
0.5 N alcoholic potassium hydroxide and neu-
tralizing excess of the latter with 0.5 N hydro-
chloric acid. The I.P. assay is similar.

Uses. — Ethyl chloride is so volatile that when
sprayed upon the skin it may absorb sufficient
heat in vaporization to cause superficial freezing
in the area to which applied. This freezing makes
peripheral nerve endings insensitive and produces
local anesthesia. It is used where short and super-
ficial anesthesia is desired for small areas to
incise furuncles and perform similar minor oper-
ative procedures. The thawing that follows at
times may cause considerable pain. Less than
freezing application, however, has proven valu-
able as a form of counter-irritation to relieve
myofascial and visceral pain syndromes (Travell,
Arch. Phys. Med., 1952, 33, 291). The protracted
myofascial pain following activation of a trigger
area depends on a reflex pain cycle maintained
by the tirgger area. Transitory local block of
trigger areas may relieve such referred pain per-
manently. Painful muscle spasm, including stiff

556 Ethyl Chloride

Part I

neck, trismus, lumbago, sciatica, ankle and heel
pain, tennis elbow and shoulder pain, have re-
sponded to this therapy. The chest pain of acute
coronary thrombosis has also been so treated
(Travell, Circulation, 1951. 3, 120). First and
second degree household burn pain may be
promptly and permanently relieved (Travell,
/. Pharmacol., 1951. 101, 36). Bingham (Military
Surg., 1945, 96, 121) and others reported good
results with ethyl chloride spray in treatment of
sprains. This is simpler than injection of procaine
and does not mask deeper lesions. It should not
be applied to broken skin. Bingham sprayed the
skin over the involved joint and directed con-
tinuous use of the joint. Neither strapping nor
casts were needed. The technique of application,
however, has been improved by Travell. With the
patient holding his head higher than the region
to be sprayed in order to avoid inhalation the
container is held about 2 feet away. The jet
stream is aimed to meet the body at an acute
angle, not perpendicularly. The stream is applied
in one direction only. Sweeps start at the trigger
zone and move slowly to the reference zone. Such
sweeps are repeated rhythmically, a few seconds
on and a few off. The skin should not be frosted,
for such excessive cooling often may increase
muscle spasm and pain. Seidelin (Lancet, 1913,
1, 1663) destroyed superficial epithelioma by
freezing them with ethyl chloride. Lewis and
Marginson (Arch. Dermat. Syph., 1944, 50, 243)
and others (Arch. Dermat. Syph., 1943, 48, 511;
South. M. J., 1930, 23, 1128) advocate the spray
in treatment of trichophytosis (athlete's foot) ;
the entire lesion is sprayed in one treatment until
frosted. Immediate improvement of vesicles,
pustules, denudation and sweating was observed.
Although best results were obtained with vesicular
stages, all types, including those with dermatitis
due to secondary infection, improved. They cau-
tion against spilling the liquid on the skin because
deeply frozen skin is slow to heal and uncom-
fortable. Faust (J. A.M. A., 1937. 108, 386) recom-
mends it in creeping eruption due to hookworm
larvae infesting the skin.

Ethyl chloride has also been used by inhalation
as a general anesthetic. Its action is extremely
rapid and brief. It is similar to divinyl ether but
is more toxic to the cardiovascular system and
more likely to cause nausea and vomiting. Inhala-
tion of a concentration of 4 to 5 volumes per
cent will induce surgical anesthesia and 2 to 3
will maintain it but induction (l/i to 1J^ minutes)
and recovery (a few minutes) is so rapid that it
is difficult, even with experience, to maintain
smooth anesthesia. It does not irritate respira-
tory' mucosa. Anesthetic and toxic doses are too
nearly alike. Lundy. Adams and Seldon (Surg.,
1945, 18, 6) do not endorse this use of ethyl chlo-
ride because there are other similar but less toxic
anesthetics. According to Guedel (J.A.M.A., 1921,
77, 427), there are two types of toxicity from
overdosage of ethyl chloride. About 90 per cent
are the spasmodic type, in which there is spasm
with consequent obstruction to respiration and
such spasm interferes with artificial respiration.
Infrequently symptoms are those of progressive
depression. In physiological action ethyl chloride

closely resembles chloroform, although it is less
depressant to the heart (Guedel and Knoefel,
Am. J. Surg., 1936. 34, 496). On account of its
great flammability it should not be used near a
light or flame. Coste and Chaplin (Brit. J.
Anazsth., 1937, 14, 115) report a concentration of
5 to 15 volumes per cent of ethyl chloride will
explode. S

In addition to its medicinal uses ethyl chloride
is important in manufacture of tetraethyl lead, in
making ethyl cellulose, as a catalyst in synthetic
rubber manufacture and as a refrigerant.

The dose, by inhalation or spray, is sufficient
to produce the effect desired.

Storage. — Preserve "in tight containers, pref-
erably hermetically sealed, and remote from fire."
U.S.P.

ETHYL NITRITE SPIRIT. N.F.

Spirit of Nitrous Ether. Sweet Spirit of Nitre,
[Spiritus ^Ethylis Nitritis]

"Ethyl Nitrite Spirit is an alcohol solution of
ethyl nitrite containing not less than 3.5 per cent
and not more than 4.5 per cent of C2H5ONO."
N.F.

"Xiter." .lEther Xitricus Alcoholicus. Fr. Ether nitreux-
alcoolise. Ger. Versuszter Salpetergeist. It. Spirito d'etere
nitroso.

The N.F. does not provide a method for the
preparation of this spirit. A process formerly
official involved reaction of an aqueous solution
of sodium nitrite, sulfuric acid and alcohol to pro-
duce ethyl nitrite, which was neutralized, dehy-
drated, and then dissolved in alcohol. For details
of the process see U.S.D., 22nd ed., p. 1016. Com-
mercial processes of manufacturing ethyl nitrite
involve reaction between alcohol and. nitric acid
in the presence of copper and sulfuric acid.

Properties of Ethyl Nitrite. — Pure ethyl
nitrite is pale yellow, has a pleasant ethereal and
somewhat apple-like odor. It boils at 18°, and has
a specific gravity of 0.900 at 15.5°. The density
of its vapor is 2.627. Litmus is not affected by it.
It is soluble in 48 parts of water, and in all pro-
portions in alcohol. It is highly flammable, and
burns with a white flame without residue. In its
pure state it is never used in medicine.

Description. — "Ethyl Nitrite Spirit is a clear,
mobile liquid with a pale yellow or faintly green-
ish yellow tint. It has a fragrant, ethereal, pungent
odor free from acridity, and a sharp, burning
taste. It is volatile and flammable, and rapidly
decomposes on exposure to light and air. When
recently prepared or even after being kept for
some time with but little exposure to light and
air. Ethyl Nitrite Spirit is neutral to dry litmus
paper. After long standing or upon being exposed
to fight and air, it acquires an acid reaction. The
specific gravity of Ethyl Nitrite Spirit is not more
than 0.823." N.F.

Standards and Tests. — Identification. — Ethyl
nitrite spirit, when a test tube half filled with it
is immersed in a bath at 65° and kept at that
temperature until the spirit is heated to the same
degree, boils when a few small pieces of broken
glass are added. Acidity. — No effervescence occurs
when a crystal of potassium bicarbonate is added

Part I

Ethyl Oxide 557

to 5 ml. of the spirit. Aldehyde. — A yellow color,
not turning to a decided brown on standing over-
night, is produced on adding a mixture of 5 ml.
of potassium hydroxide T.S. and 5 ml. of distilled
water to 10 ml. of the spirit. N.F.

Assay. — In N.F. VII ethyl nitrite spirit was
assayed by titrating the iodine liberated by re-
action with potassium iodide in a hydrochloric
acid solution with 0.1 iV sodium thiosulfate under
an atmosphere of carbon dioxide. In the present
N.F. essentially the same reaction, but using
diluted sulfuric acid as a source of hydrogen ions,
is carried out in a nitrometer so that the nitric
oxide gas also formed in the reaction may be
measured. The chemical reaction representing the
assay is as follows :

2C2H5NO2 + 2KI + H2SO4 -+

2C2H5OH + I2 + 2NO + K2SO4

The volume of gas liberated, and the temperature
and barometric pressure are observed. The vol-
ume, in ml., is multiplied by 0.307 (which is the
weight of 1 ml. of ethyl nitrite vapor at 25° and
760 mm. multiplied by 100. for percentage) and
divided by the weight of ethyl nitrite spirit taken
for assay. Temperature and pressure corrections
based on the gas laws are applied to this result.
N.F.

Alcohol Content. — From 85 to 93 per cent,
by volume, of C2H5OH. In determining the alco-
hol content of the spirit it must be treated with
sodium hydroxide to prevent distillation of ethyl
nitrite; this converts the ethyl nitrite to ethyl
alcohol and sodium nitrite. Since the former prod-
uct will be distilled from the mixture along with
the alcohol originally present, a correction must
be applied for the alcohol thus produced. N.F.

Stability. — It is to be noted that the N.F.
specifies that the spirit be preserved in small, well-
filled, tight containers, in a cool and dark place.
Storage of the spirit in a partially filled stock
bottle from which the liquid is dispensed as
needed will result in its rapid decomposition;
spirit obtained in bulk should be packaged into
smaller containers as soon as the stock container
is opened. Andrews (/. A. Ph. A., 1932, 21, 799)
found that in a tightly stoppered bottle kept in a
refrigerator in the dark the loss of nitrite is about
5 to 6 per cent in the first two weeks, and about
26 per cent at the end of 8 months; exposed to
direct sunlight, the spirit loses 100 per cent of its
activity in 2 weeks. A spirit prepared with 99 per
cent alcohol kept better than one made by the
official formula.

Because it is so readily decomposed, mixtures
of the spirit with other substances should as far
as possible be avoided; in many of the mixtures
in which it is prescribed the spirit is destroyed in
a matter of minutes or hours.

Uses. — Ethyl nitrite spirit has the action of
other nitrites (see Sodium Nitrite). Its inhalation
produces acceleration of the pulse with the char-
acteristic leaden purplish color of the lips, mouth
and finger tips, followed by flushing of the face,
giddiness, nausea, muscular debility, and violent
headache. Thompson et al. (/. A. Ph. A., 1933,
22, 487) reported that in the dog a dose equiva-

lent to about 3 ml. of the spirit for a man pro-
duced a brief fall in the blood pressure, but that
with larger doses (equivalent to 10 ml.) the reduc-
tion in the blood pressure lasted for several hours.
It is rarely employed, however, to produce the
full physiological action of nitrites, its chief use
being to relax the blood vessels of the skin and
thereby increase perspiration. It was formerly a
popular diaphoretic in mild fevers, especially in
children. Because of its action on the circulation
it also exercises at times a diuretic influence. S

Dose, 2 to 4 ml. (approximately Yi to 1 flui-
drachm).

Storage. — Preserve "in small, well-filled tight
containers, in a cold, dark place, remote from
fire." N.F.

Off. Prep. — Compound Opium and Glycyr-
rhiza Mixture, N.F.

ETHYL OLEATE.

JEthylis Oleas

B.P.

Ethyl Oleate is required to contain not less
than 98.0 per cent w/w of C20H38O2. It may be
prepared by esterifying oleic acid with ethyl
alcohol.

Description. — Ethyl oleate is a pale yellow
oil, having a strong and disagreeable odor and
taste. It is insoluble in water, but is miscible
with vegetable oils.

Standards and Tests. — Acid value. — Not
over 0.5. Iodine value. — Between 77 and 84
(iodine monochloride method). Weight per ml. —
Between 0.869 and 0.870, at 20°. Peroxide.— The
iodine liberated from potassium iodide by 1 ml.
of ethyl oleate, in a mixture with glacial acetic
acid and chloroform, is decolorized by 1 ml. of
0.005 N sodium thiosulfate.

Assay. — Following neutralization of any acid
in 2 Gm. of ethyl oleate the latter is saponified by
heating with 0.5 N alcoholic potassium hydroxide
for 2 hours; the excess of alkali is titrated with
0.5 N sulfuric acid, using phenolphthalein as indi-
cator. Each ml. of 0.5 N alcoholic potassium hy-
droxide represents 155.3 mg. of C20H38O2.

Uses. — Ethyl oleate is permitted to be used
as an alternative vehicle in the B.P. injections
of desoxycorticosterone acetate, menaphthone,
estradiol monobenzoate, progesterone, and testos-
terone propionate.

ETHYL OXIDE. U.S.P. (B.P.)

Solvent Ether, [.ffithylis Oxidum]
C2H5.O.C2H5

"Ethyl Oxide contains from 96 per cent to 98
per cent of C4H10O, the remainder consisting of
alcohol and water. Caution. — Ethyl Oxide must
not be used for anesthesia. Ethyl Oxide is highly
flammable. Do not use where it may be ignited."
U.S.P.

B.P. Solvent Ether; .ffither Solvens. ^ther Depuratus.
Fr. fither rectifie du commerce. Sp. Oxido de Etilo.

Description. — "Ethyl Oxide agrees in de-
scription and physical properties with Ether."
U.S.P.

Standards and Tests. — Aldehyde. — No color
develops in either liquid when 10 ml. of ethyl

558 Ethyl Oxide

Part I

oxide is occasionally shaken, during 2 hours, with
1 ml. of potassium hydroxide T.S. in a glass-
stoppered cylinder protected from light. Peroxide.
— No color is seen in either liquid (on viewing
transversely against a white background) when
10 ml. of ethyl oxide is shaken for 1 minute with
1 ml. of freshly prepared 1 in 10 solution of po-
tassium iodide in a glass-stoppered cylinder. Other
requirements. — Ethyl oxide meets all other re-
quirements under Ether. U.S.P.

Uses. — It is imperative that this grade of ether
not be used for producing anesthesia. It is recog-
nized officially only to provide standards for ether
sufficiently pure for various chemical and pharma-
ceutical manipulations and available at a lower
price than that of the highly purified anesthetic
ether.

As noted under Ether, it is possible that ethyl
oxide stored in containers bearing cork or rubber
stoppers will contain an appreciable amount of
extractive matter which may interfere in processes
in which this solvent is employed. If such stop-
pers, rather than those of glass or metal, are used,
they should be wrapped with tin foil. When ethyl
oxide is to be used as a solvent it should be kept
in mind that water dissolves in it, to the extent
of about 1.5 per cent at room temperature (see
Ether).

Lepper (Chem. Ztg., 1942, 66, 314) observed
that use of a peroxide-containing ether for de-
termination of fats may result in an explosion,
usually after evaporation of the ether and on
heating the residue at 100° or over, but sometimes
even when as much as one-fifth the original vol-
ume remains. He recommended treating the ether
with ferrous sulfate and sulfuric acid to remove
peroxide, or with potassium permanganate and
potassium hydroxide to remove both peroxide and
aldehyde.

Storage. — "Preserve Ethyl Oxide in partly
filled, tight, light-resistant containers, remote
from fire. It is recommended that Ethyl Oxide
be kept at a temperature not exceeding 25°."
U.S.P.

Off. Prep. — Aspidium Oleoresin; Collodion,
U.S.P., B.P.; Spirit of Ether, B.P.

ETHYL VANILLIN. N.F.
0C2H5

HO —f \— CHO

3-Ethoxy-4-hydroxybenzaldehyde.

Ethyl vanillin has the same structure as van-
illin (q.v.), except that an ethoxy (OC2H5) group
replaces the methoxy (OCH3) of vanillin. Ethyl
vanillin should not be confused with ethyl vanil-
late, which is C6H3(OH)(OCH3)(COOC2H5),
and has been used as a fungicide and for treat-
ment of histoplasmosis.

Description. — "Ethyl Vanillin occurs as fine
white or slightly yellowish crystals. Its taste and
odor are similar to the taste and odor of vanillin.
It is affected by fight. Its solutions are acid to
litmus. One Gm. of Ethyl Vanillin dissolves in

about 100 ml. of water at 50°. It is freely soluble
in alcohol, in chloroform, in ether, and in solu-
tions of alkali hydroxides. Ethyl Vanillin melts
between 76° and 78°." N.F.

Standards and Tests. — Identification. — (1)
On warming ethyl vanillin with hydrochloric acid,
then adding hydrogen peroxide and allowing the
mixture to stand until precipitation is complete,
subsequent addition of benzene produces a violet
color in the benzene layer on shaking (distinction
from vanillin). (2) Ethyl vanillin is extracted
from ether by a saturated solution of sodium
bisulfite, from which it is precipitated by acids.
(3) Lead subacetate T.S. produces a white pre-
cipitate when added to a cold solution of ethyl
vanillin ; the precipitate is sparingly soluble in hot
water but soluble in acetic acid. Loss on drying. —
Not over 1 per cent, when dried over sulfuric acid
for 4 hours. Residue on ignition. — Not over 0.05
per cent. N.F.

Uses. — Ethyl vanillin is used as a flavoring
agent. It possesses a finer and more intense
vanilla-like odor than that of vanillin.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

ETHYLENE. U.S.P.

[iEthylenum]
CH2 = CH2

"Ethylene contains not less than 99 per cent
by volume of C2H4." U.S.P.

"Caution — Ethylene is highly flammable. Do
not use where it may be ignited." U.S.P.

Ethene; defiant Gas; Etherin; Elayl. Fr. Ethylene.
Ger. Athylen. Sp. Etileno.

Ethylene is one of the products of the dry dis-
tillation of many organic substances. Large sup-
plies of the gas are available from the cracking
of natural gas as well as from the cracking of
petroleum hydrocarbons. It is also obtained by
dehydration of ethyl alcohol. In Germany it has
been produced in large quantities by hydrogena-
tion of acetylene.

Description. — "Ethylene is a colorless gas,
somewhat lighter than air, and has a slightly sweet
odor and taste. A liter of Ethylene at a pressure
of 760 mm. and at 0° weighs 1.260 Gm. One
volume of Ethylene dissolves in about 4 volumes
of water at 0° and in about 9 volumes of water at
25°. One volume of it dissolves in about 0.5 vol-
ume of alcohol at 25° and in about 0.05 volume
of ether at 15.5°." U.S.P.

Standards and Tests. — Identification. — (1)
Ethylene dissolves slowly in sulfuric acid but rap-
idly in fuming sulfuric acid and in concentrated
solutions of potassium permanganate. (2) Bro-
mine T.S. is decolorized by passing ethylene
through it. Acidity or alkalinity. — 2000 ml. of
ethylene passed through recently boiled and cooled
distilled water containing 0.2 ml. of 0.01 N hydro-
chloric acid and methyl red T.S. as indicator
should not either increase or decrease the acidity
by more than the equivalent of 0.2 ml. of 0.01 N
acid. Carbon dioxide. — 1000 ml. of ethylene passed
through barium hydroxide T.S. produces no more
turbidity than that given by 1 mg. of sodium bi-
carbonate in a blank test. Acetylene, aldehyde,

Part I

Ethylene 559

hydrogen sulfide, phosphine. — 1000 ml. of ethylene
passed through silver ammonium nitrate T.S. pro-
duces no turbidity or darkening. Carbon monox-
ide.— 1000 ml. of ethylene shaken with a dilution
of blood shows no pink coloration due to carboxy-
hemoglobin, using pyrogallol and tannic acid in
the test, and matches the gray color obtained
with 1000 ml. of carbon monoxide-free air in a
blank test. U.S.P.

Ethylene is the first member of a homologous
series of unsaturated hydrocarbons the type for-
mula for which is C„H2„. Ethylene and the mem-
bers of this series in general are characterized by
relative instability and a tendency to form addi-
tion compounds, especially with the halogens.
Thus when passed into bromine, ethylene is rap-
idly absorbed with the formation of ethylene
bromide (ethylene dibromide) C2H4Br2. Besides
reacting with halogens, ethylene will react also
with halogen acids, hypo-halogen acids, sulfuric
acid, and, in the presence of catalysts, with hydro-
gen. Fuming sulfuric acid absorbs large quantities
of ethylene at room temperatures, while ordinary
sulfuric acid will do so at elevated temperatures.
By the addition of a hypo-halogen acid, for ex-
ample HCIO, a hydrin is formed which with an
alkali yields a dihydric alcohol (ethylene glycol).
When passed through a hot tube, ethylene yields
carbon, hydrogen, methane, ethane and acetylene.
Ethylene acts as a divalent radical in combining
with acids to form salts and yields derivatives
important in organic syntheses.

Assay. — A volume of 100 ml. of ethylene, ac-
curately measured in a mercury-filled gas burette
or nitrometer, is passed into a gas pipette contain-
ing bromine T.S. which absorbs the ethylene as
dibromide. The residual gas is returned to the
measuring burette, then passed into a pipette con-
taining potassium hydroxide solution to absorb
bromine vapor which may have been withdrawn
from the bromine pipette. Again the residual gas
is returned to the measuring burette; its volume
should not exceed 1 ml., indicating the presence
of at least 99 per cent of ethylene. U.S.P.

Uses. — The use of ethylene as an anesthetic
was suggested by Luckhardt in 1923, and since
that time it has been extensively employed both in
this country and in Europe. Herb (J.A.M.A.,
1933, 51, 1716), from a study of the literature
on 1,000,000 cases of ethylene anesthesia, con-
cluded that it has the advantages over ether of
being less unpleasant to inhale, causing no reflex
respiratory disturbances, salivation or bronchor-
rhea, and less post-operative vomiting, and that
induction and recovery are much more rapid, re-
quiring but 2 to 5 minutes each; furthermore, that
it is more effective than nitrous oxide and, since
larger amounts of oxygen can be used with it,
there is less liability of cyanosis. Its chief dis-
advantage is that it will not produce as complete
muscular relaxation as will ether or cyclopropane,
and in abdominal operations it is often necessary
to supplement the ethylene with ether because
sufficient concentrations of ethylene cause
hypoxia. In this million cases, five deaths were
attributed to the anesthetic, and two of these to
impurity of the ethylene. It is an almost non-
toxic substance which is excreted largely un-
changed in the expired air. It does not depress

the respiratory center and it is useful for patients
with cardiac or pulmonary disease. Studies with
deuterium-labeled ethylene showed that it does not
sensitize the heart to fibrillate after epinephrine
(Carr et al, Anesth., 1951, 12, 230). Preanes-
thetic sedation is essential to facilitate induction
of anesthesia, to increase the depth obtainable
and to decrease the required concentration of
ethylene. Induction of anesthesia is accomplished
with a mixture of 90 per cent ethylene and 10 per
cent oxygen, then surgical anesthesia (third stage,
plane 1) can be maintained with 80 per cent
ethylene. Surgical anesthesia requires about 140
mg. per 100 ml. concentration in the blood.
Analgesia without unconsciousness is obtained
with 25 to 35 per cent ethylene in air; although
this is adequate for the first stage of labor it is
not used in obstetrics because of the explosion
hazard of such concentrations.

Toxicology. — In the early history of ethy-
lene anesthesia a violent explosion, which led to
the death of the patient, caused widespread fear
of the dangerous flammability of this gas. While
caution in its use should at all times be exercised,
attention is directed, however, to the studies of
Salzer (J.A.M.A., 1929, 92, 2096), in which he
found that the explosive range of ethylene-air
mixtures was limited between 4 and 22 per cent
of ethylene, but that mixtures of ether were
explosive with from 2 to 50 per cent of ether;
furthermore, because ethylene is a gas there is
less danger of fire than with liquid ether. In oxy-
gen the explosive range is from 3.1 to 79.9 per
cent of ethylene. For practical purposes the 80
per cent ethylene-20 per cent oxygen mixture
commonly used is in the explosive range. While
it is true that there is a danger of electric sparks
igniting ethylene vapor in the operating room,
the same is equally true of ether vapor. Flames
and sparks must be kept out of the room and
the air should be humidified. With care an elec-
tric cautery can be used. The most dangerous
time is just after ethylene has been discontinued
when the concentration drops from the high,
less-explosive, anesthetic level to the lower,
explosive concentrations. Ethylene and nitrous
oxide cannot be used together because of the
explosive nature of the mixture. For a review
of the explosion problem see Cole {Surgery,
1945, 18, 7).

Another unfortunate happening which retarded
the popularity of this anesthetic was the occur-
rence of several cases of poisoning by carbon
monoxide from impure gas. Sherman et al.
{J. AM. A., 1927, 88, 1228) found several lots
of commercial ethylene containing appreciable
quantities of carbon monoxide, and reported
three cases of poisoning, two of which were fatal.

Agricultural Use. — Aside from its anesthetic
uses, ethylene is used to hasten ripening of vari-
ous fruits and vegetables. How far this practice
affects the nutritive value of fruits, especially
the vitamin content, has not been established with
absolute certainty, but the present evidence indi-
cates that the degree of any effect is not serious.
According to Bagster (Proc. Roy. Soc. Queens-
land, 1939, 50, 153) oranges treated with ethy-
lene suffer no loss in catalase or ascorbic acid. It
is believed to hasten the decomposition of chloro-

560 Ethylene

Part I

phyll, reduce the amount of tannins, raise the
sugar content, and increase the activity of hydro-
lyzing and oxidizing enzymes of the plant. Some
evidence exists (Brooks, Chetn. Abs., 1943, 37,
4149) that development of stem-rot in oranges
is accelerated under certain conditions and it is
advised, therefore, that treatment with ethylene
be eliminated or applied only to fruit that really
requires it.

Ethylene is an important starting material in
many organic syntheses, including those of ethy-
lene glycol and ethyl alcohol.

The usual dose is that amount required by
inhalation to cause the desired anesthesia.

Labeling. — "Label Ethylene with the state-
ment 'Caution — Ethylene is flammable, and a
mixture of it with oxygen or air will explode
when brought in contact with a flame or other
causes of ignition.' " U.S.P.

Storage. — Preserve "in tight containers, re-
mote from fire." U.S.P.

ETHYLENEDIAMINE SOLUTION.
U.S.P. (LP.)

Liquor iEthylenediamine

"Ethylenediamine Solution contains not less
than 67 per cent of ethylenediamine (C2H8N2)."
U.S.P.

The LP. recognizes Ethylenediamine Hydrate,
requiring it to contain not less than 97.4 per
cent and not more than the equivalent of 101.0
per cent of C2H8N2.H2O (the theoretical con-
tent of ethylenediamine in the hydrate is 76.96
per cent).

I. P. Ethylenediamine Hydrate; Aethylenediamini
Hydras. 1,2-Ethanediamine. 1,2-diaminoethane. Sp. Sohtcidn
de Etilenediamina .

Ethylenediamine, NH2.CH2.CH2.NH2. may be
prepared by the reaction of ethylene dibromide
and ammonia, or by the reaction of ethylene
dichloride with either aqueous or anhydrous am-
monia at elevated temperature and pressure.
The usual commercial product contains about
30 per cent of water.

Description. — "Ethylenediamine Solution is
a clear, colorless, or only slightly yellow liquid,
having an ammonia-like odor and a strong alka-
line reaction. It is miscible with water and with
alcohol." U.S.P. The LP. gives the density of
ethylenediamine hydrate as between 0.950 and
0.970, and the boiling range as from 119° to
121°.

Standards and Tests. — Identification. — A
purplish blue color results when 3 drops of a 1 in
6 dilution of ethylenediamine solution is shaken
with 2 ml. of a 1 in 100 solution of cupric sul-
fate. Heavy metals. — The limit is 20 parts per
million. Ammonia and other bases. — The weight
of ethylenediamine dihydrochloride obtained by
evaporating a weighed sample of about 1.5 ml.
of ethylenediamine solution in the presence of
diluted hydrochloric acid to dryness on a steam
bath, followed by heating of the residue to con-
stant weight at 110°, corresponds, when multi-
plied by 0.4517, to within ±0.5 per cent of the
weight of ethylenediamine calculated from the
result of the assay. U.S.P.

Assay. — About 1.5 ml. of the solution is
weighed, diluted with distilled water, and titrated
with 1 N hydrochloric acid, using bromophenol
blue T.S. as indicator; the equivalence point
corresponds to the formation of ethylenediamine
dihydrochloride. Each ml. of 1 N hydrochloric
acid represents 30.05 mg. of C2H.8N2. U.S.P. The
I. P. assay is similar but bromocresol green is
used as the indicator.

Uses. — Ethylenediamine solution is recognized
officially because it is employed in the manufac-
ture of aminophylline injection to provide a suffi-
cient excess of the amine to keep the theophylline
in solution. It is also employed in manufactur-
ing the aminophylline, but when the latter is
used for preparing injections it is likely not to
contain sufficient ethylenediamine to produce a
clear solution, particularly in the case of solu-
tions containing 500 mg. of aminophvlline in
2 ml.

In the body ethylenediamine appears to be
destroyed, as is ammonia, without increasing
body alkalinity. Its toxic properites are appar-
ently slight; the minimal fatal dose for mice,
according to Barbour and Hjort (/. Lab. Clin.
Med., 1920, 5), is 0.75 Gm. per kilogram when
administered hypodermically. In non-fatal doses
ethylenediamine causes a temporary' fall in body
temperature and an increase in respiration. Be-
cause of its solvent action on protein, ethylene-
diamine was at one time suggested for dissolving
diphtheritic membranes.

Ethylenediamine solution finds wide usage in
many organic syntheses, including the prepara-
tion of various medicinals, dyes, andw rubber ac-
celerators; its alkaline character is utilized for
solubilizing water-insoluble acids, proteins, resins
and gums, and for neutralizing acidity in oils
as well as removing sulfur and other objection-
able compounds from sulfate wood turpentine,
oils, benzene, etc.

The dihydrochloride of ethylenediamine is a
salt employed medicinally because it liberates hy-
drochloric acid on alkaline hydrolysis in the
system (see Chlor-Ethamine, Part II); the dihy-
driodide is used as a source of iodide ion (see
Iod-Ethamine, Part II).

Storage. — Preserve "in tight containers."
U.S.P.

ETHYLMORPHINE HYDRO-
CHLORIDE. U.S.P.

Ethylmorphinium Chloride, [iEthylmorphinae
Hydrochloridum]

CI" 2H20

CaHgO

Dionin (Merck). ^Ethylraorphinum Chlorhydricum;
iEthylmorphinae Chlorhydras; Morphinum ^Ethylatum Hy-
drochloricum. Fr. Chlorhydrate d'ethylmorphine ; Codethy-
line. Ger. Athylmorphinhydrochlorid. It. Cloridrato di

etilmorfina. Sp. Clorhidrato de etilmorfina.

Part I

Eucalyptol 561

Ethylmorphine is the ethyl ether of morphine,
analogous to codeine which is the methyl ether.
Ethylmorphine is made by reacting morphine
with ethyl iodide or diethyl sulfate, in the pres-
ence of an alkali. The hydrochloride is obtained
by neutralizing the base with hydrochloric acid.

Description. — "Ethylmorphine Hydrochloride
occurs as a white, or faintly yellow, odorless,
microcrystalline powder. It melts with decom-
position at about 123°. One Gm. of Ethylmor-
phine Hydrochloride dissolves in 10 ml. of water
and in 25 ml. of alcohol. It is slightly soluble in
ether and in chloroform." U.S.P.

Standards and Tests. — Identification. — (1)
A drop of ferric chloride T.S. added to a solution
of 10 mg. of ethylmorphine hydrochloride in 10
ml. of sulfuric acid produces, on warming on a
water bath, at first a green color, then a deep
violet-blue and, after the addition of a drop of
nitric acid, a deep red. (2) A solution of ethyl-
morphine hydrochloride responds to tests for
chloride. Specific rotation. — Not less than — 102°
and not more than — 105°, when determined in
a solution containing 200 mg. in each 10 ml. and
calculated on the anhydrous basis. Distinction
from codeine hydrochloride. — A white turbidity
is immediately produced on adding 1 ml. of am-
monia T.S. to 5 ml. of a 1 in 25 solution of ethyl-
morphine hydrochloride. Acidity. — A solution of
500 mg. of ethylmorphine hydrochloride in 15 ml.
of water requires not over 0.3 ml. of 0.02 N
sodium hydroxide for neutralization, using methyl
red T.S. as indicator. Water. — Not over 10 per
cent, when dried at 110° in vacuum over phos-
phorus pentoxide for 4 hours or by the Karl
Fischer method. Residue on ignition. — Ignition of
200 mg. of ethylmorphine hydrochloride yields a
negligible residue. Ammonium compounds. — Am-
monia is not evolved on heating an aqueous solu-
tion of ethylmorphine hydrochloride with sodium
hydroxide, as confirmed by a test with litmus
paper held in the vapors escaping from the solu-
tion. Morphine. — Addition of 1 ml. of a 1 in 10
dilution of ferric chloride T.S. and 1 ml. of a 1 in
100 solution of ethylmorphine hydrochloride to
a solution or 50 mg. of potassium ferricyanide in
10 ml. of water does not produce at once a green
or blue color. U.S.P.

Incompatibilities. — The incompatibilities of
ethylmorphine hydrochloride are those of alka-
loids and their salts in general.

Uses. — Ethylmorphine hydrochloride is official
for its topical use as a chemotic agent in the con-
junctival sac. In its general effect, it is inter-
mediate between morphine and codeine, being
somewhat closer to the latter (Gardemann, Arch,
exp. Path. Pharm., 1932, 167, 422; May, Am. J.
Med., 1953, 14, 540). As an analgetic or hypnotic
drug it is somewhat more active than codeine.
Like codeine it is less euphoric in its action than
morphine; Joel {Deutsche med. Wchnschr., 1929,
p. 102) concluded that the liability of addiction
was less than with morphine. Internally, ethyl-
morphine has been used to allay cough and relieve
pain. Although it is less active than morphine it
is likewise less constipating and addicting. Linden-
mayr {Berl. klin. Wchnschr., 1912) recommended
its internal use in acute coryza.

Locally, ethylmorphine is decidedly irritant to
delicate mucous membranes, as those of the con-
junctiva or nose, apparently increasing the flow
of lymph beyond the extent explicable by this
local irritation. After the initial burning sensation
there is local anesthesia. Feldman and Sherman
{Arch. Ophth. 1943, 29, 989) found by slit lamp
observation that 0.25 per cent solution of ethyl-
morphine hydrochloride instilled into the con-
junctival sac produces immediate and marked
dilatation of the deep network of both bulbar and
limbal vessels and only slight effect on the super-
ficial vessels, also marked edema, whereas his-
tamine has greater superficial effect. Ethylmor-
phine hydrochloride is widely employed as a
lymphagogue in such affections of the eye as iritis,
glaucoma, corneal ulcer, vitreous opacities, and
fresh scarring of the cornea. It is employed for
this purpose in concentrations of 1 to 10 per cent,
freshly prepared. Aqueous solutions of this sub-
stance will, on standing, frequently show separa-
tion of crystals which may irritate the eye me-
chanically. Some ophthalmologists, therefore, rec-
ommend that it be used in an ointment. Faleiros
{Chem. Abs., 1942, 36, 3264) reported beneficial
results in luetic interstitial keratitis from the use
of injections of a 10 per cent solution under the
conjunctiva.

In chronic catarrhal middle ear disease with
deafness, ethylmorphine hydrochloride has been
injected via eustachian catheter into the middle
ear (Randall, cited by Gleason, Manual of Dis-
eases of the Nose, Throat, and Ear, 4th ed.,
Saunders, 1918, p. 569) or with a fine hypodermic
needle through the postero-inferior quadrant of
the tympanic membrane into the middle ear
(Trowbridge, Arch. Otolaryng., 1944, 39, 523).
Improvement in both deafness and tinnitus, with
minimal untoward reactions, was reported with a
dose of 0.25 ml. of 1.5 per cent solution, increas-
ing to 3.5 per cent concentration gradually at
intervals of once or twice weekly. Presumably
this solution causes a sterile inflammatory reac-
tion with increased lymphatic flow in the ear.
Drops of ethylmorphine hydrochloride solution
have been used in atropic rhinitis, [v]

The dose of ethylmorphine hydrochloride when
taken internally has varied from 8 to 60 mg. (ap-
proximately yi to 1 grain). For external use, by
instillation into the conjunctival sac, a 1 to 5 per
cent solution is commonly used (but see above).

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

EUCALYPTOL. U.S.P., B.P.

Cineol, [Eucalyptol]

CH,
I

H2C — C — O

CHj
I '
CH,

H2C— C— C(CH3)

3'2

"Eucalyptol is obtained from eucalyptus oil
and from other sources." U.S.P. The B.P. de-

562 Eucalypto!

Part I

scribes eucalyptol as the anhydride of menthane-
1 :8-diol.

Cineol; Cineole; Cajeputol; Cajuputol. Eucalyptolum.
Fr. Eucalyptol; Oxyde de terpilene. Cer. Eukalyptol;
Zineol; Terpan. It. Eucaliptolo. Sp. Eucaliptol.

Eucalyptol may be obtained by fractional dis-
tillation of eucalyptus oil. It may also be obtained
from cajuput oil, which contains up to 65 per
cent of eucalyptol.

Description. — "Eucalyptol is a colorless
liquid, having a characteristic, aromatic, distinctly
camphoraceous odor, and a pungent, cooling,
spicy taste. Eucalyptol is insoluble in water.
It is miscible with alcohol, with chloroform, with
ether, with glacial acetic acid, and with fixed
and volatile oils. One volume of Eucalyptol dis-
solves in 5 volumes of 60 per cent alcohol. The
specific gravity of Eucalyptol is not less than
0.921 and not more than 0.924. Eucalyptol con-
geals at a temperature not lower than 0°. Eucalyp-
tol distils between 174° and 177°." U.S.P.

Standards and Tests. — Identification. — A
white crystalline mass of eucalyptol-phosphoric
acid forms on gradually adding phosphoric acid
to an equal volume of eucalyptol in a test tube
placed in a freezing mixture; on addition of warm
water eucalyptol separates. Optical rotation. —
Not more than ±0.3° in a 100-mm. tube. Refrac-
tive index. — Not less than 1.4550 and not more
than 1.4600, at 20°. Phenols.— (I) The volume of
eucalyptol is not diminished by shaking it with an
equal volume of sodium hydroxide T.S. (2) No
violet color develops on adding a drop of ferric
chloride T.S. to 10 ml. of the aqueous layer from
a mixture of 1 ml. of eucalyptol and 20 ml. of
water which has previously been shaken. U.S.P.

Uses. — Eucalyptol has long been used, both
internally and externally, as an aromatic and
antiseptic. Internally it is a stimulating expecto-
rant in the treatment of chronic bronchitis. Its
flavor is less objectionable than that of many
other drugs of this group, but if used too freely
eucalyptol is likely to produce disturbances of
the nervous system. For local application it has
mildly anesthetic and antiseptic activity; it has
been used in treating inflammatory conditions of
the nose and throat in the form of a 0.5 to 2
per cent solution in liquid petrolatum. For use
as a steam inhalation 4 ml. of eucalyptol may
be added to 500 to 1000 ml. of water.

Eucalyptol has been found to be germicidal
at greater dilutions than phenol but it is decidedly
slower in its action; the phenol coefficient thus
depends also on time of exposure. At five minutes
exposure eucalyptol and phenol were found to be
of approximately equal germicidal activity
(Grieg-Smith, Bot. Abs., 1921, 7, 189). Miller
(Am. J. Pharm., 1931, 103, 34) found the phenol
coefficient of eucalyptol to be about 2.

Eucalyptol is sometimes used in the formula-
tion of dentifrices and douche powders. It is
included in certain temporary dental fillings in
approximately 0.25 per cent concentration. For-
merly it was used as a vermifuge but it has
been abandoned in favor of more efficient
remedies.

Toxicology. — The lethal dose of eucalyptol
for rats is about 1.7 Gm. per Kg. of body weight,
when given orally (Brownlee, Quart. J. P., 1940,
13, 130). The toxic symptoms were hypersensi-
tiveness to noise, cyanosis, stupor, and epilepti-
form convulsions, with death resulting from re-
spiratory- failure; in non-fatal amounts it caused
a fall of blood pressure, primary respiratory
stimulation followed by depression, and in-
creased reflexes. See also the toxicology of Euca-
lyptus Oil.

Eucalyptol has been administered, as an ex-
pectorant, in a dose of 0.3 ml. (approximately
5 minims).

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep.— N. F. Antiseptic Solution; Alka-
line Aromatic Solution; Ephedrine Sulfate Jelly;
Compound Zinc Sulfate Powder, N.F.

EUCALYPTUS OIL. N.F., B.P.

Oleum Eucalypti

"Eucalyptus Oil is the volatile oil distilled with
steam from the fresh leaves of Eucalyptus
Globulus Labillardiere, or from other species of
Eucalyptus (Fam. Myrtacece). Eucalyptus Oil
contains not less than 70 per cent of eucalyptol
(CioHisO)." N.F. The B.P. does not designate
the particular species from which the oil is ob-
tained, simply requiring it to belong to the
genus Eucalyptus, and to contain not less than
70.0 per cent, by weight, of cineole. CioHisO.

Oleum Eucalypti Globuli ^Ethereum; Essentia Eucalypti.
Fr. Essence d'ecalyptus. Ger. Eukalyptusol. It. Essenza
di eucalipto. Sp. Esencia de eucalipto.

The genus Eucalyptus was named by L'Heritier
in 1788, from the two Greek words, di (well)
and -/.aAV'.-rrco (I cover) in allusion to the opercu-
lum formed of the fused petals and calyx lobes,
which covers the flower until the stamens have
matured and then separates from the calyx tube
by transverse dehiscence. This genus comprises
over 500 species and about 130 varieties, mostly
evergreen trees, all natives of Australia, Tas-
mania and Malayan regions. The leaves are sim-
ple and entire on young shoots and seedlings,
dorsiventral. opposite, sessile, with cordate bases;
on older parts they are usually bifacial, alternate,
with twisted petioles and lanceolate to falcate in
outline, the leaf parenchyma containing numerous
oil-glands. The flowers vary from white through
yellow to red and are arranged singly or in
corymbs or panicles of umbels. Each has an
obconic. bell-shaped or oblong calyx tube achate
to the base of the ovary, the calyx lobes connate,
forming a fid which separates from the calyx
tube by transverse dehiscence, numerous stamens
and a compound pistil with an undivided style.
The fruit is a 3- to 6-celled woody pyxis con-
taining numerous small seeds, many of which
are sterile.

Some species, according to Kemer, attain a
height of 140 to 152 meters and so become close
rivals of the giant sequoias of California, which
have hitherto been claimed to be the tallest trees
known.

Part I

Eucalyptus Oil 563

Most of the species do not require excessive
heat for their perfecting, and some of them are
able to resist moderate frosts. Over forty species
are being grown successfully in the United States,
chiefly in California, where volatile oil has been
produced on an experimental scale and leaves
collected in commercial amounts.

Eucalyptus Globulus, commonly called blue
gum-tree or Australian fever-tree, is a large
evergreen tree, attaining a height of 300 or even
350 feet, with a smooth, ash-colored bark. The
leaves attain a foot in length, and vary, accord-
ing to age, from a glaucous white to a bluish-
green color. The flowers are large, pinkish- white,
axillary, occurring singly, or in clusters. Al-
though its wood is very resinous, hard, and dura-
ble, the tree is remarkable for the rapidity of
its growth, reaching, under favorable circum-
stances, a height of fifty feet in five or six years.
It flourishes best in valleys having a rich, moist
soil, and has very largely been naturalized in
many semi-tropical countries, partly on account
of its economic value, but chiefly because of the
reputation it enjoys as a means of drying up
miasmatic bogs.

Under the title Eucalyptus the U.S. P. X recog-
nized the leaf of E. Globulus and described it as
follows :

"Unground Eucalyptus. — Blades lanceolate,
curved, from 8 to 30 cm. in length and from 2 to
7.5 cm. in breadth, apex acute or acuminate;
base unequal, obtuse or rounded; petiole twisted,
from 5 to 35 mm. in length; margin uneven,
revolute; coriaceous; both surfaces varying from
pale yellowish-green to grayish-green and more or
less glaucous, glabrous, glandular-punctate and
with numerous small, circular brown dots of cork;
veins of the first order anastomosing to form a
vein nearly parallel with the margin; odor aro-
matic; taste aromatic, bitter and cooling." U.S.P.
X. For histology see U.S.D., 22nd ed., p. 745.

The oils distilled from the leaves and from
the twigs or wood of the various species of this
very large genus, are so dissimilar in composition
and properties that the generic term "eucalyptus
oil" is without definite meaning unless the species
is known. Gildemeister and Hoffman (Aether-
ische Oele, 1899, p. 690) divided the eucalyptus
oils into 5 groups according to their constituents,
viz.: Group 1, cineol-containing oils, among which
is the official oil. The most important species
of this group is the E. Globulus but several other
species, notably E. maideni, E. syderoxylon, and
E. polybractea produce oils high in cineol. The
E. incinata, E. cineorijolia, E. dumosa, E. odorata,
and E. salicifolia also belong to this group but
their cineol content rarely reaches the official
requirement. Group 2, citronellal-containing oils,
of which group Eucalyptus maculata is the most
important; Group 3, citral-containing oils, of
which E. staigeriana F. von Muell. is the typical
example; Group 4, peppermint-smelling oils, of
which Eucalyptus piperita is an example; and
Group 5, less known oils of varying odor.

Description. — "Eucalyptus Oil is a colorless
or pale yellow liquid, having a characteristic,
aromatic, somewhat camphoraceous odor, and a

pungent, spicy, cooling taste. Eucalyptus Oil is
soluble in 5 volumes of 70 per cent alcohol. The
specific gravity of Eucalyptus Oil is not less
than 0.905 and not more than 0.925." N.F.

Standards and Tests. — Congealing tempera*
ture. — Not lower than —15.4°, indicating not
less than 70 per cent of eucalyptol (CioHisO).
Refractive index. — Not less than 1.4580 and not
more than 1.4700, at 20°. Reaction.— A 1 in 5
solution of the oil in 70 per cent alcohol is
neutral to moistened litmus paper. Heavy metals.
— The oil meets the requirements of the test for
Heavy metals in volatile oils. Phellandrene. — ■
No crystals form within 10 minutes in a mixture
of 2.5 ml. of eucalyptus oil, 5 ml. of petroleum
benzin, 5 ml. of a 5 in 8 solution of sodium
nitrite, and 5 ml. of glacial acetic acid. N.F.

Assay. — The assay of eucalyptus oil for its
cineol content has long been a matter of research
and many methods have been proposed. For a
review of these, see U.S.D., 22nd ed., p. 745.
The N.F. utilizes the congealing point of the oil
as an approximation of its content of eucalyptol.

The B.P., however, requires an assay for cineol
by the following method: Three Gm. of the oil
of eucalyptus or eucalyptol (previously dried by
shaking with calcium chloride) is mixed with 2.1
Gm. of melted o-cresol. In this mixture is placed
a thermometer graduated in fifths of a degree,
the mixture is then stirred to induce crystalliza-
tion, and the highest reading of the thermometer
is taken as the freezing point. The determination
is repeated until consecutive concordant results
are obtained. From a table the per cent of cineol,
corresponding to the observed freezing point, is
noted.

Composition. — The oil from Eucalyptus
Globulus contains principally eucalyptol (cineol)
and a smaller amount of pinene and other ter-
penes. Schimmel & Co. reported (Ber., April,
1888) obtaining several of the aldehydes of the
fatty series, notably valeraldehyde, and probably
butyraldehyde and capronaldehyde, in oil from
Eucalyptus Globidus.

Eudesmol, C15H26O, a crystalline camphor ob-
tained from the oil of E. piperita Smith, by H. G.
Smith and R. T. Baker, also occurs in oil from
E. Globulus. Semmler and Mayer (Ber., 1912,
45, 1390) suggested that eudesmol is a tricyclic
sesquiterpene alcohol.

Uses. — Eucalyptus oil is an active germicide,
though less active than many other volatile oils.
Eucalyptol is probably a less efficient antibacte-
rial agent than eucalyptus oil. The oil is absorbed
from the intestinal tract, eliminated partially
through the breath, to which it imparts its odor,
and also, as an oxidation product, through the
urine, to which it gives an odor resembling that
of violets.

Eucalyptus oil is used locally as an antiseptic,
especially in the treatment of infections of the
upper respiratory tract and in certain types of
skin disease. Internally it has found use as a
stimulating expectorant in chronic bronchitis.
Sometimes it has been administered by inhalation;
a few drops of the oil are added to boiling water
and the mixture of oil vapor and steam inhaled.

564 Eucalyptus Oil

Part I

The oil is also included in some formulations
which are inhaled directly, without the use of
steam. It has been employed in asthma, either
by internal administration or by inhalation.

Eucalyptus oil has also been used as a vermi-
fuge, against the hookworm. At one time it was
used in the treatment of malarial fever, though
there is no basis for such use.

Toxicology. — Several cases of poisoning with
eucalyptus oil have been reported; Barker and
Rowntree (Bull. Johns Hopkins Hosp., 1918, 29,
215) collated 29 cases of poisoning, of which
7 were fatal. The smallest fatal dose was 3.5 ml.,
but recovery occurred after about 20 ml. and in
one case 30 ml. The most common symptoms
were epigastric burning with nausea and usually
vomiting; dizziness and muscular weakness also
occurred almost uniformly. The skin was pale,
or sometimes cyanotic, the extremities cold, the
pulse rapid and weak, the pupils generally con-
tracted; the intellection was almost always af-
fected, the patients in most instances being
dazed and drowsy. In severe poisoning delirium
was common and occasionally associated with
convulsions. One of the earliest symptoms was
a feeling of suffocation. The odor of the oil was
strong on the breath, often remaining for 1 or 2
days, and was sometimes perceptible also in the
urine and feces. In some persons ordinary thera-
peutic doses give rise to dermatitis.

In the treatment of poisoning emesis should
be induced and gastric lavage performed; nik-
ethamide may be used to counteract depression of
respiration, but it should be used with care if
camphor along with eucalyptus is present. Mucus
should be removed from respiratory passages
and oxygen given where necessary. Antibiotics
should be used prophylactically (Craig, Archives
of Disease in Childhood, 1953, 28, 475).

Eucalyptus oil has been administered in doses
of 0.2 to 0.6 ml. (approximately 3 to 10 minims),
commonly in the form of an emulsion, or on sugar.

Storage. — Preserve "in tight containers."
N.F.

EUCATROPINE HYDROCHLORIDE.

U.S.P.

Eucatropinium Chloride, 4-Mandeloxy-l,2,2,6-tetramethyl-
piperidine Hydrochloride, [Eucatropinae Hydrochloridum]

^ Vchcoo

"Eucatropine Hydrochloride, dried over sul-
furic acid for 4 hours, contains not less than
99 per cent of C17H25NO3.HCI." U.S.P.

Euphthalmine Hydrochloride (Schering & Glatz). Sp.
Clorhidrato de Eucatropina.

Eucatropine is closely related to eucaine, one
of the early local anesthetics; the methods of
synthesis are similar. Eucatropine may be pre-
pared by reacting diacetonamine and acetalde-

hyde to produce vinyl-diacetonamine, which is
reduced with sodium amalgam to vinyl-diacetone-
alkamine; this is methylated at the nitrogen atom
by means of methyl iodide and alkali and then
esterified with an alcoholic solution of mandelic
acid to produce eucatropine, which is phenyl-
glycolyl - methyl - vinyl - diacetone - alkamine, also
referred to as l,2,2,6-tetramethyl-4-mandeloxy-
piperidine. The hydrochloride of the base is the
official salt.

Eucatropine differs from eucaine (described
in Part II) in having a methyl group attached
to nitrogen and in being a mandelate rather than
a benzoate ester.

Description. — "Eucatropine Hydrochloride
occurs as a white, granular, odorless powder. Its
solutions are neutral to litmus. Eucatropine
Hydrochloride is very soluble in water, and freely
soluble in alcohol and in chloroform; it is insolu-
ble in ether. Eucatropine Hydrochloride melts
between 183° and 186°." U.S.P.

Standards and Tests. — Identification. — (1)
Precipitates are produced in a 1 in 50 solution
of eucatropine hydrochloride by sodium carbon-
ate T.S., mercuric-potassium iodide T.S., iodine
T.S., trinitrophenol T.S. and many other reagents
for alkaloids. (2) The melting point of the free
base obtained in the assay, recrystallized from
petroleum benzin, is between 111° and 114°. (3)
A solution of eucatropine hydrochloride responds
to the test for chloride. Residue on ignition. —
Not more than 0.1 per cent. Atropine, scopola-
mine or hyoscy amine. — No violet color results
on adding 5 drops of 0.5 N alcoholic potassium
hydroxide together with a fragment of potassium
hydroxide to the residue obtained by evaporating
to dryness a mixture of 5 drops of nitric acid
and 50 mg. of eucatropine hydrochloride. U.S.P.

Assay. — About 500 mg. of eucatropine hydro-
chloride, previously dried for 4 hours over sul-
furic acid, is dissolved in water, the solution made
alkaline with ammonia T.S. and the eucatropine
extracted with ether. The residue remaining after
evaporation of ether is estimated by residual titra-
tion using 0.1 iV solutions of sulfuric acid and
sodium hydroxide. U.S.P.

Uses. — Eucatropine hydrochloride, introduced
into medicine in 1897, is used to dilate the pupil
without paralyzing accommodation, as in ophthal-
moscopy and in diagnosis of adhesions of the iris.
Mironescu (Therap. Monatsch., 1905, 19, 378)
studied its effects upon rabbits; he found it to
act like atropine and to have very low toxicity.

The utility of eucatropine depends on the
shortness of its action and its relative inertness
except on the iris. Mydriasis develops in about
30 minutes and persists for about 2 hours. Hale
(Illinois M. J., 1903, 5, 539) reported that it
produced only very slight disturbance of accom-
modation and that it did not affect ocular ten-
sion or irritate the cornea, as does cocaine (see
also Gradle, Am. J. Ophth., 1936, 19, 37). It
d«es not cause an increase in intraocular tension
in normal eyes but caution is required in older
people, as is the case with any atropine-like
drug, lest the patient have unrecognized glau-
coma. Chen and Poth (J. Pharmacol., 1929, 36,

Part I

Evans Blue

565

429) found the mydriatic power of eucatropine
to be slightly greater than that of cocaine.

A 2 per cent solution is instilled into the con-
junctival sac. The maximum amount of the drug
thus applied is usually 2 or 3 drops of a 10
per cent solution, which may be repeated once in
5 minutes.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

EUGENOL. U.S.P.

[Eugenol]

OCH,

CH2CH— CH«

"Eugenol is obtained from clove oil and from
other sources." U.S.P.

Eugenol, the main constituent of clove oil,
may be obtained from the latter by treatment
with a solution of sodium hydroxide, which con-
verts the eugenol to sodium eugenolate, soluble
in the alkaline solution; this solution is separa-
rated from the residual oil, treated with acid to
liberate free eugenol, which is subsequently
washed and distilled in steam or under vacuum.
Eugenol is also found in pimenta, cinnamon
leaves, sassafras, canella, bay and other plants.

Eugenol is 2-methoxy-4-allylphenol or 3-
methoxy-4-hydroxy-allylbenzene, and is of chemi-
cal interest as the starting compound in a
synthesis of vanillin. It is first converted to iso-
eugenol (in which the isomeric alpha-propenyl
group replaces the allyl of eugenol) by heating
with alkali, after which it is acetylized and oxi-
dized. Iso-eugenol also occurs naturally in several
oils, including clove, nutmeg and ylang-ylang.

Description. — "Eugenol is a colorless, or pale
yellow liquid, having a strongly aromatic odor
of clove and a pungent, spicy taste. Exposure
to air causes it to become darker and thicker.
Eugenol is optically inactive. Eugenol is slightly
soluble in water. It is miscible with alcohol, with
chloroform, with ether, and with fixed oils. One
volume of Eugenol dissolves in 2 volumes of 70
per cent alcohol. The specific gravity of Eugenol
is not less than 1.064 and not more than 1.070."
U.S.P.

Standards and Tests. — Boiling range. — Eu-
genol distills between 250° and 255°. Refractive
index. — Not less than 1.5400 and not more than
1.5420 at 20°. Hydrocarbons. — A clear mixture,
which may become turbid on exposure to air, re-
sults on mixing 18 ml. of water with a solution
of 1 ml. of eugenol in 20 ml. of 0.5 N sodium
hydroxide. Phenol. — A transient grayish green,
but not a blue or violet, color is produced on
adding 1 drop of ferric chloride T.S. to 5 ml. of
the filtrate from a mixture of 1 ml. of eugenol
with 20 ml. of water. U.S.P.

The B.P.C. refractive index range (20°) for
eugenol is 1.540 to 1.542. The identification tests
for eugenol require formation of a blue color with

ferric chloride in alcohol solution, and develop-
ment of an odor of vanillin on heating with alka-
line potassium permanganate solution.

Uses. — The medicinal properties and uses of
eugenol are practically the same as those of clove
oil (q.v.). Eugenol appears to be slightly less
active as an antiseptic than the natural oil.
Eugenol is used by dentists for disinfecting root-
canals, as a local anodyne for the relief of
hypersensitive dentine and pain and irritation
incident to hyperemic and inflamed vital pulps,
and as a component of the zinc-eugenol cement
employed as a temporary filling for carious teeth.

Eugenol has been used to treat patients with
gastric or duodenal ulcers by instilling it into
the stomach in doses of 0.12 Gm. per Kg. of
body weight; after 15 minutes the eugenol was
aspirated as completely as possible. The course
of treatment consisted of two such applications
each week for three weeks. Of 15 patients thus
treated, complete relief was obtained in 6 pa-
tients, partial relief in 5, and no relief in 4. The
period of complete relief persisted for 12, 19
and 21 months, respectively, in 3 patients
(Bandes et al., Gastroenterology, 1951, 18, 391).
Eugenol has also been used internally as an anti-
septic antipyretic, in doses of 3 ml. daily.

Dose, 0.12 to 0.3 ml. (approximately 2 to 5
minims). Up to 3 ml. (approximately 45 minims)
has been given in a period of 24 hours. It is
usually used topically.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

Off. Prep. — Zinc Compounds and Eugenol
Cement, N.F.

EVANS BLUE. U.S.P.

NaOj!

S03Na

"Evans Blue contains not less than 95 per cent
and not more than 105 per cent of C34H24N6-
Na40i4S4, calculated on the dried basis." U.S.P.

Azovan Blue, B.P.C. T-1824.

This diazo dye, the tetrasodium salt of 4,4'-bis-
[7-(l-amino-8-hydroxy-2,4-disulfo)naphthylazo]-
3,3'-bitolyl, may be prepared by coupling of 1
mole of diazotized o-tolidine with 2 moles of
1 -amino-8-naphthol-2 ,4-disulf onic acid.

Description. — "Evans Blue is a green, bluish
green, or brown powder. It is odorless. The dried
product is hygroscopic. Evans Blue is very solu-
ble in water. It is very slightly soluble in alcohol
and practically insoluble in benzene, in carbon
tetrachloride, in ether, and in chloroform." U.S.P.

Standards and Tests. — Identification. — (1)
On adding sodium nitroferricyanide T.S. to a
solution of a sodium fusion of the dye a red-
violet color appears, indicating the presence of
sulfide. On adding ferrous sulfate and ferric chlo-
ride to another portion of the same solution a
blue color appears, indicating the presence of
cyanide. (2) A 0.00035 per cent solution of Evans

566

Evans Blue

Part I

Blue exhibits maximum absorbance at about 610
mn. Insoluble substances. — Not over 0.05 per cent
is insoluble in water. Loss on drying. — Not over
15 per cent, when dried at 105° for 2 hours.
Residue on ignition. — Not less than 27 per cent
and not more than 31 per cent, calculated on the
dried basis. Chloride. — No turbidity develops on
adding silver nitrate T.S. under the conditions of
the test. Acetate. — No odor of acetic acid or ethyl
acetate develops on heating a solution of the dye
with a mixture of sulfuric acid and alcohol. Heavy
metals. — The limit is 70 parts per million. U.S. P.

Assay. — The absorbance of a 0.00035 per cent
solution of the dye, in water, is determined at
610 mn, with a suitable spectrophotometer. U.S.P.

Uses. — Evans blue is a diazo dye used as a
diagnostic agent for the determination of blood
volume by the colorimetric method. It serves as
a guide in ascertaining the amount of blood,
plasma, or other fluid to be administered in con-
ditions accompanied by diminished blood volume
and to detect impending shock (see J.A.M.A.,
1952, 150, 1486; also von Porat, Acta med.
Scandinav., Supplement 256, 1951).

When injected intravenously Evans blue com-
bines with plasma albumin and leaves the blood
stream very slowly. Its optical density is in direct
proportion to its concentration. The exact fate of
the dye in the body has not yet been determined.
It is known that it diffuses from the capillaries
into extravascular tissues. Small quantities are
excreted through the bile and some is taken up
by wandering phagocytes. As far as is known it
does not appear in the feces, in the cerebrospinal
fluid, or in the urine if the kidneys are normal.
When used in amounts recommended for deter-
mination of blood volume, no toxic reactions have
been reported, though with considerably higher
dosage there may be blue staining of the skin and
sclerae. Pulmonary embolism has been produced
in experimental animals with large doses.

In normal persons the dye is usually completely
mixed with the circulating blood in 9 minutes, the
time being prolonged to 15 minutes in the pres-
ence of severe shock or congestive heart failure.
It is administered intravenously in the fasting
state and under basal conditions. The subject
must be recumbent for at least 15 minutes. Given
as a single injection into the antecubital vein, the
dose is 25 mg. of the dye, as 5 ml. of an 0.5 per
cent aqueous solution, which has been diluted
further with 1 to 2 ml. of sterile isotonic sodium
chloride solution (see J.A.M.A., 1952, 150, 1486).
A 10-ml. sample of blood is withdrawn before the
Evans blue is administered. Exactly 10 minutes
after injection (or 15 minutes in the presence of
shock or congestive heart failure) another 10 ml.
blood sample is withdrawn. Each sample is placed
into a 4-ml. hematocrit tube containing 1 mg. of
dried heparin sodium as an anticoagulant. Hema-
tocrit determinations are made and samples of
the plasma are evaluated for color (optical den-
sity) in a suitable photometer. For comparison
a standard containing a 1 : 500 concentration of
the dye employed, in normal dye-free plasma, is
used. The total plasma volume equals 5 ml.
(volume of dye solution injected) X 500 (dilution
of the standard) X optical density of the stand-

ard -s- optical density of unknown dye-tinged
plasma. The total blood volume equals plasma
volume -7- 1 — (0.96 X hematocrit). The aver-
age plasma volume in the adult male is 45 ml. per
Kg. of body weight ; the average blood volume is
85 ml. per Kg. of body weight.

Evans blue is administered in a single injection
of 25 mg. of dye (5 ml. of 0.5 per cent solution),
further diluted with 1 to 2 ml. of sterile isotonic
sodium chloride solution. The dye is available in
ampuls containing 5 ml. of 0.5 per cent solution.

EVANS BLUE INJECTION. U.S.P.

"Evans Blue Injection is a sterile solution of
Evans blue in water for injection. It contains not
less than 95 per cent and not more than 105 per
cent of the labeled amount of dried C34H24N6-
Na40i4S4." U.S.P.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." U.S.P.

Usual Size. — Approximately 25 mg. in 5 ml.

EXPECTORANT MIXTURE. N.F.

Stoke's Expectorant, Mistura Pectoralis

Mix 35 ml. of senega fluidextract and 35 ml. of
squill fluidextract with 175 ml. of camphorated
opium tincture, add to this a solution of 18 Gm.
of ammonium carbonate in 85 ml. of purified
water, and enough tolu balsam syrup to make
1000 ml. Mix the product thoroughly. N.F.

Alcohol Content. — From 11 to 14 per cent,
by volume, of C2H5OH. N.F.

This is an old, but unscientific, nauseating ex-
pectorant. The N.F. gives the average dose as
4 ml. (approximately 1 fluidrachm).

Storage. — Preserve "in tight containers."
N.F.

FENNEL. N.F., B.P.

Fennel Seed, Fceniculum

"Fennel is the dried, ripe fruit of cultivated
varieties of Fceniculum vulgare Miller (Fam.
Umbelliferce)." N.F. The B.P. definition is
similar.

Fennel Seed or Fruit. Fructus Fceniculi. Fr. Fenouil
doux; Fruit de fenouil. Ger. Fenchel; Fencheltee. It.
Finocchio. Sp. Hinojo.

Fceniculum vulgare is a stout, glabrous, bi-
ennial or perennial, aromatic herb 3 to 5 feet
tall with green stems and pinnately decompound
leaves having numerous, filiform, terminal seg-
ments. The small yellow flowers are in large,
flat, terminal compound umbels, with from 13 to
20 rays, and destitute of involucres. The fruit is
an oblong oval cremocarp. The plant is a native
of southern Europe and Asia Minor, growing wild
upon sandy and chalky ground throughout the
Continent, and is also abundant in Asia. It is ex-
tensively cultivated in Europe, Morocco, Syria,
and India, as well as in this country, especially in
Kentucky. It has escaped from gardens and is
naturalized in the eastern United States. Two
subspecies of Fceniculum vulgare are cited in the
literature, namely, F. piperitum Coutinho, a wild
form occurring in Sicily, and F. capillaceum
(Gilib.) Holmboe, a Mediterranean form with

Part I

Fennel Oil

567

leaves divided into hairlike segments, extensively
cultivated in England and on the Continent. F.
capillaceum occurs in 3 varieties, namely, var.
a-vulgare, var. $-dulce, and var. y-azoricum. In
India, fennel is said to be obtained from F. pan-
morium DC, which is now considered only a
variety of the official plant. The fruits are brown-
ish, 6 to 7 mm. in length and possess a sweet
taste. They are said to yield 0.72 per cent of
volatile oil containing fenchone. Sicilian fennel
or Carosella is the fruit of F. vulgare var. piperi-
tum Hort. ; Subsp. piperitum Coutinho (F. piperi-
tum DC). Its young tender stems enclosed in
the sheathing leaf stalks are eaten raw by the
natives of southern Italy and Sicily.

F. vulgare var. dulce (DC) Alef., Sweet fen-
nel, Florence fennel or Finocchio, bears a gen-
eral resemblance to F. vulgare, but differs in hav-
ing its stem somewhat compressed at the base,
its radical leaves somewhat distichous, and the
number of rays in the umbel only from 6 to 8. Its
flowers appear earlier, and its young sweet shoots,
or turions, are eaten in Italy boiled or as a salad.

Prior to World War II, most of our supply
came from Italy, France, Netherlands, Yugoslavia,
Morocco, India, Roumania and Argentina.
French fennel is shipped mostly from Marseilles,
Levant fennel from Trieste, Indian fennel from
Bombay and London. The French, Levant, Ital-
ian and Indian fennels are yellow to yellowish-
brown. The Roumanian variety is small and
green. Japanese fennel is greenish-brown, ovoid,
and from 3 to 4 mm. long and 2 to 3 mm. broad,
and possesses a sweet, camphoraceous taste. Dur-
ing 1952, a total of 324,161 pounds of fennel
entered this country from the Netherlands,
Czechoslovakia, Argentina, France, W. Germany,
Bulgaria, Syria, Italy and Egypt.

The roots of fennel were formerly employed
in medicine, but are generally inferior in virtues
to the fruit. It is stated that manufacturers of
the oil usually distil the whole plant.

For histological differences of the commercial
varieties, see monograph by Hartwich and Jama
(Ber. deutsch. pharm. Ges., 1909, p. 306). Rosen-
thaler (ibid., 1913, p. 570) reported a pharma-
cognostical study pf a Chinese fennel.

Adulterants. — Commercial fennel varies
greatly in quality, this being due either to lack of
care in harvesting or to deliberate adulteration. It
may contain sand, dirt, stem tissues, weed seeds,
or other material to an extent that amounts to
adulteration. The fruits, especially the powder,
may be deficient in volatile oil, inferring that
they have been partly exhausted. Exhausted or
otherwise inferior fennel has been occasionally
improved in appearance by the use of a factitious
coloring. (See Spaeth, Pharm. Zentr., 1908, p.
545; and 1913, p. 736). Bitter fennel (F. piperi-
tum) has in some instances been substituted for
the true article. It may be distinguished from
the latter by its smaller size and bitter taste.
For a discussion of the adulteration of fennel,
see Berger (Pharm. Zentr., 1938, 79, 585).

Fennel is subject to the attacks of insects and
must therefore be carefully stored in tight con-
tainers.

Description. — "Unground Fennel occurs as

nearly cylindrical cremocarps, from 4 to 15 mm.
in length and from 1 to 3.5 mm. in breadth,
some having a slender stalk from 2 to 10 mm.
in length. The cremocarp is light brown to light
olive, with 5 prominent, light-colored, longitudi-
nal primary ribs on each mericarp, and at the
summit a short, conical stylopodium. The com-
missural surface of the mericarp is fiat, with
3 narrow, light-colored, longitudinal areas sepa-
rated by 2 darker areas containing vittae. Fennel
has an aromatic and characteristic odor and
taste, resembling that of anise." N.F. For histol-
ogy see N.F. X.

"Powdered Fennel is yellowish brown. It shows
colorless, irregular, angular fragments of endo-
sperm, the cells being filled with aleurone grains,
each containing a rosette of calcium oxalate 2
to 5 n in diameter; and fragments containing
vittas, the latter being from 100 to 200 n in
width. Fibers are few and strongly lignified, with
numerous oblique, simple pits, and occasional
reticulate thickenings. Tracheids and vessels with
spiral or annular thickenings are few. Numerous
globules of fixed oil separate in mounts made
with chloral hydrate T.S." N.F.

Standards and Tests. — Foreign organic mat-
ter.— Not over 4 per cent. Acid-insoluble ash. —
Not over 1.5 per cent. N.F.

Constituents. — The medicinal value of fen-
nel apparently depends on its volatile oil, of
which about 2 to 4 per cent is present (Kofler,
Arch. Pharm., 1935, 213, 388). It also contains
about 12 per cent of a fixed oil.

Uses. — Fennel seed was used by the ancients.
It is an aromatic, and is employed as a carmina-
tive, and as a corrigent of less pleasant medicinals,
particularly senna and rhubarb. An infusion may
be prepared by adding 8 to 12 Gm. (approxi-
mately 2 to 3 drachms) of the seeds to 500 ml.
(approximately 1 pint) of boiling water. In in-
fants the infusion was frequently employed as
an enema for expulsion of flatus.

Dose, of the bruised or powdered seeds, from
0.3 to 1 Gm. (approximately 5 to 15 grains).

Storage. — Preserve "in tight containers." N.F.

Off. Prep.— Fennel Oil, U.S.P.; N.F.; Com-
pound Powder of Liquorice, B.P.

FENNEL OIL. U.S.P.

[Oleum Fceniculi]

"Fennel Oil is the volatile oil distilled with
steam from the dried ripe fruit of Fceniculum
vulgare Miller (Fam. Umbelliferce). Note. — If
solid material has separated, carefully warm the
Oil at a low temperature until it is completely
liquefied and thoroughly mix it before using."
U.S.P.

Fr. Essence de fenouil. Get. _ Fenchelol. It. Essenza
di finocchio. Sp. Esencia de Hinojo.

For description of the fennel plant see under
Fennel. Fennel seeds are reported to yield from
about 2.5 per cent to 3.8 per cent of oil. The oil
used in this country is imported.

Description. — "Fennel Oil is a colorless or
pale yellow liquid, having the characteristic odor
and taste of fennel. One volume of Fennel Oil
dissolves in 1 volume of 90 per cent alcohol. The

568

Fennel Oil

Part I

specific gravity of Fennel Oil is not less than
0.953 and not more than 0.973." U.S.P.

Standards and Tests. — Congealing tempera-
lure. — Not lower than 3°. Optical rotation. — Not
less than +12° and not more than +24°, in a
100-mm. tube. Refractive Index. — Not less than
1.5280 and not more than 1.5380, at 20°. Heavy
metals. — The oil meets the requirements of the
test for Heavy metals in volatile oils. U.S.P.

Constituents. — Fennel oil contains anethol,
usually in amounts of about 60 per cent, also
d-pinene, phellandrene, dipentene, fenchone,
methyl-chavicol, anisic aldehyde, and anisic acid.
Fenchone is the constituent which gives the dis-
agreeable bitter taste to many of the commercial
oils. Limonene has been reported to be a con-
stituent, at least of some fennel oils. The pro-
portion of the different ingredients in oil of
fennel varies considerably according to its source.
Japanese oil contains about 75 per cent of anethol
and 10 per cent of fenchone. The French (sweet
or Roman) oil is practically free of fenchone,
while that from Russian fruits contains from
18 to 22 per cent of this constituent.

Uses. — Fennel oil is mildly carminative and
is sometimes used in infantile colic, but it is
more important for its use as a flavor.

Dose, 0.2 to 0.3 ml. (approximately 3 to 5
minims).

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Glycyrrhiza Syrup, U.S.P.; Fen-
nel Water; Carminative Mixture; Compound
Senna Powder, N.F.

FENNEL WATER. N.F.

Aqua Foeniculi

"Fennel Water is a clear, saturated solution of
oil of fennel in purified water, prepared by one
of the processes described under Waters." N.F.

Fr. Eau de fenouil. Ger. Fenchelwasser. It. Acqua
di finocchio. Sp. Ayua de Hinojo.

Uses. — This is a pleasant vehicle with a flavor
suggesting anise water. It is, however, rarely
prescribed.

FERRIC AMMONIUM CITRATE.
N.F., B.P. (LP.)

[Ferri Ammonii Citras]

"Ferric Ammonium Citrate contains not less
than 16.5 per cent and not more than 18.5 per
cent of Fe." N.F.

The B.P. defines Ferric Ammonium Citrate as
a complex ammonium ferric citrate, containing
not less than 20.5 per cent and not more than 22.5
per cent of Fe. The LP. rubric is identical with
that of the U.S.P.

B.P. Ferri et Ammonii Citras. LP. Iron and Ammonium
Citrate. Ammonio- ferric Citrate; Soluble Ferric Citrate;
Ammonio-citrate of Iron. Ferri et Ammoniae Citras; Fer-
rum Ammonio-citricum; Ferroammonium Citricum; Ferri
Citras Ammoniacalis: Ferrum Citricum Amoniatum. Fr.
Citrate de fer ammoniacal; Citrate ferrico-ammonique.
Ger. Braunes Ferri-ammonium-citrat; Eisenoxydammonium-
citrat. It. Citrato di ferro ammoniacale. Sp. Citrato de
hierro amoniacal; Citrato de Amonio Ferrico; Citrato
ferrico-araonico; Citratos de hierro y de amonio.

The B.P. states that this salt may be prepared
by saturating a warm aqueous solution of citric

acid with freshly precipitated ferric hydroxide,
adding a slight excess of ammonia, evaporating,
and drying the residue at a temperature not
exceeding 40°.

In this preparation, iron appears to exist in
combination with ammonium citrate as a complex
whose chemical nature is not known with cer-
tainty. For a discussion of the reaction of cilric
acid with ferric hydroxide see Peltz and Lynn
(/. A. Ph. A., 1938, 27, 774). They found that
on exposure to sunlight, citric acid is decomposed
by ferric hydroxide, with formation of carbon
dioxide and ferrous compounds.

Description. — "Ferric Ammonium Citrate
occurs as thin, transparent, garnet red scales or
granules, or as a brownish yellow powder. It is
odorless or has a slight ammoniacal odor, and a
saline, mildly ferruginous taste. It is deliquescent
in air and is affected by light. Its solutions are
neutral or acid or alkaline to litmus. Ferric Am-
monium Citrate is very soluble in water. It is
insoluble in alcohol." N.F.

Standards and Tests. — Identification. — (1)
When strongly heated, ferric ammonium citrate
chars and finally leaves a residue of ferric oxide.
(2) Addition of ammonia T.S. to a 1 in 100 solu-
tion of ferric ammonium citrate darkens the solu-
tion but does not produce a precipitate. (3) A
white precipitate is produced on heating to boiling
a mixture of 5 ml. of 1 in 100 solution of ferric
ammonium citrate, 0.3 ml. of potassium perman-
ganate T.S. and 4 ml. of mercuric sulfate T.S.
(4) After precipitating the iron in 10 ml. of a
1 in 10 solution of ferric ammonium citrate by
boiling with an excess of potassium hydroxide
T.S., then filtering, a 4-ml. portion of the filtrate,
slightly acidified with acetic acid, gradually de-
posits a white, crystalline precipitate when mixed
with 2 ml. of calcium chloride T.S. Tartrate. —
The remainder of the filtrate from the preceding
test, when more strongly acidified with acetic acid
and allowed to stand 24 hours, does not yield a
white, crystalline precipitate. Lead. — The limit
is 20 parts per million, the test being performed
by the dithizone method. Ferric citrate. — A blue
precipitate is not produced when potassium ferro-
cyanide T.S. is added to a 1 in 100 solution of
ferric ammonium citrate unless the latter has been
acidified with hydrochloric acid. N.F.

The B.P. specifies arsenic and lead limits of 4
and 50 parts per million, respectively; the corre-
sponding LP. limits are 5 and 20 parts per million.

Assay. — About 1 Gm. of the salt is dissolved
in distilled water, acidified with hydrochloric acid
and potassium iodide added. After standing 15
minutes in the dark, the iodine liberated by the
ferric iron is titrated with 0.1 N sodium thiosul-
fate, using starch T.S. as indicator. A blank on
the reagents is performed. Each ml. of 0.1 N
sodium thiosulfate represents 5.585 mg. of Fe.
N.F. The B.P. assay is similar except that a pre-
liminary oxidation with 0.1 N potassium per-
manganate is provided to oxidize any iron which
may not be in the ferric state. The LP. assay is
essentially that of the U.S.P.

Uses. — This compound of iron is characterized
by relative freedom from astringency and local
irritant action. A dose of 6 Gm. daily has been

Part I

Ferric Ammonium Citrate, Green

569

found to produce an average rise of 1 per cent
per day in the blood hemoglobin level of patients
with hypochromic anemia (Fowler and Barer,
J.A.M.A., 1939, 112, 110). It is used less fre-
quently than formerly. Aqueous solutions con-
taining up to 50 per cent of the salt, with a little
thymol or chloroform to retard growth of molds,
have been used as dosage forms. Such solutions
should be well diluted with water before use and
taken through a straw or other drinking tube to
minimize discoloration of the teeth. In the dry-
state, the salt is administered in capsules. For
intramuscular injection, the green ferric ammo-
nium citrate was employed because it was less
likely to coagulate protein and to cause pain.
Ferric ammonium citrate has a mild laxative
action in some patients. 0

Dose, from 1 to 2 Gm. (approximately 15 to
30 grains) three or four times daily after meals.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

Off. Prep. — Ferric Ammonium Citrate Cap-
sules; Beef, Iron and Wine, N.F.

FERRIC AMMONIUM CITRATE
CAPSULES. N.F.

[Capsulae Ferri Ammonii Citratis]

"Ferric Ammonium Citrate Capsules contain
an amount of iron (Fe) corresponding to not less
than 15.5 per cent and not more than 19.5 per
cent of the labeled amount of ferric ammonium
citrate." N.F.

Sp. Cdpsulas de Cxtrato de Amonio Ferrico.

Usual Size. — 500 mg. (approximately lYz
grains).

GREEN FERRIC AMMONIUM
CITRATE. N.F.

Ferri Ammonii Citras Viridis

"Green Ferric Ammonium Citrate contains
ferric citrate equivalent to not less than 14.5
per cent and not more than 16 per cent of Fe."
N.F.

Ferrum Citricum Ammoniatum Viride. Ger. Griines
Ferri-ammoniumcitrate. Sp. Citratos de hierro y de amonio
verdes.

The process of manufacturing this salt is essen-
tially the same as for ferric ammonium citrate
except that more citric acid is employed and the
quantity of ammonia added is reduced to that
required to produce a green solution of acid reac-
tion. It would appear that in the green compound
the ferric citrate is present as a different complex
from that represented in the red salt; the com-
position of neither salt, however, is known with
certainty.

Description. — "Green Ferric Ammonium Cit-
rate occurs as thin, transparent, green scales, as
granules, as a powder, or as transparent green
crystals. It is odorless, and has a mildly ferrugi-
nous taste. It may deliquesce in air and is affected
by light. Its solutions are acid to litmus paper.
Green Ferric Ammonium Citrate is very soluble
in water. It is insoluble in alcohol." N.F.

Standards and Tests. — Identification. — (1)
A reddish brown precipitate is produced and am-

monia evolved on heating 100 mg. of green ferric
ammonium citrate with 5 ml. of potassium hy-
droxide T.S. (2) The yellow-green color of a 1 in
100 solution of green ferric ammonium citrate is
changed to orange or reddish brown on adding
ammonia T.S., but no precipitate is produced.
(3), (4). These tests are the same as identifica-
tion tests (3) and (4) under Ferric Ammonium
Citrate. Tartrate. — This is the same as the corre-
sponding test under Ferric Ammonium Citrate.
N.F.

Assay. — This is the same as the assay specified
for Ferric Ammonium Citrate. N.F.

It is commonly believed that the suitability for
injection of ferric ammonium citrate depends
largely on its content of ammonium citrate; when
less than the equivalent of 8 per cent of ammonia
is present, severe local reactions are likely to
occur, while a content considerably above 8 per
cent, as ammonia, is also likely to cause local
irritation.

Uses. — Following administration of iron by
mouth, a considerable, and variable, proportion
remains unabsorbed, probably being precipitated
in the intestines as phosphate, sulfide and other
insoluble salts. When injected parenterally the
dose is, therefore, much smaller than when the
iron compound is given orally.

The red ferric ammonium citrate is not suitable
for injection because it causes severe local irrita-
tion; the green ferric ammonium citrate, being
less irritant when thus used, is accordingly official.
But injections of even this salt are quite painful;
procaine or other local anesthetic must be em-
ployed. The injections should never be given hy-
podermically, rather always injected deeply into
the muscles. On occasion, generalized toxic symp-
toms follow the injection; these include a feeling
of general warmth, palpitation, nausea, hyperpnea
and distention of the veins in the neck.

It is hardly ever necessary, or desirable, to treat
anemia with injections of iron (Heath and Patek,
Medicine, 1937, 16, 267). Most patients with
iron deficiency anemia respond to orally adminis-
tered iron and are able to tolerate such admin-
istration. Parenteral iron is utilized, however, to
form new hemoglobin in patients with hypo-
chromic anemia. Heath, Strauss and Castle
(J. Clin. Inv., 1932, 11, 1293) estimated that
32 mg. of green ferric ammonium citrate given
intramuscularly is equivalent to 1 Gm. adminis-
tered orally. On this basis, the daily intramuscular
injection, which is painful, of 100 mg. (approxi-
mately 1^2 grains) of the green citrate for sev-
eral weeks would produce only about half the
rise in hemoglobin level which could be obtained
by oral administration of one of the several iron
preparations. The Council on Pharmacy and
Chemistry of the American Medical Association,
in voting to omit ampuls of green ferric am-
monium citrate, stated "such preparations have
no place in modern iron therapy; they often
cause untoward reactions and do not provide a
sufficiently effective amount of iron when admin-
istered, as they are, by intramuscular or subcu-
taneous injection" (Reports, 1941). So far efforts
to develop an iron preparation suitable for intra-
venous injection have failed, due to the occur-

570

Ferric Ammonium Citrate, Green

Part I

rence of toxic reactions (Goetsch. Moore and
Minnich, Blood, 1946, 1, 129). However, a col-
loidal saccharated iron oxide solution for intra-
venous use has been tested extensively (see
under Ferric Oxide, Saccharated, in Part II), and
appears to have some merit, [vj

The usual dose is 100 mg. (approximately \l/2
grains), given intramuscularly two or three times
a week.

Storage. — Preserve "in tight, light-resistant
containers." X.F.

FERRIC CACODYLATE. X.F.

Iron Cacodylate, [Ferri Cacodylas]

Fe[(CH3)2As02]3.*H20

"Ferric Cacodylate. dried at 105° for 2 hours,
contains not less than 11 per cent and not more
than 16 per cent of Fe, and not less than 41 per
cent and not more than 45 per cent of As." X.F.

Iron DLmethj-larsonatK

An anhydrous compound of the composition
indicated above would contain 11.97 per cent
of iron and 4S.14 per cent of arsenic, from which
it is apparent that the official product conforms
only approximately to this formula. The article
of commerce is quite variable, even beyond the
rather wide X.F. limits (see Bull. X.F. Com.,
1946. 14, 11). Before World War II ferric caco-
dylate was manufactured in France, the product
produced there by a secret process being superior,
from the standpoint of the preparation of non-
irritant solutions suitable for parenteral injec-
tion, to those produced in domestic laboratories.
During the war the product manufactured in this
country, presumably by the interaction of freshly
precipitated hydrous ferric oxide and cacodylic
acid (see Sodium Cacodylate). has been con-
stantly improved so that relatively non-irritant
parenteral solutions may be prepared from it
(see studies of Moore and Sommers. /. .4. Ph. A..
1950. 39, 302).

Description. — "Ferric Cacodylate occurs as a
yellowish, amorphous powder. One Gm. of Ferric
Cacodylate dissolves in about 30 ml. of water.
It is very slightly soluble in alcohol." X.F.

In order to effect complete solution of ferric
cacodylate in water it is usually necessary to heat
the latter and to continue heating until all of the
solid dissolves. It is characteristic of such solu-
tions that the color becomes darker on prolonged
heating; it is said that a solution which is of
somewhat darker color is likely to be less irritat-
ing, on parenteral administration, than a solution
which is lighter in color (.though of equivalent
concentration).

Standards and Tests. — Identification. — (1)
A 1 in 50 solution of ferric cacodylate. acidified
with hydrochloric acid, responds to tests for
ferric salts and iron. (2) Ferric cacodylate burns
with a bluish flame, emitting a garlic-like odor.
(3) The odor of cacodyl is apparent within an
hour after mixing a few drops of a 1 in 100
aqueous solution of ferric cacodylate with 2 ml.
of hypophosphorous acid T.S. Loss on drying. —
Xot over 5 per cent when dried for 2 hours at

105°. Monomethylar senate. — Addition of calcium
chloride T.S. to a solution of ferric cacodylate
should produce no turbidity, either in the cold or
on heating. Arsenate or phospfiate. — Xo turbidity
should develop within an hour after the addition
of magnesia mixture T.S. to the filtrate obtained
by heating to boiling a solution of ferric cacodyl-
ate. containing some hydrochloric acid, which has
been made alkaline with stronger ammonia T.S.
and then filtered. Chloride. — The limit is 200
parts per million. Sulfate. — Xo turbidity is pro-
duced within 30 seconds following addition of
barium chloride T.S. to a 1 in 50 solution of
ferric cacodvlate acidified with hvdrochloric acid.
X.F.

Assay. — For iron. — About 500 mg. ferric ca-
codylate, previously dried at 105° for 2 hours,
is dissolved in distilled water containing hydro-
chloric acid and the solution heated to boiling.
Ammonia T.S. is added to precipitate hydrous
ferric oxide, which is filtered off, washed with hot
water, dissolved in hydrochloric acid and. after
dilution with distilled water, estimated through
liberation of iodine which is titrated with 0.1 N
sodium thiosulfate. Each ml. of 0.1 AT sodium
thiosulfate represents 5.5 S 5 mg. of Fe. For ar-
senic.— About 200 mg. of dried ferric cacodylate
is heated in a Kjeldahl flask with potassium sul-
fate, starch and sulfuric acid which oxidizes the
organic portion of the molecule and reduces the
arsenic to a valence of +3. The arsenic is then
distilled out of the mixture, in hydrogen chloride
vapor, as arsenous chloride, and this is received
in distilled water; after neutralizing the distillate
with sodium hydroxide and adding sodium bicar-
bonate the trivalent arsenic is oxidized to the
pentavalent state by titration with 0.1 N iodine,
using starch T.S. as indicator. A blank test is
performed on the reagents. Each ml. of 0.1 N
iodine represents 3.746 mg. as As. X.F.

Uses. — This salt has been used, rather empiri-
cally, for leukemia, lymphadenosis (Hodgkin*s
disease, syphilis), serious anemias, and as a tonic
in debilitated and neurasthenic states. Lederer
and Renaer {Schweiz. med. Wchnschr., 1947, 77,
1061) treated anemia successfully with daily
slow intravenous injections. It has been combined
with strychnine and glycerophosphates (see un-
der Arsenic Trioxide and under Sodium Cacodyl-
ate for the actions of this arsenical compound).
Pelner (Ind. Med.. 1944. 13, 826) reported dra-
matic and immediate relief from pain and an
increase in the range of motion in cases of acute
subdeltoid bursitis following intravenous injec-
tion of 60 mg. of ferric cacodylate in 5 ml. of
sterile, distilled water (see also Bensema and
Shoun. Arizona Med., 1951. 8, 37). Montgomery
{JAMA., 1916. 66, 491) reported that it may
give rise to a disagreeable garlic-like odor of the
breath, even when given hypodermically.

The usual dose, parenterally. is 60 mg. (ap-
proximately 1 grain), well-diluted: orally, the
dose should not exceed 30 mg. (approximately
Yi grain) three times daily because inorganic
arsenic may be liberated more rapidly by the
digestive juices than in the tissues.

Storage. — Preserve "in tight containers." N.F.

Part I

Ferric Chloride Tincture

571

FERRIC CHLORIDE SOLUTION.
N.F. (B.P.)

Iron Perchloride Solution, [Liquor Ferri Chloridi]

"Ferric Chloride Solution is a water solution
containing, in each 100 ml., not less than 37.2
Gm. and not more than 42.7 Gm. of FeCta, and
not less than 3.85 Gm. and not more than 6.6
Gm. of HC1." N.F. The B.P. recognizes Solution
of Ferric Chloride as an aqueous solution con-
taining 15.0 per cent w/v of FeCb (limits, 14.25
to 15.75).

B.P. Solution of Ferric Chloride; Liquor Ferri Per-
chloridi. Ferrura Sesquichloruretum Solutum; Liquor
Ferri Sesquichlorati; Liquor Stypticus; Ferrum Sesqui-
chloratum Solutum; Solutio Chloruri Ferrici. Fr. Chlorure
ferrique dissous; Solution officinale de perchlorure de fer;
Perchlorure de fer dissous. Ger. Eisenchloridlosung. It.
Cloruro ferrico liquido; Soluzione di cloruro ferrico. Sp.
Solucion de cloruro ferrico; Cloruro ferrico liquido.

Neither the B.P. nor the N.F. gives any for-
mula for preparing this solution. Ferric chloride
may be prepared by the oxidation of ferrous
chloride, formed by action of hydrochloric acid
on iron. As oxidizing agents nitric acid or chlo-
rine may be used. For a description of methods of
preparation, see U.S.D., 22nd ed., p. 612.

Description. — "Ferric Chloride Solution is a
yellowish orange liquid, having a faint odor of
hydrochloric acid and an acid reaction. It is
affected by light. Ferric Chloride Solution is
miscible in all proportions with alcohol. The spe-
cific gravity of Ferric Chloride Solution is not
less than 1.29 and not more than 1.35." N.F.

Standards and Tests. — Identification. — A 1
in 10 aqueous dilution of the solution responds
to tests for ferric iron and for chloride. Alkalies
and alkaline earths. — The residue obtained after
evaporating and igniting the filtrate from a por-
tion of solution from which iron has been pre-
cipitated with ammonia is not over 0.1 per cent
of the weight of the solution. Nitrate.— -To the
filtrate from a portion of solution from which
the iron has been precipitated with ammonia are
added indigo carmine T.S. and sulfuric acid: the
resulting blue color should not disappear in 1
minute. Ferrous salts. — A brown color, not at
once turning to green or greenish-blue, is pro-
duced on the addition of a few drops of freshly
prepared potassium ferricyanide T.S. to a 1 in
20 aqueous dilution of the solution. Copper or
zinc. — The filtrate from the solution after pre-
cipitation of the iron with ammonia T.S. is color-
less and does not yield a precipitate with hydro-
gen sulfide T.S. Lead. — The limit is 50 parts per
million. N.F. The B.P. includes also limit tests
for copper, zinc, and sulfate; the arsenic and
lead limits are 2 and 15 parts per million, re-
spectively.

Assay. — For iron. — The ferric iron in a 1.5-
ml. portion of solution liberates an equivalent
amount of iodine which is titrated with 0.1 N
sodium thiosulfate, using starch T.S. as indicator.
Each ml. of 0.1 N sodium thiosulfate represents
16.22 mg. of FeCl3. For hydrochloric acid. — The
total chloride in about 500 mg. of solution is de-
termined by the Volhard method, using 0.1 N
silver nitrate and 0.1 N ammonium thiocyanate
solutions, and the result calculated to per cent of

HC1. From this is subtracted the per cent w/v of
FeCte found in the preceding assay, multiplied by
0.6745 (the ratio of 3 times the molecular weight
of HC1 to the molecular weight of FeCte) ; the
difference represents chlorine not combined with
iron, expressed as HC1. Each ml. of 0.1 N silver
nitrate represents 3.647 mg. of HC1. N.F.

The B.P. assay is similar to that of the N.F.
except that any ferrous iron which may be pres-
ent is first oxidized by 0.1 N potassium perman-
ganate.

Uses. — This preparation is of interest as hav-
ing led Pravaz to the invention of a syringe —
which was the forerunner of the modern hypo-
dermic syringe — for the purpose of injecting
ferric chloride solution in the destruction of nevi
and other vascular tumors through the precipita-
tion of the blood. This treatment, however, has
passed out of vogue because of the danger of
emboli being carried to other parts. The solution
is, however, a very powerful astringent and styp-
tic and is useful for arresting hemorrhages from
cut surfaces or wounded vessels by causing the
formation of a hard coagulum through precipi-
tation of proteins.

It is, in itself, rarely employed as an internal
remedy but is the basis for the still popular
ferric chloride tincture. E

Dose, of the N.F. preparation, 0.06 to 0.3 ml.
(approximately 1 to 5 minims).

Storage. — Preserve "in tight, light-resistant
containers, and avoid continuous excessive heat."
N.F.

Off. Prep. — Ferric Chloride Tincture; Ferric
Citrochloride Tincture, N.F.

FERRIC CHLORIDE TINCTURE. N.F.

Iron Tincture, [Tinctura Ferri Chloridi]

"Ferric Chloride Tincture is a hydro-alcoholic
solution containing, in each 100 ml., not less than
13 Gm. and not more than 15 Gm. of FeCte."
N.F.

Tincture of Iron Perchloride. Tinctura Ferri Per-
chloridi.

Mix 350 ml. of ferric chloride solution with
enough alcohol to make 1000 ml. N.F.

Description. — "Ferric Chloride Tincture is
a yellowish orange liquid, having a slightly ethe-
real odor, a very astringent taste, and an acid
reaction. Its specific gravity is about 1.00." N.F.

The ethereal odor of the tincture is the result
of the formation of a small amount of ethyl
chloride and possibly also some ethyl acetate.
Formation of such esters was formerly con-
sidered to be sufficiently important to warrant
aging the tincture three months before use to
permit some esterification to take place.

Standards and Tests. — Identification. — Fer-
ric chloride tincture responds to tests for ferric
iron and for chloride. After the tincture has
been exposed to daylight for some time it yields
a greenish or bluish color with potassium ferri-
cyanide T.S., indicative of the presence of some
ferrous salt. Nitrate. — The test is identical with
that specified for Ferric Chloride Solution. N.F.

Osol (Am. J. Pharm., 1931, 103, 638) observed

572

Ferric Chloride Tincture

Part I

that while there was some reduction of iron
to the ferrous state when ferric chloride tincture
was exposed to sunlight in a clear glass bottle the
extent of the change was not considerable.

Assay. — The assay is based on reactions uti-
lized in the assay for iron under Ferric Chloride
Solution. N.F.

Alcohol Content. — From 58 to 64 per cent,
by volume, of C2H5OH. N.F.

Incompatibilities. — Iron in the tincture is
precipitated by alkalies and by substances pro-
ducing an alkaline reaction. With iodides it lib-
erates iodine and is reduced to the ferrous state.
Tannin-containing solutions produce with it a
bluish-green color; acacia mucilage yields a
brown semi-transparent jelly. Certain incompati-
bilities of ferric ion, such as those with benzoate,
salicylate or tannic acid, are avoided through use
of ferric citrochloride tincture.

Uses. — In the past, ferric chloride tincture
was used with the idea that it exerted some
mystical curative properties in erysipelas, diph-
theria and other infections. As a hematinic it is
inferior to other compounds of iron because its
marked astringent and irritant effects on the
stomach make it difficult to administer a dose
large enough to be of value. Thus 1 ml. (approxi-
mately 15 minims) represents but 45 mg. (ap-
proximately 0.7 grain) of iron. The tincture is
an effective protein precipitant and is occasion-
ally used as a styptic. As an astringent it is some-
times mixed with equal parts of glycerin and
water and applied by means of a swab in the
treatment of pharyngitis; its use as a gargle is
not to be recommended as its acidity makes it
injurious to the teeth.

Like other iron salts it forms non-toxic com-
pounds with toxicodendrol and is therefore useful
as a prophylactic against ivy poisoning. It is also
of some value in the early stages of rhus derma-
titis but it will not penetrate the skin sufficiently
to neutralize a well-established inflammation.
Traub and Tennen (J.A.M.A., 1936, 106, 1711)
called attention to the permanent pigmentation
following application of a ferric chloride solution
in the treatment of ivy poisoning; the use of
iron-containing lotions in vesicular, bullous or
exudative dermatoses is for this reason to be dis-
couraged. Gradual disappearance in a patient
of this pigmentation over a period of 6 years
was reported by Strauss (Arch. Derm. Syph.,
1947, 55, 692). M

Dose, from 0.3 to 2 ml. (approximately 5 to
30 minims), well diluted with water.

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

Off. Prep. — Iron and Ammonium Acetate
Solution, N.F.

FERRIC CITROCHLORIDE
TINCTURE. N.F.

[Tinctura Ferri Citrochloridi]

"Ferric Citrochloride Tincture is a hydro-alco-
hol solution containing, in each 100 ml., ferric
citrochloride equivalent to not less than 4.48
Gm. of Fe." N.F.

Tasteless Tincture of Ferric Chloride; Tasteless Tinc-
ture of Iron.

Mix 350 ml. of ferric chloride solution with
150 ml. of water, dissolve 450 Gm. of sodium
citrate in this mixture with the aid of gentle
heat, and add 150 ml. of alcohol. When the
solution has cooled, add enough water to make
1000 ml. Set the tincture aside in a cold place
for a few days, in order that excess saline matter
may separate, then filter the liquid. N.F.

The iron in this tincture is present as a com-
plex citrate-containing ion; its exact composition
is not known.

Assay. — A 5 ml. portion of tincture is heated
with a mixture of hydrochloric acid and distilled
water until the solution is clear, after which
it is assayed in the same manner as Ferric Chloride
Solution is assayed for iron. N.F.

Alcohol Content. — From 13 to 15 per cent,
by volume, of C2H5OH. N.F.

Uses. — Because the iron in this tincture is
present as a complex with citrate the character-
istic astringent action of hydrated ferric iron is
absent. Accordingly, this tincture was preferred
by some over ferric chloride tincture, which con-
tains the same amount of iron, for use as a
hematinic; neither preparation is much used for
this purpose today. For the same reason the
ferric citrochloride tincture is of no value where
an astringent effect is desired. The tincture may
be combined with tannin-containing drugs with-
out producing a bluish black coloration.

Dose, from 0.3 to 2 ml. (approximately 5 to
30 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

Off. Prep. — Iron, Quinine and Strychnine
Elixir, N.F.

FERRIC GLYCEROPHOSPHATE.

N.F.

[Ferri Glycerophosphas]

Fe[C3H5(OH)2P04]3

"Ferric Glycerophosphate, calculated on the
anhydrous basis, contains not less than 17 per
cent of Fe, corresponding to not less than 94.5
per cent of C9H2iFe20i8P3."

Ferric Glycerinophosphate; Iron Glycerophosphate. Fer-
rum Glycerinophosphoricum. Ger. Ferriglycerophosphat;
Glycerinphosphorsaures Eisenoxyd.

This salt may be prepared by dissolving freshly
precipitated ferric hydroxide in glycerophosphoric
acid, evaporating the solution under reduced pres-
sure and scaling it upon glass plates.

Description. — "Ferric Glycerophosphate oc-
curs as orange to greenish yellow, transparent,
amorphous scales, or powder. It is odorless, and
nearly tasteless. A solution of Ferric Glycero-
phosphate (1 in 20) is acid to litmus paper.
It is affected by light. One Gm. of Ferric
Glycerophosphate dissolves slowly in about 2 ml.
of water. It is insoluble in alcohol." N.F.

Standards and Tests. — Identification. — A 1
in 20 aqueous solution of ferric glycerophosphate
responds to tests for ferric iron and for glycero-

Part I

Ferric Phosphate, Soluble 573

phosphate. Loss on drying. — Not over 12 per
cent, when dried to constant weight at 130°.
Chloride. — The limit is 0.14 per cent. Phosphate.
— The turbidity produced by the addition of
10 ml. of cold ammonium molybdate T.S. to
10 ml. of a 1 in 60 solution of ferric glycero-
phosphate is not greater than that produced by
a solution containing 0.96 mg. of potassium
biphosphate in 10 ml. to which 10 ml. of cold
ammonium molybdate T.S. has been added. Sul-
fate.— The limit is 0.2 per cent. Arsenic. — An
aqueous solution of ferric glycerophosphate
meets the requirements of the test for arsenic.
Lead. — The limit is 50 parts per million. N.F.

Assay. — About 1 Gm. of ferric glycerophos-
phate is dissolved in water. The solution is acidi-
fied with hydrochloric acid, some sodium bicarbo-
nate is added to generate sufficient carbon dioxide
to exclude air from the glass-stoppered flask con-
taining the mixture and, after adding potassium
iodide, the iodine liberated by the reduction of
ferric iron is titrated with 0.1 iV sodium thio-
sulfate, using starch T.S. as indicator. A blank
test is performed on the reagents. Each ml. of
0.1 N sodium thiosulfate represents 31.09 mg.

Of C9H2lFe20l8P3.

The salt is official only because it is an ingre-
dient of the Compound Glycerophosphates Elixir.

Dose, from 200 to 600 mg. (approximately 3 to
10 grains).

Storage. — Preserve "in tight, light-resistant
containers." N.F.

Off. Prep. — Compound Glycerophosphates
Elixir, N.F.

FERRIC HYPOPHOSPHITE. N.F.

[Ferri Hypophosphis]

"Ferric Hypophosphite, dried at 105° for 2
hours, contains not less than 21.8 per cent of
Fe, corresponding to not less than 98 per cent
of Fe(PH202)3.

"Caution should be observed in compounding
Ferric Hypophosphite with other substances, as
an explosion may occur if it is triturated or heated
with nitrates, chlorates, or other oxidizing agents."
N.F.

Iron Hypophosphate. Ferrum Hypophosphorosum Oxy-
datum. Fr. Hypophosphite de fer. Ger. Ferrihypophos-
phit; Unterphosphorigsaures Eisenoxyd. Sp. Hipofosfito
de hierro; Hipotosfito ferrico.

This salt may be prepared by interaction of
aqueous solutions of ferric chloride and calcium
hypophosphite.

Description. — "Ferric Hypophosphite occurs
as a white or grayish white powder, and is per-
manent in the air. It is odorless, and nearly
tasteless. One Gm. of Ferric Hypophosphite dis-
solves in about 2300 ml. of water, and in about
1200 ml. of boiling water. It is more readily
soluble in the presence of hypophosphorous acid,
or in a warm, concentrated solution of an alkali
citrate, forming a greenish solution with the
latter." N.F.

Standards and Tests. — Identification. — 1
Gm. of ferric hypophosphite, dissolved in 15 ml.
of acetic acid by boiling and the solution filtered,
responds to tests for ferric iron and for hypo-

phosphite. Loss on drying. — Not over 3 per cent,
when dried at 105° for 2 hours. Carbonate and
calcium. — No effervescence occurs on adding
500 mg. of ferric hypophosphite to 5 ml. of acetic
acid; on heating to boiling and filtering, the
filtrate shows no turbidity within 1 minute after
adding 0.5 ml. of ammonium oxalate T.S. Phos-
phate.— No crystalline precipitate results on
adding 0.5 ml. of magnesia mixture T.S. and
ammonia T.S. to the acidified filtrate from 500
mg. of ferric hypophosphite boiled with 10 ml.
of sodium hydroxide T.S. Sulfate. — The limit is
100 parts per million. Arsenic. — 200 mg. meets
the requirements of the test for arsenic. Lead. —
The limit is 50 parts per million. N.F.

Assay. — To about 1 Gm. of ferric hypophos-
phite, dried at 105° for 2 hours, is added nitro-
hydrochloric acid (to oxidize hypophosphite ion)
and the mixture evaporated to dryness on a
water bath; hydrochloric acid is added and again
evaporated to dryness, after which the residue
is dissolved in water with the aid of hydrochloric
acid. Potassium iodide is added and the liberated
iodine is titrated with 0.1 N sodium thiosulfate,
using starch T.S. as indicator. A reagent blank
test is performed. Each ml. of 0.1 N sodium
thiosulfate represents 25.08 mg. of Fe(PH202)3.
N.F.

Ferric hypophosphite is a feeble chalybeate,
but the only reason for its official recognition
is that it is an ingredient of the therapeutic
hodgepodge known as Compound Hypophosphites
Syrup.

Dose, from 200 to 600 mg. (approximately 3
to 10 grains).

Storage. — Preserve "in well-closed contain-
ers." N.F.

Off. Prep. — Compound Hypophosphites
Syrup, N.F.

SOLUBLE FERRIC PHOSPHATE.

N.F.

Ferric Phosphate with Sodium Citrate,
[Ferri Phosphas Solubilis]

"Soluble Ferric Phosphate is ferric phosphate
rendered soluble by the presence of sodium cit-
trate, and yields not less than 12 per cent and
not more than 15 per cent of Fe." N.F.

Soluble Iron Phosphate. Ferri Phosphas, U.S. P. IX;
Ferrum Phosphoricura cum Natrio Citrico; Ferrum Phos-
phoricum Solubile. Fr. Citro-phosphate de fer et de soude.
Ger. Losliches Ferriphosphat.

The adjective soluble distinguishes this prepa-
ration from normal ferric phosphate, which was
at one time official. The latter occurs as an in-
soluble yellowish powder; the soluble product
occurs as thin, bright-green scales.

Soluble ferric phosphate may be prepared by
dissolving ferric citrate in distilled water and
adding sodium phosphate. From the clear solu-
tion a scale salt may be obtained by the usual
procedure. For the process of U.S. P. 1890, see
U.S.D., 22nd ed., p. 469.

Description. — "Soluble Ferric Phosphate oc-
curs as thin, bright green, transparent scales, or
as granules. It is without odor, and has an acid,
slightly salty taste. Soluble Ferric Phosphate is

574 Ferric Phosphate, Soluble

Part I

stable in dry air when protected from light, but
when unprotected, soon becomes discolored. A
solution of Soluble Ferric Phosphate (1 in 10)
is acid to litmus paper. Soluble Ferric Phosphate
dissolves freely in water. It is insoluble in alcol-
col." X.F.

Standards and Tests. — Identification. — (1)
A reddish brown color, but no precipitate, is
formed on adding an excess of ammonia T.S. to
an aqueous solution of soluble ferric phosphate.
(2) After removing the iron from 10 ml. of a 1 in
10 solution of soluble ferric phosphate by boiling
with excess sodium hydroxide T.S. and filtering,
the acidified filtrate yields a precipitate of mag-
nesium ammonium phosphate on addition of
magnesia mixture T.S. and a slight excess of
ammonia T.S. This precipitate, after washing.
turns greenish yellow when treated with a few
drops of silver nitrate T.S. (distinction from
pyrophosphate). Ammonium salts. — A reddish
brown precipitate is formed, but no ammonia is
evolved, on boiling 100 mg. of soluble ferric
phosphate with 5 ml. of sodium hydroxide T.S.
Lead. — The limit is 50 parts per million. X.F.

Assay. — An aqueous solution of about 1 Gm.
of soluble ferric phosphate is reacted with potas-
sium iodide in the presence of hydrochloric acid
and the liberated iodine is titrated with 0.1 N
sodium thiosulfate. A reagent blank test is also
performed. Each ml. of 0.1 A' sodium thiosulfate
represents 5.535 mg. of Fe. N.F.

Uses. — Soluble ferric phosphate is one of the
best preparations to use when it is desired to
administer iron in solution. It is as free from
astringency as any of the official salts of iron,
has little tendency to disturb digestion and is an
active chalybeate. It is. however, rarely used.

The usual dose is 250 mg. (approximately 4
grains) three or four times daily.

Storage. — Preserve ''in well-closed, light-re-
sistant containers." X.F.

Off. Prep. — Iron, Quinine and Strychnine
Phosphates Elixir, NJP.

FERRIC SUBSULFATE SOLUTION.

X.F.

Monsel's Solution, Basic Ferric Sulfate Solution,
[Liquor Ferri Subsulfatis]

''Ferric Subsulfate Solution is a water solu-
tion containing, in each 100 ml., basic ferric sul-
fate equivalent to not less than 20 Gm. and not
more than 22 Gm. of Fe." NJP.

Add 55 ml. of sulfuric acid to 800 ml. of puri-
fied water in a suitable porcelain dish, heat the
mixture nearly to 100°, add 75 ml. of nitric acid,
and mix well. Divide 1045 Gm. of ferrous sul-
fate, coarsely powdered, into 4 approximately
equal portions, and add a portion at a time to
the hot liquid, stirring after each addition until
effervescence ceases. If. after the ferrous sul-
fate has dissolved, the solution has a black color,
add nitric acid, a few drops at a time, while
heating and stirring, until red fumes cease to
be evolved. Boil the solution until it assumes
a red color and is free from nitric acid, as indi-
cated by the test below, while maintaining the

volume at about 1000 ml. by addition of purified
water. Cool, add enough purified water to make
1000 ml. and filter, if necessary, until the product
is clear. Note. — If the solution is exposed to
low temperatures crystallization may occur; the
crvstals will redissolve on warming the solution.
X.F.

The reaction which takes place is suggested to
be as follows:

12FeS04 + 3H2SO4 + 4HX03 -»

3Fe40(S04)5 + 4X0 + 5H2O

Ferric subsulfate contains insufficient sulfate
radical to satisfy completely the valence of the
iron. The four iron atoms shown in the formula
normally combine with six sulfate groups; in the
subsulfate, an oxygen takes the place of one of
these.

For many years the U.S. P.. and later the X.F.,
included also a Ferric Sulfate Solution, which
represented 10 per cent, by weight, of Fe. This
is about half the amount of iron in ferric sub-
sulfate solution but the concentration of sulfuric
acid was sufficient to form the normal sulfate.
Ferric sulfate solution was used to prepare the
freshly precipitated Magma Ferri Hydroxidi
once widely employed as an antidote for arsenic
poisoning (see under Arsenic Trioxide).

Description. — "Ferric Subsulfate Solution is
a reddish brown liquid, odorless or nearly so,
with a sour, strongly astringent taste. Ferric Sub-
sulfate Solution is acid to litmus paper, and it is
affected by light. Ferric Subsulfate Solution is
miscible with water and with alcohol. Its specific
gravity is about 1.543." NJP.

Standards and Tests. — Identification. — Sep-
arate portions of a 1 in 20 aqueous dilution of
the solution yield a brownish red precipitate with
ammonia T.S., a blue precipitate with potassium
ferrocyanide T.S., and a white precipitate, in-
soluble in hydrochloric acid, with barium chloride
T.S. Nitrate. — On adding a clear crystal of fer-
rous sulfate to a cooled mixture of equal volumes
of sulfuric acid and a 1 in 10 aqueous dilution of
the solution, the crystal does not become brown,
nor does a brownish black color develop around it.
Ferrous salts. — Addition of a few drops of freshly
prepared potassium ferricyanide T.S. to 2 ml. of
a 1 in 20 aqueous dilution of the solution produces
a brown color, the solution remaining free from
even a transient green or greenish blue color. NJP.

Assay. — A 10-ml. portion of the solution is
diluted to 100 ml. with distilled water and a
10-ml. aliquot of the dilution assayed in the same
manner as Ferric Chloride Solution. N.F.

Uses. — This is a powerful and valuable styptic
which will effectively stop bleeding. It may be
applied full strength by means of a small cotton
swab. While not employed for any systemic
effect it has been occasionally employed to check
hematemesis from gastric ulcer in doses of from
0.12 to 0.3 ml. (approximately 2 to 5 minims),
properly diluted.

Storage. — Preserve "in tight, fight-resistant
containers, and in a moderately warm place (not
under 22°)." NJP.

Part I

Ferrous Carbonate, Saccharated 575

FERROUS CARBONATE MASS. N.F. FERROUS CARBONATE PILLS. N.F.

Vallet's Mass, [Massa Ferri Carbonatis]

"Ferrous Carbonate Mass contains not less
than 36 per cent and not more than 41 per cent
of FeCOs." N.F.

Vallet's Ferruginous Mass. Massa Pilularum Ferri Car-
bonici; Pilulae Ferri Carbonici Valleti. Fr. Pilules de
carbonate ferreux ; Pilules dites de Vallet. Ger. Valletsche
Eisenpillen. It. Pillole di carbonato ferroso ; Pillole di
Vallet. Sp. Masa de carbonato ferroso.

Dissolve 1000 Gm. of ferrous sulfate and 460
Gm. of monohydrated sodium carbonate sepa-
rately in 2000-ml. portions of boiling purified
water; add 200 ml. of syrup to the solution of
the iron salt, filter both solutions, and cool. To the
sodium carbonate solution, contained in a bottle
of 5000-ml. capacity, gradually add the solution
of the iron salt, rotating the bottle frequently
until carbon dioxide no longer escapes. Add enough
purified water to fill the bottle, stopper it tightly,
and set aside until the ferrous carbonate has
settled. Pour off the supernatant liquid and wash
the precipitate, by decantation, using a mixture of
1 volume of syrup and 19 volumes of purified
water, until the washings no longer have a salty
taste. Drain the precipitate on a muslin strainer
and express as much of the water as possible. Mix
the precipitate at once with 380 Gm. of honey and
250 Gm. of sucrose in a tared dish and evaporate
the mixture, on a water bath, until its weight is
reduced to 1000 Gm. N.F.

The name Vallet's mass, by which this prepara-
tion is popularly known, comes from the name of
the Paris physician who, in 1837, proposed this
formula for a ferrous carbonate preparation.
Earlier, in 1831, another Paris physician, Blaud,
had proposed a formula for ferrous carbonate
pills (see the succeeding article) in which potas-
sium carbonate is used as the alkali, together with
modifications of the base.

Ferrous carbonate mass occurs as a soft pilular
mass, a dark greenish-gray in color, becoming
very dark on exposure, and with a strong ferrugi-
nous taste. The use of honey, sucrose and syrup
in the preparation of the mass is not only to pro-
vide a basis for the mass but, more important,
to retard oxidation of the ferrous iron. For the
formula of so-called powdered Vallet's mass, see
U.S.D., 21st edition, p. 682.

Assay. — About 1 Gm. of the mass is dissolved
in diluted sulfuric acid, the solution diluted with
distilled water, and at once titrated with 0.1 N
eerie sulfate, using orthophenanthroline T.S. as
indicator. The eerie sulfate oxidizes ferrous iron
to the ferric state without oxidizing any of the
saccharine matter, which would be the case with
other oxidants. Each ml. of 0.1 N eerie sulfate
represents 11.59 mg. of FeC03. N.F.

Uses. — Ferrous carbonate mass was once highly
popular for the treatment of simple anemia and
chlorosis; the frequency of its use, however, has
decreased, especially since the introduction of
stable preparations of ferrous sulfate, [v]

Dose, from 0.3 to 1 Gm. (approximately 5 to
15 grains) three times daily.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

Ferruginous Pills, Chalybeate Pills, Blaud's Pills,
[Pilulae Ferri Carbonatis]

"Each Pill contains not less than 60 mg. of
FeCOs." N.F.

Iron Pill. Pilulae Ferri Carbonici (It.) ; Pilulae Ferri
Carbonici Blaudii; Pilula Ferri; Pilulae ex Blaud. Fr.
Pilules ferrugineuses de Blaud. Ger. Blaudsche Pillen.
It. Pillole di carbonato ferroso. Sp. Pildoras de Blaud;
Pildoras de carbonato ferroso.

Triturate 9.5 Gm. of potassium carbonate with
about 5 drops of glycerin and mix thoroughly with
16 Gm. of ferrous sulfate, in clear crystals, and 4
Gm. of finely powdered sucrose, the two latter
having been previously triturated together to a
uniform, fine powder. When the reaction is com-
plete, incorporate 1 Gm. of finely powdered traga-
canth and 1 Gm. of althea, in very fine powder,
together with enough purified water, if necessary,
to obtain a mass of pilular consistence. Divide
into 100 pills. N.F.

Assay. — Five pills are pulverized and then
assayed by the method employed for Ferrous
Carbonate Mass. N.F.

Uses. — Introduced by the Paris physician
Blaud, in 1831, these pills were formerly widely
used for treatment of anemia. The official pill,
containing 60 mg. of ferrous carbonate, is not a
convenient form to administer the relatively large
dose (estimated at 2 to 4 Gm.) of ferrous car-
bonate required by an adult afflicted with severe
anemia. Also, unless the pills are freshly prepared,
there is the possibility that the iron has in large
part oxidized, and that the pill may pass through
the intestinal tract without being absorbed. If a
sufficient number of the pills is taken they may be
of value in less severe forms of anemia.

The N.F. average dose is 5 pills, to be taken
three times daily.

Storage. — Preserve "in well-closed contain-
ers." N.F.

SACCHARATED FERROUS
CARBONATE. N.F.

[Ferri Carbonas Saccharatus]

"Saccharated Ferrous Carbonate contains, in
each 100 Gm., not less than 15 Gm. of FeCOs."
N.F.

B.P. Saccharated Iron Carbonate. Ferrum Carbonicum
Saccharatum; Ferrum Carbonicum cum Saccharo. Fr.
Carbonate ferreux sucre. Ger. Zuckerhaltiges Ferrokar-
bonat. It. Carbonato di ferro con zucchero.

Dissolve 85 Gm. of sucrose in 2000 ml. of hot
purified water; then dissolve 500 Gm. of ferrous
sulfate in this solution, add 3 ml. of diluted sul-
furic acid, mix, and filter the solution. Dissolve
350 Gm. of sodium bicarbonate in 5000 ml. of
purified water at a temperature not exceeding 50°,
and filter the solution. Gradually add the ferrous
sulfate solution to that of sodium bicarbonate in a
container having a capacity of about 10 liters
and mix the contents by rotating the container.
Fill the container with boiling purified water,
allow the precipitate to subside, and then decant
the clear supernatant liquid. Wash the precipitate
by decantation, using a hot mixture of 1 volume

576 Ferrous Carbonate, Saccharated

Part I

of syrup and 19 volumes of purified water, until
the decanted liquid gives but a slight cloudiness
with barium chloride T.S. Drain the precipitate,
transfer it to a porcelain dish containing 615 Gm.
of sucrose and 100 Gm. of lactose, and mix well.
Evaporate the mixture to dryness on a water bath,
reduce the residue to a powder, weigh it, and mix
sufficient well-dried sucrose with it, if necessary,
to make the product weigh 1000 Gm. To mini-
mize oxidation make this preparation in the short-
est possible time." N.F.

Ferrous carbonate oxidizes readily to the ferric
state, but in the presence of sugars the rate of
atmospheric oxidation is materially reduced. Thus
saccharated ferrous carbonate is much more de-
pendable as a source of ferrous iron than is ferrous
carbonate by itself.

Amy, Taub and Blythe (/. A. Ph. A., 1934, 23,
672) found saccharated ferrous carbonate to be
stable in all types of glass containers for at least
one year. ,

Description. — "Saccharated Ferrous Carbon-
ate occurs as a light olive-gray, odorless powder,
which gradually becomes oxidized by contact with
air. Saccharated Ferrous Carbonate is only par-
tially soluble in water." N.F.

Standards and Tests. — Identification. — (1)
On adding 5 ml. of hydrochloric acid to 10 to 20
mg. of saccharated ferrous carbonate copious evo-
lution of carbon dioxide occurs and a greenish yel-
low solution is produced. (2) A solution of 1 Gm.
of saccharated ferrous carbonate in 5 ml. of hy-
drochloric acid, diluted to 100 ml. with distilled
water, responds to tests for ferrous iron. Sulfate.
— The limit is 0.5 per cent. Lead. — The limit is
50 parts per million. N.F.

Assay. — About 2 Gm. of saccharated ferrous
carbonate is assayed by the method employed for
Ferrous Carbonate Mass. N.F.

Uses. — Ferrous carbonate, in its several offi-
cial forms, is used for treatment of iron deficiency
(hypochromic) anemia. It is not as astringent as
many other salts of iron, and thus is relatively
well tolerated by the stomach. On exposure to air
ferrous carbonate absorbs oxygen and is changed
to the ferric state; the oxidation is retarded by
the addition of sugar, although the protection
is not complete. N.F. saccharated ferrous carbon-
ate contains one-half or less the amount of fer-
rous carbonate represented in ferrous carbonate
mass. S

The N.F. gives the usual dose as 250 mg. (ap-
proximately 4 grains).

Storage. — Preserve "in tight containers." N.F.

FERROUS GLUCONATE. U.S.P.

[Ferri Gluconas]

[CH2OH(CHOH)4.COO]2Fe.2H20

"Ferrous Gluconate contains not less than 11.5
per cent of Fe, calculated on the dried basis."
U.S.P.

Ferrous gluconate may be prepared by the in-
teraction in solution of barium gluconate and
ferrous sulfate; the liquid is filtered to remove
the barium sulfate and then concentrated, prefer-
ably in an inert atmosphere to reduce the tend-

ency to oxidation, until on standing fine crystals
of ferrous gluconate crystallize. Other methods of
manufacture include neutralization of gluconic
acid with ferrous carbonate, and solution of re-
duced iron in gluconic acid.

Iron Gluconate. Fergon (Stearns) ; Gluco-Ferrum (Vanpelt
& Brown); Irox (Cole).

Description. — "Ferrous Gluconate occurs as
a yellowish gray or pale greenish yellow powder
with a slight odor resembling that of burned
sugar. Its 1 in 20 solution is acid to litmus. One
Gm. of Ferrous Gluconate dissolves in about 10
ml. of water with slight heating. It is nearly
insoluble in alcohol." U.S.P.

Standards and Tests. — Identification. — (1)
Crystals of gluconic acid phenylhydrazide deposit
when a mixture of 5 ml. of warm 1 in 10 aqueous
solution of ferrous gluconate, 0.65 ml. of glacial
acetic acid and 1 ml. of freshly distilled phenylhy-
drazine is heated on a water bath for 30 minutes,
then cooled, and the inner surface of the container
scratched with a stirring rod. (2) A 1 in 20 aque-
ous solution of ferrous gluconate responds to the
test for ferrous salts. Loss on drying. — Not over
10 per cent, when dried at 105° for 4 hours.
Chloride. — The limit is 700 parts per million.
Sulfate. — The limit is 0.1 per cent. Oxalic acid.
— A solution of ferrous gluconate is acidified with
hydrochloric acid and extracted with ether; on
evaporating the ether, the residue, when dissolved
in distilled water, produces no turbidity on addi-
tion of calcium chloride T.S. in the presence of
acetic acid. Ferric iron. — Ferrous gluconate con-
tains not more than 2 per cent of ferric iron, as
determined by liberation of iodine from potassium
iodide, followed by titration with 0.1 N sodium
thiosulfate. Each ml. of 0.1 N sodium thiosulfate
represents 5.585 mg. of ferric iron.. Reducing
sugars. — From a solution of ferrous gluconate
the iron is precipitated with hydrogen sulfide,
the precipitate filtered off, and the hydrogen sul-
fide boiled out of the filtrate; on testing the solu-
tion with alkaline cupric tartrate T.S. no red
precipitate is obtained. N.F.

Assay. — About 1.5 Gm. of ferrous gluconate
is dissolved in distilled water and treated with
zinc dust and diluted sulfuric acid whereby the
ferric iron in the salt is reduced to the ferrous
state ; the excess zinc is filtered off, and the filtrate
titrated with 0.1 N eerie sulfate, using orthophen-
anthroline T.S. as indicator. Each ml. of 0.1 N
eerie sulfate represents 5.585 mg. of Fe. N.F.

Uses. — This salt is in common and effective
use for the treatment of iron-deficiency (hypo-
chromic) anemia. Because of the frequency of
gastrointestinal disturbances with adequate doses
of many of the older iron preparations, Reznikoff
and Go'ebel (/. Clin. Inv., 1937. 16, 547) tried
ferrous gluconate and found it to be both effective
and almost entirely free of untoward effects.
Jasinki (Schweiz. med. Wchnschr., 1950, 80, 59)
reported successful treatment of iron deficiency
anemias and studied the concentration of iron
in blood serum following its oral administration.
Patients with iron deficiency anemia showed a
much higher concentration of iron following in-
gestion than did non-anemic persons or those with

Part I

Ferrous Iodide Syrup 577

anemia not resulting from deficiency of iron. The
increase in serum iron concentration at 1, 3 and 7
hours after an oral dose of ferrous gluconate was
generally greater than after the same dose of iron
in the form of reduced iron. These findings are
compatible with the current concept that absorp-
tion of iron is proportional to the degree of tissue
deficiency of that element and also that soluble
ferrous iron is absorbed the best.

Although abdominal distress with ferrous sul-
fate is infrequent, it is believed (Teeter, J. A.M. A.,
1945, 127, 973) that the gluconate is often toler-
ated when the sulfate is not (see also Reznikoff,
Med. Clin. North America, 1944, 28, 368).
Otherwise there is no difference in the action and
uses of these two ferrous salts.

Toxicology. — A study of the oral toxicity of
several iron compounds, by Somers (Brit. M. J.,
1947, 2, 201), indicates that the lethal dose is
related to the content of iron in the compound.
For ferrous gluconate the median lethal dose per
Kg. of body weight is as follows: rabbit, 3.5 Gm. ;
guinea pig, 2.1 Gm.; mouse, 6.6 Gm. See also the
discussion under Ferrous Sulfate.

The usual dose is 300 mg. (approximately 5
grains) 3 or 4 times daily, by mouth, before or
after meals. The range of dose is 200 to 600 mg.,
with a maximum single dose of about 600 mg.,
and a maximum in 24 hours of about 2.5 Gm.

Storage. — Preserve "in tight containers." N.F.

FERROUS GLUCONATE TABLETS.

U.S.P.

"Ferrous Gluconate Tablets contain not less
than 93 per cent and not more than 107 per cent
of the labeled amount of Ci2H22FeOi4.2H20."
U.S.P.

Usual Size. — 300 mg. (5 grains).

FERROUS IODIDE SYRUP. N.F.

[Syrupus Ferri Iodidi]

"Ferrous Iodide Syrup contains, in each 100
ml., not less than 6.5 Gm. and not more than 7.5
Gm. of Fel2, representing approximately 5 per
cent of Fel2, by weight." N.F.

Syrupus Ferri Iodureti Gallicus; Sirupus Ferri Iodati.
Fr. Sirop d'iodure de fer; Sirop d'iodure ferreux. Ger.
Jodeisensirup ; Eisenjodiirsirup. It. Sciroppo di joduro
ferroso. Sp. Jarabe de yoduro ferroso, concentrado.

The syrup may be prepared as follows: Place
20 Gm. of iron, in the form of fine, bright wire,
in a 500-ml. flask, add 60 Gm. of iodine and 200
ml. of purified water, and shake the mixture
occasionally, checking the reaction, if necessary,
by placing the flask in cold water. When the
liquid is colored green and the odor of iodine is
lost, heat to boiling, and dissolve 100 Gm. of
sucrose in the hot liquid. Filter the solution im-
mediately into a flask graduated at 1000 ml. and
containing 750 Gm. of sucrose; wash the flask
containing the iron with 240 ml. of hot purified
water in divided portions, passing the washings
successively through the filter. Agitate the mix-
ture until the sucrose has dissolved, warming if
necessary; cool the solution to 25°, add 5 ml. of
hypophosphorous acid and enough purified water

to make 1000 ml. Mix well and strain. Note. —
To retard discoloration, 1.3 Gm. of citric acid
may replace the hypophosphorous acid. N.F.

Description. — "Ferrous Iodide Syrup is a
transparent, pale yellowish green, syrupy liquid,
having a sweet, ferruginous taste and a slightly
acid reaction. Its specific gravity is about 1.37."
N.F.

Standards and Tests. — Identification. — (1)
A blue precipitate forms on adding a few drops
of potassium ferricyanide T.S. to 5 ml. of the
syrup. (2) A deep blue color develops on adding
3 drops of chlorine T.S. to a mixture of 5 ml.
of the syrup and a few drops of starch T.S. Free
iodine. — No blue color is produced in the syrup
by starch T.S. N.F.

Assay. — The iodide in 10 ml. of syrup is de-
termined by the Volhard method, using 0.1 N
silver nitrate and 0.1 AT ammonium thiocyanate.
Each ml. of 0.1 N silver nitrate represents 15.48
mg. of Fel2. N.F.

It is well known that ferrous iodide syrup
darkens on standing. Although many explana-
tions of the change have been advanced, the work
of Husa and Klotz (/. A. Ph. A., 1934, 23, 679,
774) shows these to be inadequate; they con-
clude that the deterioration involves several dif-
ferent changes which occur simultaneously, but
at different rates. The darkening is due chiefly
to the decomposition of levulose formed by the
inversion of sucrose; this reaction Krantz (/. A.
Ph. A., 1923, 12, 964) found to be 96.2 per cent
complete in 20 days. By replacing the sucrose
in the syrup with 700 Gm. per liter of dextrose,
a satisfactory product is obtained, according to
Husa and Klotz. This formula has, however, the
disadvantage of having some of the dextrose
crystallize at refrigerator temperatures, for which
reason Husa and Pedrero (ibid., 1950, 39, 67)
recommended reducing the amount of dextrose
to 600 Gm., and incorporating 0.8 Gm. each of
saccharin sodium and sodium benzoate, per liter,
They reported also that use of citric acid in
place of hypophosphorous acid, as authorized by
the N.F., is disadvantageous in that iodine is
liberated under all conditions of storage except
in sunlight. Amy and Steinberg (Am. J. Pharm.,
1931, 103, 504) found that the color of the glass
container has no effect on the stability of the
syrup — a conclusion to be expected from the
preceding.

Incompatibilities. — Ferrous iodide syrup is
decomposed by oxidizing agents with liberation
of iodine and conversion of the ferrous salt to a
ferric compound. The syrup is also incompatible
with alkalies.

Uses. — Ferrous iodide syrup combines the
alterative action of iodine with the hematinic
action of iron. It was a popular remedy in
chronic types of tuberculosis, especially in the
scrofula of children. It has, however, no advan-
tage over an extemporaneous combination of an
iodide with ferruginous tonic, and has the draw-
back that the dose of either ingredient cannot be
altered singly.

Dose, for an adult, 0.6 to 2.5 ml. (approxi-

578

Ferrous Iodide Syrup

Part I

mately 10 to 40 minims); for a child of two
years, 0.12 to 0.5 ml. (approximately 2 to 8
minims).

Storage. — Preserve "in tight containers." N.F.

FERROUS SULFATE. U.S.P. (B.P.)
LP.

Iron Sulfate, [Ferri Sulfas]

"Ferrous Sulfate contains an amount of FeSCU
equivalent to not less than 99.5 per cent and not
more than 104.5 per cent of FeS04.7H20." U.S.P.
The B.P. requires not less than 97.0 per cent and
not more than the equivalent of 103.0 per cent
of FeSO-i./KbO; the corresponding LP. limits are
99.0 to 104.0 per cent.

B.P. Ferrous Sulphate; Ferri Sulphas. LP. Ferrosi
Sulfas. Green Vitriol; Iron Vitriol; Iron Protosulfate.
Ferrum Sulfuricum Purum; Ferrum Sulfuricum; Ferrum
Vitriolatum Purum; Ferrum Sulfuricum cum Alcohole
Prxcipitatum; Ferrosus Sulphas. Fr. Sulfate de protoxyde
de fer officinal; Sulfate ferreux pur; Protosulfate de fer.
Ger. Ferrosulfat; Schwefelsaures Eisenoxydul; Reiner
Eisenvitriol. It. Solfato ferroso all'alcool ; Vitriolo verde.
Sp. Sulfato ferroso.

The U.S.P. 1870 described a process for making
this salt by the action of sulfuric acid on iron,
followed by crystallization ; a modification of the
process is still employed for preparing the purest
grade of the salt.

Commercial ferrous sulfate, or copperas, is
manufactured in large quantities from iron pyrites
(FeS2) by exposure to air and moisture. Fer-
rous sulfate is also obtained in many chemical
processes as a by-product, as in the manufacture
of alum, in the precipitation of copper from
solutions of copper sulfate by scraps of iron, in
the manufacture of hydrogen, etc. Commercial
ferrous sulfate is far from being pure. Besides
containing some ferric sulfate, it is generally con-
taminated with other salts, such as those of
copper, zinc, aluminum, and magnesium.

Description. — 'Terrous Sulfate occurs as
pale, bluish green crystals or granules. It is odor-
less, has a saline, styptic taste, and is efflorescent
in dry air. Its solutions are acid to litmus. On
exposure to moist air, the crystals rapidly oxidize
and become coated with brownish yellow basic
ferric sulfate. When Ferrous Sulfate has thus
deteriorated, it must not be used. One Gm. of
Ferrous Sulfate dissolves in 1.5 ml. of water, and
in 0.5 ml. of boiling water. It is insoluble in
alcohol." U.S.P. The LP. states that 1 part of
ferrous sulfate is soluble in 4 parts of glycerin.

Standards and Tests. — Identification — Fer-
rous sulfate responds to tests for ferrous salts,
and for sulfate. Acidity. — The filtrate from a
mixture of 1 Gm. of ferrous sulfate which has
been agitated during 5 minutes with 10 ml. of
alcohol does not immediately redden moistened
blue litmus paper. Heavy metals. — The limit is
160 parts per million. U.S.P. The B.P. and LP.
further specify that 1 Gm. shall form a clear
solution in 2 ml. of recently boiled and cooled
water as a test for absence of basic sulfate of
iron. Both compendia limit arsenic to 2 parts per
million and lead to 30 parts per million.

Assay. — A solution of 1 Gm. of ferrous sul-
fate in 25 ml. of diluted sulfuric acid is titrated

with 0.1 N potassium permanganate, which oxi-
dizes the ferrous iron to the ferric state. Each
ml. of 0.1 N potassium permanganate represents
15.19 mg. of FeSOi or 27.80 mg. of FeSO4.7H.2O.
U.S.P.

Incompatibilities. — The cation of ferrous
sulfate is precipitated by alkalies and their car-
bonates, and the anion by calcium salts. With
preparations containing tannic acid or gallic acid
a bluish-black compound will form if the iron
has become partially oxidized. Even the weakest
of oxidizing agents converts ferrous iron to the
ferric state.

Uses. — In the early years of the 20th century
ferrous sulfate had all but disappeared from use
as a remedial agent. With evidence (see under
Iron) indicating that ferrous salts are more effi-
cient than ferric in treating anemia ferrous sul-
fate has again come into general use in the treat-
ment of hypochromic anemia. Given in rather
large doses it is prone to upset the gastrointestinal
tract through local irritation; most patients,
however, tolerate it in therapeutic doses. In pa-
tients with gastrointestinal symptoms, it may be
wise to commence with a single dose daily and
to increase at weekly intervals to two and then to
three doses.

Anemia following frequent donation of blood
was found to respond to ferrous sulfate adminis-
tration but not to high-protein diet alone (Bate-
man, Ann. Int. Med., 1951, 34, 393). Prophy-
lactic use of iron seems to be indicated for indi-
viduals donating blood at intervals of 6 to 8
weeks.

Locally ferrous sulfate has been employed in
the treatment of chronic conjunctivitis, leukor-
rhea and similar conditions in concentrations of
0.2 to 2 per cent.

Especially in the impure form known as cop-
peras, ferrous sulfate has found extensive use as
a disinfectant and deodorant. Its germicidal value
is low, Sternberg having found that a 20 per cent
solution was not certainly fatal to bacteria after
2 hours' exposure. Its deodorant properties, how-
ever, are quite marked.

Toxicology. — With widespread and extensive
use of ferrous sulfate in the form of attractively
colored and pleasantly flavored tablets and elixirs,
many cases of accidental poisoning of children
have occurred (see editorial, J.A.M.A., 1952,
148, 1280). Patients should be warned to keep
such preparations out of reach of small children
and it has been suggested that labels on the
containers carry such a warning statement. The
editorial refers to reports of 34 cases of poison-
ing during the preceding 10 years; almost half of
these terminated fatally. The syndrome is charac-
terized by initial vomiting, hematemesis, tachy-
cardia, and vascular collapse which seems to be
due to shock from the corrosive action on the
stomach. Shock persists for 12 to 24 hours, after
which the patient often appears to improve but
later relapses and sometimes dies. Smith et al.
(New Eng. J. Med., 1950, 243, 641) reported
failure of the gray cyanosis to respond to oxygen
inhalation but that rapid relief followed intra-
venous injection of methylrosaniline chloride.

Part I

Ferrous Sulfate Syrup 579

Spencer (Brit. M. J., 1951, 2, 1112) observed a
rapid rise of serum iron concentration to 15 to
100 times normal and suggested that toxic effects
on the central nervous system caused death.

Autopsy findings include: edema and conges-
tion of the stomach, with hemorrhagic and ne-
crotic patches particularly on the crests of the
rugae and similar changes in the proximal portion
of the small intestine; congestion, cloudy swell-
ing and necrosis of the liver, kidney, heart, pan-
creas, spleen and lungs. In a case reported by
Swift et al. (J. Pediatr., 1952, 40, 6) there was
thrombosis of the mesenteric vessels draining the
corroded areas. Prain (Brit. M. J., 1949, 2, 1019)
concluded that liver damage resulted in passage
of toxic substances into the systemic circulation
from the intestine. The initial shock was ascribed
by Smith (/. Path. Bad., 1952, 64, 467) to a
high concentration of ferritin (vasodepressor ma-
terial responsible for shock, according to Mazur
and Shorr— editorial, J.A.M.A., 1952, 150, 36)
resulting from the high concentration of iron
combining with apoferritin in the liver. Observa-
tions of Crismon (Am. J. Med., 1950, 8, 523) on
the mesoappendix circulation of the rat have
demonstrated loss of sensitivity to epinephrine
after intravenous injection of ferrous iron; rutin
corrected the depressed sensitivity.

In treatment of poisoning, emesis within an
hour of ingestion is helpful and gastric lavage
with an aqueous solution of sodium bicarbonate
to remove and dilute the iron salt, followed by
bismuth subcarbonate orally as a protective, is
indicated (Thompson, Brit. M. J., 1950, 1, 645).
Dimercaprol is contraindicated since it aggra-
vates the symptoms; the toxicity of the dimerca-
prol-iron complex is greater than that of the iron
salt. Since iron as a heavy metal may interfere
with the essential function of sulfhydryl groups
in tissues, it is recommended that methionine,
tocopherol (vitamin E), and the vitamin B com-
plex be employed in treatment of iron poisoning.

Dose. — The usual dose for adults and children
is 300 mg. (approximately 5 grains) 3 times daliy
after meals; the range of dose is 200 to 600 mg.
The maximum safe dose is 600 mg. and 1.8 Gm.
in 24 hours is not exceeded. For infants a dose
increasing gradually to 200 mg. daily, divided into
3 or more portions, is given.

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep.— Exsiccated Ferrous Sulfate,
U.S.P., B.P., LP.; Ferrous Sulfate Syrup; Fer-
rous Sulfate Tablets, U.S. P.; Ferrous Carbonate
Mass; Ferrous Carbonate Pills; Saccharated Fer-
rous Carbonate; Ferric Subsulfate Solution, N.F.

EXSICCATED FERROUS SULFATE.
U.S.P. (B.P.) I.P.

Dried Ferrous Sulfate, [Ferri Sulfas Exsiccatus]

"Exsiccated Ferrous Sulfate contains not less
than 80 per cent of anhydrous ferrous sulfate
(FeS04)." U.S.P. The B.P. requires not less than
77.0 per cent, and the I.P. not less than 80.0 per
cent, of FeSGi; both compendia define the prod-
uct as ferrous sulfate deprived of part of its water

of crystallization by drying at a temperature
of 40°

B.P. Exsiccated Ferrous Sulphate; Ferri Sulphas Ex-
siccatus. I.P. Ferrosi Sulfas Exsiccatus. Dried Iron
Sulfate. Ferrum Sulfuricura Siccum. Fr. Sulfate ferreux
desseche. Ger. Getrocknetes Ferrosulfat. Sp. Sulfato
Ferroso Desecado.

Description. — "Exsiccated Ferrous Sulfate is
a grayish white powder. Exsiccated Ferrous Sul-
fate dissolves slowly in water. It is insoluble in
alcohol." U.S.P.

Standards and Tests. — Identification. — Ex-
siccated ferrous sulfate responds to tests for fer-
rous salts and for sulfate. Insoluble substances. —
1 Gm. of exsiccated ferrous sulfate is practically
completely soluble in dilute hydrochloric acid
(1 in 4). Heavy metals. — The limit is 200 parts
per million. U.S.P.

The B.P. arsenic limit is 3 parts per million;
that for lead is 50 parts per million. The corre-
sponding I.P. limits are 4 and 50 parts per million,
respectively.

Assay. — Exsiccated ferrous sulfate is assayed
in the same manner as ferrous sulfate. U.S.P.

Uses. — Exsiccated ferrous sulfate is the pre-
ferred form of the salt for making tablets and
capsules, the hydrated salt being more trouble-
some to manipulate in manufacturing processes.
In prescribing the dried sulfate it should be kept
in mind that 200 mg. (approximately 3 grains)
of it is equivalent to about 300 mg. (approxi-
mately 5 grains) of the hydrated salt.

The average dose is 200 mg. (approximately
3 grains), three times daily after meals, with a
range of 200 to 400 mg.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

FERROUS SULFATE SYRUP. U.S.P.

[Syrupus Ferri Sulfatis]

"Ferrous Sulfate Syrup contains, in each 100
ml., not less than 3.75 Gm. and not more than
4.25 Gm. of FeS04.7H20." N.F.

Dissolve 40 Gm. of ferrous sulfate, 2.1 Gm. of
citric acid, 2 ml. of peppermint spirit, and 200
Gm. of sucrose in 450 ml. of purified water; filter
the solution until clear. Dissolve 625 Gm. of
sucrose in the clear filtrate, and add enough
purified water to make 1000 ml. Mix thoroughly
and strain, if necessary, through cotton. N.F.

This formula, proposed by Clarke (/. A. Ph. A.,
1940, 29, 499) under the name Elixir of Ferrous
Sulfate, was first adopted by the N.F. as being
the best one available from the standpoints of
pharmaceutical elegance, taste and stability; be-
cause of the very low alcohol content it was de-
cided to call it a syrup rather than an elixir. A
sample of the syrup stored at 120° F. for a month,
with the container opened nearly every day as
during use, was found to have increased slightly
in its content of ferrous iron due, presumably, to
concentration by evaporation (Martin and Green,
Bull. N.F. Com., 1945, 13, 149).

Assay. — A 25-ml. portion of the syrup is mixed
with diluted sulfuric acid and distilled water and

580 Ferrous Sulfate Syrup

Part I

the solution titrated with 0.1 N eerie sulfate,
using orthophenanthroline T.S. as indicator. Each
ml. of 0.1 N eerie sulfate represents 2 7.80 mg. of
FeS04.7H20. N.F.

The usual dose is 8 ml. (approximately 2 flui-
drachms) three times daily, with a range of dose
of 4 to 12 ml. (representing 160 to 480 mg. of
ferrous sulfate).

Storage. — Preserve "in tight containers." N.F.

FERROUS SULFATE TABLETS.
U.S.P. (B.P., LP.)

[Tabellae Ferri Sulfatis]

"Ferrous Sulfate Tablets contain not less than
95 per cent and not more than 110 per cent of
the labeled amount of FeSOi.TEbO. An equiva-
lent amount of exsiccated ferrous sulfate may be
used in place of FeS04.7H>0. in preparing the
Tablets." U.S.P. The B.P. recognizes Tablets of
Exsiccated Ferrous Sulphate and requires that
each tablet of average weight contain FeSCu in
an amount not less than 70.0 per cent and not
more than 80.0 per cent of the prescribed or
stated amount of Exsiccated Ferrous Sulphate.
The LP. definition is the same as that of the
U.S.P.

B.P. Tablets of Exsiccated Ferrous Sulphate. I. P.
Compressi Ferrosi Sulfatis. Feosol Tablets (Smith, Kline
& French Laboratories) ; Ferad (Burroughs W ellcome) ;
Ironate (IV yet h): Irosul (Haskell); Sulferrous (Chicago
Pharmacol). Sp. Tabletas de Sulfato Ferroso.

In order to insure having the iron in the ferrous
state the tablets are usually coated to prevent
oxidation; however, they should not be enteric-
coated because disintegration in the stomach and
upper bowel is desired.

Storage. — Preserve "in tight containers."
U.S.P.

Usual Sizes. — 5 grains (approximately 300
mg.) of ferrous sulfate.

HUMAN FIBRIN FOAM. B.P.

The B.P. defines Human Fibrin Foam as a dry
artincial sponge of human fibrin, prepared by
clotting with thrombin a foam of a solution of
human fibrinogen, then drying the clotted foam
from the frozen state and sterilizing by dry heat
in the final containers. The product prepared in
the United States is subject to the regulations of
the National Institutes of Health of the United
States Public Health Sen-ice.

Description. — Human fibrin foam occurs as
a fine white sponge of firm texture ; it is insoluble
in water. B.P. Fibrin foam (human) consists of
small, yellowish, rectangular, fragile, sponge-like
pieces which become compressible and resilient
when completely wetted with water. NJV.R.

Uses. — Human fibrin foam acts as a mechani-
cal coagulant, and in combination with thrombin
gives a chemical as well as a mechanical matrix
for coagulation of blood in case of hemorrhage. It
is absorbed within a short time after being em-
bedded in living human tissue. Fibrin foam is
used in surgery of the brain, liver, kidneys and
other organs where ordinary methods of hemo-
stasis are ineffective or inadvisable.

Fibrin foam is used by impregnating it with
a freshly prepared solution of thrombin in nor-
mal saline solution and then applying the foam,
cut to shape if desired, to the bleeding area. As it
need not be removed from the area after bleed-
ing has stopped there is no danger of causing
recurrence of bleeding, as would be the case with
a cotton applicator; in time the foam is absorbed,
with minimal tissue reaction. Cooper and Hoen
(Mil. Surg., 1948, 102, 55) used the foam effec-
tively for decubitus ulcers. Quick (J. A.M. A.,
1951, 145, 4) used a pledget soaked in thrombin
solution for bleeding in the wound of a hemo-
philiac following dental surgery.

A fibrin film has also been prepared by inter-
action of fibrinogen and thrombin so as to form
a strong, rubbery sheet which can be stretched
reversibly from 2 to 3 times its original length.
It may be prepared in various shapes and thick-
nesses, also in the form of seamless tubing and
its mechanical properties may be varied from a
soft, rubber-like consistency to a parchment-like
consistency. The fine structure of the film con-
tains pores which in one type are of the order of
60 Angstrom units in diameter; hemoglobin
molecules in solution pass through these pores
readily, but plasma globulins are partially and
fibrinogen molecules are completely retained. The
mechanical properties of certain of these fibrin
films make them suitable for use as dural substi-
tutes and in prevention of meningocerebral ad-
hesions; the duration of their persistence in the
body can be adjusted by suitable treatment of
the film. The films have been used in neurosur-
gical operations, appearing to be well suited for
such uses; patients observed for as long as 15
months failed to show unfavorable sequelae (see
Fern' and Morrison, /. Clin. Inv., 1944. 23, 566;
Hawn et al., ibid., 1944, 23, 566; Cohn and
Ferry, U. S. Patent 2,385,803 (1945); Ingraham
et al, J. AM. A., 1945, 128, 1088; Singer, /. Neu-
rosurg., 1945, 2, 102). For detailed reports of
other uses of fibrin film see Cohn, Science, 1945,
101, 51; Ingraham and Bailev, J. AM. A., 1944,
126, 680; Frantz, Bull. N. Y. Acad. Med., 1946,
22, 102).

In connection with the uses of fibrin foam
mentioned above, there has been developed a
substitute for it in the form of a partially de-
natured gelatin occurring in spongy form (see
Absorbable Gelatin Sponge, in Part I). With it
may be employed thrombin derived from bovine
sources, which is stated to be quite as satisfac-
tory as human thrombin. For certain hemostatic
purposes oxidized surgical gauze or cotton is
useful (see Oxidized Cellulose, in Part I).

Fibrin film is applied topically in an amount,
size, and shape determined by the particular sur-
gical requirement of the patient.

Storage. — Human fibrin foam is stored at 2°
to 10° C. when packaged with an accompanying
vial of thrombin. If dispensed by itself, fibrin
foam may be stored at 50° C. It has an expira-
tion date of 3 years when stored under these
conditions. Fibrin foam is a sterile product and
must be dispensed in the container in which it
was placed by the manufacturer.

Part I

Fibrinogen, Human 581

Usual Size. — Fibrin foam is usually available
in a combination package containing 250 mg. of
fibrin foam in a sterile jar, a vial containing 200
units of thrombin, and a vial containing 20 ml.
of sodium chloride injection.

HUMAN FIBRINOGEN. B.P.

"Human Fibrinogen is a dried preparation of
the soluble constituent of liquid human plasma
which, on the addition of thrombin, is transformed
to fibrin. It has a molecular weight of 400,000
to 500,000. It may be prepared from liquid hu-
man plasma by precipitation with organic sol-
vents under controlled conditions of pH, ionic
concentration and temperature. It contains not
less than 15.0 per cent and not more than 16.0
per cent of nitrogen, N, of which not less than
85 per cent is contained in the clot formed by
the addition of thrombin." B.P.

Fibrinogen may be recovered from fraction I
obtained in the Cohn method of fractionating
plasma (see Normal Human Plasma). To comply
with the requirements of the National Institutes
of Health, applicable to this product, the plasma
must be fractionated within 48 hours of with-
drawal from the donor. The generic name pareno-
gen has been recognized for the product by the
Council on Pharmacy and Chemistry of the
American Medical Association.

Description. — Fibrinogen, vacuum-dried from
the frozen state, occurs as a white powder or
friable solid, readily soluble in sodium chloride
injection to form a colorless solution which may
clot spontaneously on standing.

Uses. — Fibrinogen is essential for coagulation
of blood, thrombin acting on it to form a fibrin
clot (Stefanini, Am. J. Med., 1953, 14, 64). A
fibrin foam prepared by action of thrombin on
fibrinogen is official in B.P. Fibrinogen itself
probably has limited use in the rare clinical states
of fibrinogen deficiency.

In the course of coagulation of blood thrombo-
plastin from blood platelets and/or damaged tis-
sues converts prothrombin to thrombin, which
acts upon fibrinogen. Fibrin is deposited in many
tissues in response to injury, infection, etc., and
plays an important role in the healing process.
A fibrinolysin is probably essential to dissolve
fibrin clot in injured capillaries, to recanalize
thrombi in large blood vessels and remove in-
flammatory fibrin deposits from tissues. A pro-
fibrinolysin {plasminogen) is thought to circulate
normally and to be activated by a tissue enzyme
(fibrinokinase) to form fibrinolysin (plasmin).
An antiplasmin is probably also present in cir-
culating blood. Excessive fibrinolysin, causing
hypofibrinogenemia and severe hemorrhage, oc-
curs in certain rare situations, as in premature
separation of the placenta with intrauterine fetal
death (Peckham and Middlebrook, Am. J. Obst.
Gyn., 1953, 65, 644), and metastatic prostatic
(Stefanini, Blood, 1952, 7, 1044) or pancreatic
carcinoma (McKay et al., Cancer, 1953, 6, 862).
In the latter condition, multiple peripheral throm-
boses have been a recognized clinical feature
and the question of the relative importance of

fibrinolysis or of depletion of fibrinogen due to
extensive intravascular and tissue deposition of
fibrin remains unresolved. Weiner et al. {Am. J.
Obst. Gyn., 1950, 60, 379, 1015) suggest that
thromboplastic material is released from the
uterine contents into the blood stream in compli-
cation of pregnancy. This results in extensive
fibrin formation, fibrin deposits in the tissues,
fibrin emboli and an impaired coagulation due to
deficiency of fibrinogen (Weber et al., ibid., 1952,
64, 1037; Page et al, ibid., 1951, 61, 1116).
Thromboplastic activity has been demonstrated
in amniotic fluid (Vecchietti, Riv. Ostet. Ginec,
1953, 8, 443). In several cases fetal death has
been associated with Rh isosensitization. Correc-
tion of the hypofrinogenemia requires delivery
of the uterine contents, or excision of the cancer
if possible. Whole blood or plasma in large doses
is required. Fibrinogen intravenously in a dose of
6 Gm., which represents about half of the nor-
mal total circulating fibrinogen, is recommended.
In a fatal postoperative case, Steiger et al.
{Obst. Gyn., 1953, 2, 99) found active fibrino-
lytic activity in the blood and suggested that this
was released as a part of the alarm reaction to
the disease and surgical trauma. Cortisone may
inhibit the fibrinolytic activity.

A rare congenital afibrinogenemia has been re-
ported (Frick and McQuarrie, Pediat., 1954, 13,
44; Bucek, Ann. paediat., 1951, 177, 111; and
others) as an inherited, mendelian recessive trait.
Hemorrhage occurs early in life, although usually
less severely than in hemophilia, and examination
of the blood reveals prolonged coagulation and
prothrombin times and failure of the coagulum
to retract. Hypofibrinogenemia is more frequent
than complete lack of fibrinogen. In such cases
the fibrinogen concentration must be kept above
50 mg. per 100 ml. for safety. Whole blood, stored
plasma or fibrinogen is useful.

The B.P. recognizes human fibrinogen because
of its use, in conjunction with human thrombin,
in certain surgical procedures, as in fixing nerve
sutures and facilitating adhesion of skin and
mucous membrane grafts. For the former purpose
a 2 per cent solution in water for injection is used
along with sufficient human thrombin to cause
clotting in the required time; for the latter pur-
pose 1 to 2 per cent solutions are used. The pro-
portions of the reacting components are deter-
mined empirically during use, depending on the
rate of clotting desired. When 0.9 ml. of a 2 per
cent solution of fibrinogen is added to 1 unit of
thrombin contained in 0.1 ml. of isotonic sodium
chloride solution a firm clot results in 60 seconds.

The amount and concentration of human
fibrinogen to be used are determined by the sur-
geon or physician according to the requirements
of the situation. In the rare cases of afibrino-
genemia doses of 2 to 6 Gm., dissolved in sodium
chloride injection, have been administered slowly
intravenously.

Storage. — Store human fibrinogen at 2° to
10° C. (35.6° to 50° F.). Under this condition the
expiration date is 3 years. Dispense it in the
unopened container in which it was placed by the
manufacturer.

582

Fluorescein Sodium

Part I

FLUORESCEIN SODIUM. U.S.P., B.P.

Soluble Fluorescein, Resorcinolphthalein Sodium,
[Fluoresceinum Sodicum]

No.0

COONa

"Fluorescein Sodium, dried at 105° for 4 hours,
contains not less than 98.5 per cent of C20H10-
Na205." U.S.P. The B.P. purity rubric differs
only in specifying that the result of the assay is
calculated with reference to the substance dried
to constant weight at 105°

Uranin; Uranine Yellow; Dioxyfluoran Sodium.
Fluoresceina Sodica. ,

sp.

Fluorescein may be prepared by the condensa-
tion of resorcinol and phthalic anhydride at a
temperature between 180° and 200° in the pres-
ence of zinc chloride or sulfuric acid as a de-
hydrating agent. The reaction product is ex-
tracted with water and the residue is dissolved
in alkali; from this solution fluorescein is precipi-
tated by acid. The disodium salt of this compound
is the official fluorescein sodium.

The fluorescent power of solutions of fluorescein
varies with pH. First apparent at a pH of about
4.6, fluorescence reaches a maximum intensity at
pH 8 (Boutaric and Roy, Compt. rend. acad. sc,
1939, 209, 162). Oxidizing agents, such as sodium
hypochlorite and potassium permanganate, de-
colorize fluorescein solutions.

Description. — "Fluorescein Sodium is an
orange red, odorless powder. It is hygroscopic.
Fluorescein Sodium is freely soluble in water and
sparingly soluble in alcohol." U.S. P.

Standards and Tests. — Identification. — (1)
Even at great dilution solutions of fluorescein
sodium fluoresce strongly; acidification causes the
fluorescence to disappear but subsequent alka-
linization restores this property. (2) The product
of the incineration of fluorescein sodium responds
to tests for sodium. (3) A yellow spot is produced
on placing 1 drop of a 1 in 2000 solution of fluo-
rescein sodium on filter paper; the spot becomes
deep pink in color on exposing it, while moist, to
the vapor of bromine for 1 minute, then to am-
monia vapor. Loss on drying. — Not over 7 per
cent, when dried at 105° for 4 hours. Zinc. — Addi-
tion of potassium ferrocyanide T.S. to the filtrate
obtained from a solution of fluorescein sodium in
saturated sodium chloride solution acidified with
diluted hydrochloric acid produces no turbidity.
Acriflavine. — No precipitate appears on adding a
few drops of a sodium salicylate solution to one
of fluorescein sodium. U.S.P.

Assay. — An aqueous solution of about 500 mg.
of fluorescein sodium, previously dried at 105° for
4 hours, is acidified with diluted hydrochloric acid
and the precipitated fluorescein is extracted with
several portions of a mixture of isobutyl alcohol
and chloroform. The extract is evaporated to dry-

ness, the residue dissolved in alcohol and again
evaporated to dryness, and the weight of the
fluorescein determined after heating at 105° for
1 hour. The weight of the fluorescein obtained,
multiplied by 1.132, represents the weight of
C2oHioNa205. U.S.P. The B.P. assay is the same.

Uses. — Fluorescein sodium is used in medicine
and surgery as a diagnostic agent in various
ophthalmic and circulatory conditions. More re-
cently this dye and a radioactive form of diiodo-
fluorescein have been used in the study and
localization of brain tumors.

Following intravenous injection, fluorescein is
retained in varying degrees by different bodily tis-
sues (Svien and Johnson, Proc. Mayo, 1951, 26,
142). Normally 14 per cent is excreted by the
kidneys and the remainder through the biliary
system. Nearly all of the dye is excreted in 12
hours.

In lesions of the cornea a 2 per cent solution
is dropped into the eye, and those portions which
are denuded of epithelium will show a green dis-
coloration, while healthy portions of the cornea
will remain unstained. The eye is usually anes-
thetized before instillation of fluorescein. Accord-
ing to Hamberger (Allg. med. Centr.-Ztg., 1909.
p. 368) if 2 to 3 Gm. (approximately 30 to 45
grains) is given orally the body becomes yellow
as in jaundice but in the healthy eye there is no
change of color; when there is intra-ocular dis-
ease, however, the aqueous humor assumes a
bright green color. In diseases of the conjunctiva
the eye reacts as though healthy. Fluorescein
sodium has been used in treatment of ocular
methylrosaniline poisoning resulting from frag-
ments of violet-colored indelible pencils (Hosford
and Smith, J.A.M.A., 1952, 150, 1482). It evi-
dently competes successfully with anionic groups
in the tissues for the dye to form a slightly disso-
ciated salt, making removal possible. Trumper and
Honigsberg (J.A.M.A., 1946, 131, 1275) were
able to locate fiberglass embedded in the pharynx
after applying the 2 per cent solution.

During operation for strangulated hernia, the
dye may be injected intravenously to differentiate
normal intestine, which will fluoresce, from non-
viable bowel, which fails to do so. Menaker and
Parker (Surgery, 1950, 27, 41) found that it is
useful in delineating the gall bladder and bile
ducts during surgical procedures upon these struc-
tures. For this purpose 10 ml. of a 5 per cent
solution of the dye in 5 per cent sodium bicar-
bonate is injected intravenously 4 hours prior to
operation. The biliary passages are well visualized
under ultraviolet fight equipped with a Wood's
filter in a darkened operating theater. Lange
(Surg. Gynec. Obst., 1945, 80, 346) used the dye
to differentiate in an extremity tissues with ade-
quate blood supply from that which is devitalized;
the test is unreliable in pigmented areas. Nausea
and vomiting sometimes result. Dye excreted in
the urine gives it a grass-green fluorescent color,
which disappears on the addition of acid (Dis-
combe, Lancet, 1937, 1, 86).

Gasul et al. (J. Pediatr., 1949, 34, 460) de-
scribed a technique for measuring circulation time
(the time between injection of fluorescein sodium
into the antecubital vein and the first appearance

Part I

of the dye on the patient's lips) in infants and
children. The average circulation time in normal
patients under 2 years of age is 6.5 seconds; from
3 to 13 years of age the average is 8.5 seconds.
They found it to be a simple, nontoxic and ob-
jective procedure.

Much interest has centered about the studies
of Moore and his associates in the use of fluores-
cein sodium to localize brain tumors (Ann. Surg.,
1949, 130, 637 and Am. J. Roentgen., 1951, 66,
1). His investigations are based upon the prop-
erty of central nervous system blood vessels to
permit negatively charged dyes to traverse this
blood-brain barrier only under certain pathological
conditions. In the presence of tumor, abscess cap-
sule or subdural hematoma, the dye will pene-
trate into the lesion but not into surrounding
normal brain tissue. He uses 5 ml. of a 20 per
cent solution intravenously 2 hours before open-
ing the dura. Superficial lesions become fluores-
cent when exposed to the ultraviolet light emitted
by a mercury vapor lamp equipped with a Wood's
filter. Biopsy material of subcortical lesions is
obtained by aspiration through brain needles and
examined in similar fashion. His studies indicated
that the degree of fluorescence was correlated
with the degree of malignancy. The investigations
of Svien and Johnson (loc. cit.) indicate that the
degree of fluorescence is a function of the degree
of cellularity of the tissue involved, irrespective
of whether or not the cells are malignant. These
authors have extended their studies, using radio-
active diiodofluorescein and the Geiger counter
to localize brain tumors without opening the
calvarium.

This dye is used by sanitation experts for the
purpose of tracing the course of underground
streams and the connection between cesspools and
wells. One part in two billion can be recognized
in water.

Storage. — Preserve "in tight containers."
U.S.P.

FLUORESCEIN SODIUM SOLUTION.
U.S.P.

"Fluorescein Sodium Solution is a sterile solu-
tion for ophthalmic purposes containing, in each
100 ml., not less than 1.86 Gm. and not more
than 2.10 Gm. of C2oHioNa20s. It contains a
suitable antibacterial agent." U.S.P.

Fluorescein sodium solution may be prepared
by dissolving 2 Gm. of fluorescein sodium, 3 Gm.
of sodium bicarbonate, and a "sufficient quantity"
of an antibacterial agent in sufficient purified
water to make 100 ml. U.S.P.

For uses of this solution see under Fluorescein
Sodium.

FOLIC ACID. U.S.P , B.P., LP.

Pteroylglutamic Acid, [Acidum Folicum]

Folic Acid

583

CH2NH

CONH-CH-CH2CH2C00H
COOH

"Folic Acid contains not less than 98 per cent
of C19H19N7O6 calculated on the anhydrous
basis." U.S.P. The B.P. defines Folic Acid as
£-(2-amino-4-hydroxy-6-pteridyl)methylamino-
benzoyl-L-( + )-glutamic acid; it is required to
contain not less than 94.0 per cent and not more
than the equivalent of 101.0 per cent of C19H19-
O6N7, calculated with reference to the substance
dried to constant weight at 75° at a pressure not
exceeding 5 mm. of mercury. B.P. The LP. de-
fines it as N-[4'-({ [2-amino-4-hydroxy-6-pteridyl]-
methyl}amino)benzoyl]-L-(+) -glutamic acid, re-
quiring not less than 85.0 per cent of C19H19O6N7,
calculated with reference to the substance dried
to constant weight at 105°.

The relationship of the nutritional factors vari-
ously designated as folic acid, vitamin Be, vita-
min Be conjugate, and Lactobacillus casei factor
has been confirmed. Common to all these sub-
stances is the component pteroylglutamic acid,
the structure of which is shown above, now called
folic acid and identical with the structure of the
L. casei factor isolated from liver; most of the
factors, however, are conjugates of pteroylglu-
tamic acid with additional molecules of glutamic
acid, COOH.CH2.CH2.CH(NH2)COOH, which
are joined through peptide linkages. Thus, fer-
mentation L. casei factor is pteroyldiglutamyl-
glutamic acid (also called pteroyltriglutamic acid)
and vitamin Be conjugate is pteroylhexaglutamyl-
glutamic acid (also called pteroylheptaglutamic
acid). From such conjugates folic acid may be
liberated by enzymic action, as of conjugase, or
of Taka-Diastase. While many animal species
appear to be able to utilize the conjugates, there
is evidence that some species, as well as many
pernicious anemia patients, are unable to utilize
them.

Two methods of synthesis of pteroylglutamic
acid have been published (Waller et al., Ann.
N. Y. Acad. Sci., 1946, 48, 283; Hultquist et al.,
1947, 48, Art. 5, Supplement). In the first method
2,4,5-triamino-6-hydroxypyrimidine, 2,3-dibromo-
propionaldehyde, and ^-aminobenzoylglutamic
acid are simultaneously condensed. In the second
method the quaternary salt obtained by the inter-
action of pyridine and 2,3-dibromopropionalde-
hyde is added to an aqueous solution of 2,4,5-
triamino-6-hydroxypyrimidine dihydrochloride
containing potassium iodide; the N-[(2-amino-4-
hydroxy-6-pteridyl) methyl] pyridinium iodide
which separates is heated with />-aminobenzoyl-
glutamic acid and sodium methylate in ethylene
glycol solution to yield folic acid.

Description. — "Folic Acid occurs as a yellow
or yellowish orange, odorless, crystalline powder.
Folic Acid is very slightly soluble in cold water.
It is insoluble in alcohol, in acetone, in benzene,
in chloroform, and in ether. It readily dissolves
in dilute solutions of alkali hydroxides and car-
bonates, and is soluble in hot, diluted hydrochloric
acid and in hot, diluted sulfuric acid. It is soluble
in hydrochloric acid and in sulfuric acid, yielding
very pale yellow solutions. U.S.P. Folic acid is
stated to dissolve in water to the extent of about
10 mg. per liter; the sodium salt, however, dis-

584

Folic Acid

Part I

solves to the extent of more than 15 Gm. per liter.
Folic acid is not deliquescent, hydroscopic, or
efflorescent.

Standards and Tests. — Identification. — Folic
acid exhibits ultraviolet absorption maxima at 256
mn, 283 mn, and 369 mji, in 0.1 N sodium hy-
droxide; the ratio of the absorbancy at 256 ran
to that at 369 mn is between 2.83 and 3.05.
Specific rotation. — The specific rotation, calcu-
lated on an anhydrous basis, determined in a
solution in 0.1 N sodium hydroxide containing
50 mg. of folic acid in each 10 ml. is between
+ 18° and +23°. Water.— Not over 8.5 per cent,
determined by the Karl Fischer method. Residue
on ignition. — The residue from 100 mg. is negli-
gible. U.S.P. The B.P. specifies that a 1-cm. layer
of a 0.0015 per cent w/v solution of folic acid in
0.1 N sodium hydroxide shows absorption maxima
at 256 mji, 283 van, and 368 mn, with absorbancies
of about 0.825, 0.795, and 0.285, respectively, at
these wave lengths.

Assay. — Based on the method of Hutchings
et al. (J. Biol. Chem., 1947, 168, 705), the folic
acid is reduced in an acid solution with zinc
amalgam to cleave the pteroylglutamic acid into
p-aminobenzoylglutamic acid and a pteridine. The
former product, a primary aromatic amine, is
measured colorimetrically by the method of Brat-
ton and Marshall, in which the amine is diazotized
by the action of sodium nitrite in the presence of
acid, then coupled with N-(l-naphthyl) ethylene-
diamine to produce a red derivative the optical
density of which is measured at 550 m\x in a
suitable photoelectric colorimeter. An aliquot por-
tion of unreduced folic acid solution is treated
with the diazotizing and coupling solutions to
obtain the correction for free amine in the folic
acid sample. The reference curve employed in
calculating the results is prepared from U.S. P.
£ara-aminobenzoic acid reference standard, since
this substance gives the same color, when used in
mole-equivalent quantity, as does the ^-amino-
benzoylglutamic acid obtained from folic acid.
U.S.P. This procedure may be inapplicable for the
determination of folic acid in some mixtures; in
such cases the microbiological method proposed
by Teply and Elvehjem (/. Biol. Chem., 1945,
157, 303), or one of the modifications of this
method, may be found satisfactory.

Incompatibilities. — While folic acid appears
to be quite stable in dry combinations, it shows
a number of incompatibilities in solution. Whether
alone or in combination, the stability of folic acid
in solution drops as the pH is decreased below 6;
in neutral or alkaline solution folic acid is stable.
Certain factors of the vitamin B complex, and
also ascorbic acid, have a deleterious effect on
folic acid when present in aqueous media; con-
centrated solutions of sugars tend to overcome
this incompatibility. Scheindlin (Am. J. Pharm.,
1948, 120, 103), studying the compatibility of
folic acid in liquid prescriptions, found significant
inactivation of the substance in the presence of
sulfadiazine. Folic acid is prone to decomposition
by sunlight and ultraviolet light.

Solutions of folic acid may be prepared by add-

ing sufficient sodium hydroxide to an aqueous sus-
pension of the acid to convert it to the sodium
salt; an excess of alkali should be avoided. Other
alkalis may be used, as for example methyl-
glucamine. The N.N.R. recognizes sodium folate,
which is a water-soluble salt and is available in
1 ml. ampuls containing 15 mg. ; Sodium Folvite
(Lederle) is one of the commercially available
forms.

Uses. — Occurrence. — Folic acid is not plenti-
ful in the average human diet. It is found in yeast,
green vegetables (but storage and cooking often
destroy it), wheat, meat and liver. Intestinal bac-
teria normally form this vitamin. Only a small
portion is absorbed by the intestine (Spray, Clin.
Sc, 1952, 11, 425) but the daily requirement is
probably low, perhaps as little as 0.5 mg. Even
when dietary sources are inadequate it is prob-
able that normal intestinal flora will synthesize
sufficient for a healthy person. In food it is pres-
ent as inactive conjugates; the tissues contain
enzymes (conjugases) which split these natural
forms to free folic acid. Foods also contain con-
jugase inhibitors. The form active in nucleopro-
tein synthesis is probably folinic acid which is
formed from folic acid in the tissues. Human
breast milk contains about 0.71 microgram of
folic acid per liter and infant feeding formulas
containing 50 per cent of cow's milk will provide
a similar amount of the vitamin (Castle et al.,
J.A.M.A., 1951, 146, 1028). For normal hemato-
poiesis, folic acid, ascorbic acid and cyanocobala-
min are all essential. Following ingestion of 5 mg.
of folic acid Denko (J. Applied Physiol., 1951, 3,
559) observed a peak concentration in the blood
of about 10 micrograms per 100 ml. in 30 to 120
minutes, and often again after 4 hours; urinary
excretion of 35 to 75 per cent of the dose was
complete within 24 hours.

Biochemical Significance. — As discussed
under cyanocobalamin, folic acid is also involved
in the synthesis of nucleic acid in the body (see
Wright et al., Arch. Int. Med., 1953, 92, 357).
The precursors of folic acid include para-amino-
benzoic acid, glutamic acid and pteroic acid. Folic
acid is involved in the conversion of uracil to
thymine. In tissues folic acid is reduced to the
5,6,7,8-tetrahydro derivative; ascorbic acid is
essential to this reduction. A formyl group is
added by an unknown mechanism to form folinic
acid, also known as citrovorum factor and Leuco-
vorin. Folinic acid and perhaps folic acid are also
involved in the synthesis of the purines adenine
and guanine, and the pyrimidines cytosine, uracil
and thymine, from simpler precursors. Bound
cyanocobalamin (q.v.) is subsequently involved
in the formation of nucleosides, such as thymidine,
from the purines and pyrimidines by the addition
of a pentose, either ribose or desoxyribose. The
addition of phosphate then forms nucleotides and
polynucleotides and eventually nucleic acids,
which combine with protein to form the nucleo-
proteins essential for the function of all cells of
the body. Folic acid antagonists (q.v.) act in this
scheme to inhibit formation of folic acid or to
interfere with the conversion of folic to folinic
acid (citrovorum factor) which is so much more

Part I

Folic Acid

585

active in the formation of purines than is folic
acid.

The megaloblastic, macrocytic anemias may be
considered a metabolic deficiency of nucleopro-
tein because of a deficiency of the B vitamins,
particularly folic acid and cyanocobalamin (Nutri-
tion Rev., 1952, 10, 144). Such a vitamin de-
ficiency may arise from causes encountered in
other nutritional deficiencies, including: inade-
quate intake, gastrointestinal failure of absorption
(achylia gastrica, absence of intrinsic factor,
diarrhea, neoplasm, inflammation), increased re-
quirements (infection, scurvy, thyrotoxicosis, in-
jury), and failure to utilize (severe liver disease).
In the human folic acid deficiency is manifested
as megaloblastic anemia; subclinical deficiency no
doubt exists and inhibition of purine and pyrim-
idine synthesis may play an unrecognized role
in other disorders. The extensive literature on the
role of folic acid in normal cellular metabolism
has been reviewed briefly (Lederle Bull., 1952,
17, 39). The initial observation that chickens fed
a purified diet containing the then known factors
of the vitamin B complex — thiamine, riboflavin,
pyridoxine, pantothenic acid, biotin, nicotinic
acid, choline and inositol — developed a macro-
cytic, hyperchromic anemia led to studies on
rats. These animals thrived nicely on this syn-
thetic diet unless sulfaguanidine was added to
inhibit intestinal bacteria, when the anemia ap-
peared. In monkeys a seemingly related dietary
condition known as vitamin M deficiency has
been observed. Studies of the nutritional require-
ments of bacteria indicated that growth of Lacto-
bacillus casei in a synthetic medium required the
addition of a substance present in liver, yeast or
green leaves (Snell and Peterson, /. Bad., 1940,
39, 273). Similar studies with Streptococcus
lactis R (Mitchell et al., J.A.C.S., 1941, 63, 2284)
confirmed this finding; the investigators named
the essential factor folic acid. Isolation and crys-
tallization of the L. casei factor was followed by
demonstration of its efficacy in the macrocytic
anemia of chicks and the vitamin M deficiency
in monkeys (Day et al., Proc. S. Exp. Biol. Med.,
1938, 38, 860; Hutchings et al., J. Biol. Chem.,
1941, 140, 681). Further studies in animals de-
prived of 'folic acid demonstrated essentiality of
the factor in growth, reproduction, lactation,
normal tissue respiration, protein utilization, anti-
body formation and utilization of formate, serine,
tyrosine, ribosides, glycine and heme. Folic acid
is probably active through its more active deriva-
tive folinic acid or citrovorum factor, which has
been shown to be 5-formyl-5,6,7,8-tetrahydro-
pteroylglutamic acid. This conversion seems to be
roughly proportional to the intake of folic acid.
Conversion occurs in the liver and kidney and to
a lesser extent in the bone marrow. It is aug-
mented by ascorbic acid; xanthine oxidase is
involved in the conversion.

Transmethylation. — Both folic acid and
cyanocobalamin are involved in the essential pro-
vision of methyl groups in metabolism. The con-
cept of transmethylation initially involved the
transfer of a methyl group from choline to
homocystine to form methionine (duVigneaud

et al., J. Biol. Chem., 1939, 131, 57). Bacterial
synthesis in the intestine was suspected since
feeding succinylsulfathiazole inhibited the conver-
sion (Bennett et al., ibid., 1946, 163, 235). The
addition of crude, but not of refined, liver extract
to the diet neutralized the sulfonamide inhibition.
Later duVigneaud et al. (ibid., 1945, 159, 755)
demonstrated that the methyl group was actually
synthesized in the tissues even in germ-free rats
(J.A.C.S., 1951, 73, 2 782). The lipotropic activity
of a special crude liver extract in patients with
cirrhosis of the liver suggested a similar metabolic
pathway in the human (Labby et al., J. A.M. A.,
1947, 133, 1181). Further animal studies showed
that the lipotropic action was not due to the
choline content of the liver extract (Hall et al.,
Proc. S. Exp. Biol. Med., 1948, 69, 3; J. A.M. A.,
1953, 151, 1; Gyorgy and Goldblatt, J. Exp.
Med., 1949, 90, 73). A similar lipotropic effect
of cyanocobalamin was observed by Drill and
McCormick (Proc. S. Exp. Biol. Med., 1949, 72,
388) and a sparing effect of vitamin B12 on the
choline and methionine requirement of animals
was noted (Schaefer et al., ibid., 71, 193). It
could be concluded that both cyanocobalamin and
folic acid were essential for the normal formation
of methyl groups in metabolism (Stekol et al.,
Arch. Biochem., 1952, 35, 5). Further studies
employing compounds labeled with the radio-
active isotope carbon- 14 showed that formate was
utilized in forming the methyl groups of choline
and of methionine (Welch and Sakami, Fed.
Proc, 1950, 9, 245), that the beta carbon of
serine was converted to the labile methyl group
of choline (Jansson and Mosher, J.A.C.S., 1950,
72, 3316), and that the alpha carbon of glycine is
converted to the beta carbon of serine and thence
to choline (Weissbach et al., ibid., 3317). Folic
acid is essential for the utilization of formate
(Plaut et al., J. Biol. Chem., 1950, 184, 795) and
in the form of citrovorum factor for the methyla-
tion of uracil to form thymine (see Jukes' B-Vita-
mins for Blood Formation, 1952, p. 94).

Therapeutic Uses. — Folic acid is indicated in
the treatment of the macrocytic, megaloblastic
anemias except primary pernicious anemia in
which it corrects the anemia but does not prevent
or alleviate the neurological deterioration of this
disease (Conley and Krevans, New Eng. J. Med.,
1951, 245, 529). Although a synergistic action
of folic acid and cyanocobalamin in pernicious
anemia has been reported (Reisner and Weiner,
ibid., 1952, 247, 15), the major therapeutic action
in such a combination is that of the folic acid
component since the cyanocobalamin is poorly
absorbed in such patients. If the diet is adequate,
sufficient folic acid will be available. In the pres-
ence of adequate doses of cyanocobalamin (par-
enterally or orally) in combination with intrinsic
factor, folic acid is not harmful as was feared
when the progression of neurological damage de-
spite a normal blood count was first observed
during treatment with folic acid alone (Harvey
et al, New Eng. J. Med., 1950, 242, 446). It is
noteworthy, however, that satisfactory clinical
response to citrovorum factor, in an oral dose of
10 mg. daily, was reported in some cases of

586

Folic Acid

Part I

pernicious anemia with neurological abnormality
(»i.).

The other macrocytic anemias are character-
ized by the absence of neurological manifesta-
tions, by good response to folic acid (or folinic
acid) and, in many varieties, poor or no hemato-
poietic response to cyanocobalamin parenterally
or orally (Nieweg et al., Acta med. Scandinav.,
1952, 142, 45). Hence, folic acid is the treatment
of choice in megaloblastic anemia unless the pos-
sibility of primary pernicious anemia cannot be
eliminated in the etiological diagnosis. These
macrocytic anemias include those of postgastrec-
tomy or other gastrointestinal surgery, sprue,
idiopathic steatorrhea, nutritional deficiency, preg-
nancy, and infancy. After gastric resection neuro-
logic symptoms are rare; should they occur
cyanocobalamin is indicated. In sprue, cyanoco-
balamin orally is ineffective (Rivas et al., Ann.
Int. Med., 1952, 36, 583) and some cases do not
respond to intramuscular doses (Cohen et al.,
ibid., 1533); oral doses of 10 to 15 mg. of folic
acid daily are effective in relieving the anemia
and symptoms but Rivas et al. (ibid., 1076) rec-
ommended the use of both folic acid and cyanoco-
balamin in addition to maintaining an adequate
diet. In addition to improvement in the form of
the stools and some decrease in frequency of
defecation, Badenoch (Lancet, 1952, 1, 233) re-
ported increased absorption of fat. In idiopathic
steatorrhea (non-tropical sprue), folic acid was
effective whereas the response to liver therapy
was incomplete (Conway, Brit. M. J., 1952, 1,
1098). In nutritional macrocytic anemia, folic
acid was found to be effective (Cohen et al.,
loc. cit.).

In megaloblastic anemia of pregnancy, folic
acid was effective (Israels and DaCunha, Lancet,
1952, 2, 214) whereas cyanocobalamin was inert.
An oral dose of 20 mg. daily is indicated until the
blood count has been normal for a month; in
severely anemic cases. 30 mg. daily intramuscu-
larly or 100 mg. in 250 ml. of isotonic sodium
chloride solution intravenously is suggested, par-
ticularly in the last trimester of pregnancy. "While
iron therapy is ineffective, iron is indicated in
most of these patients because of their previously
inadequate diet in an effort to prevent develop-
ment of hypochromic anemia as the megaloblastic
anemia responds to the folic acid. An adequate
dietary intake of protein, minerals and vitamins
is most important. Ritchie (/. Clin. Path., 1952,
5, 329) described a transient leukemoid response
to treatment with folic acid in these cases. In
most cases of nutritional deficiency the inade-
quate diet has been composed mainly of carbo-
hydrate. Many of these malnourished persons are
not anemic but if infection or other stressful con-
ditions are present in men or non-pregnant women
the anemia is apt to be of the hypochromic,
erythroblastic type. In other words there is a
deficiency of protein and iron but the intestinal
flora have provided sufficient folic acid to permit
maturation of the megaloblasts in the bone mar-
row. The simple designation "iron-deficiency
anemia" should be enlarged to the term "protein-
iron deficiency" to call attention to the important
and often neglected protein deficiency. In preg-

nancy, however, the demand for increased blood
volume and for fetal blood formation is tre-
mendous and may exhaust the available supply of
folic acid. The iron deficiency, though present,
becomes of lesser importance and the anemia is
that of a protein-folic acid deficiency.

In the megaloblastic anemia of infancy, folic
acid in doses of 5 mg. orally daily for two weeks
is effective (Woodruff and Peterson, Postgrad.
Med., 1951, 10, 189). After satisfactory response
in either infancy or pregnancy, continuation of
folic acid therapy is unnecessary. Ascorbic acid,
which is essential for the proper utilization of
folic acid, is often deficient in cases of megalo-
blastic anemia of infancy and should be pre-
scribed even though a frank diagnosis of scurvy
cannot be made (Castle et al., J. A.M. A., 1951,
146, 1028). Since most of these infants have
experienced inadequate pre- and post-natal nutri-
tion, iron therapy is usually indicated as a pro-
phylactic measure against hypochromic anemia
during the rapid red cell regeneration and growth
following the use of folic acid. The infant of a
mother with megaloblastic anemia of pregnancy
is likely to suffer from this type of malnutrition,
particularly if the baby is dependent on the mal-
nourished mother's milk supply (Spies et al.,
J.A.M.A., 1952, 148, 1376); in fact, folic acid
therapy of the mother will show rapid correction
of the infant's anemia. Intercurrent infection is
often present to aggravate the infant's malnutri-
tion. During severe and prolonged infections in
infants dietary supplements including folic acid,
cyanocobalamin and ascorbic acid are important
prophylactic items. Anemia associated with goat's
milk diet in an infant responded to treatment
with folic acid (Launay and Bernard, Presse
med., 1950, 58, 872).

Citrovorum Factor (Folinic Acid, Leuco-
vorin). — As pointed out above, folic acid exists
in tissues in the form of an active derivative (or
derivatives) variously referred to as citrovorum
factor (abbreviated CF). folinic acid, and Leuco-
vorin. By reduction of folic acid in the presence
of formic acid, Shive et al. (J.A.C.S., 1950, 72,
2817) and Brockman et al. (ibid., 4325) obtained
a crystalline substance, identified as 5-formyl-5,6,-
7,8-tetrahydrofolic acid (Pohland et al., J.A.CS.,
1951, 73, 3247; Roth and others, ibid., 1952, 74,
3247, 3252, 3264), which has the biological ac-
tivity of products isolated from natural sources.
It would appear that all these substances, if not
actually identical, are closely related. It is prob-
able, however, that reduced formyl derivatives of
other folic acid compounds (see beginning of this
article) exist. Moreover, the presence of an asym-
metric carbon atom in citrovorum factor has been
noted by May et al. (ibid., 1951, 73, 3067) and
it has been suggested that the synthetic compound
is a racemic mixture in which only one isomer is
biologically active. CF is an acidic compound
(Lyman and Prescott, /. Biol. Chem., 1949. 178,
523); it is stable in neutral or slightly alkaline
solution, and on steaming for 30 minutes (Bro-
quist et al., Proc. S. Exp. Biol. Med., 1949, 71,
549). It is rapidly destroyed in acid (pH 2) solu-
tion but even in dilute acid a conversion occurs
to a compound without activity for Leuconostoc

Part I

Folic Acid

587

citrovorum but which retains activity for the
growth of Lactobacillus casei and Streptococcus
fcBcalis (Jukes et al, Arch. Biochem., 1950, 26,
157). It resists oxidation.

All bacteria and animals requiring folic acid
can thrive on citrovorum factor (Hill and Briggs,
Proc. S. Exp. Biol. Med., 1951, 76, 417). Certain
bacteria, such as Leuconostoc citrovorum, require
citrovorum factor instead of folic acid. CF is
more active parenterally than orally. As discussed
under cyanocobalamin, CF is essential for nucleo-
protein synthesis, particularly of thymidine, and
also for transmethylation (v.s.). Cytological
studies of Swendseid et al. (I. Biol. Chem., 1951,
190, 791) found CF uniformly distributed in all
portions of the liver cell whereas vitamin B12
was found only in the mitochondria. Bound forms,
comparable to folic acid conjugates, exist and are
released by a conjugase enzyme found in many
tissues (Hill and Scott, Fed. Proc, 1951, 10, 197).

CF accounts for part of the total folic acid
activity of human urine (Register et al., Proc. S.
Exp. Biol. Med., 1951, 77, 837); the concentra-
tion of CF is related to intake of folic acid (Anker
et al., Fed. Proc, 1950, 9, 351) and also to purine
intake. The amount in the urine averages less
than 0.1 mg. per 100 ml. (Broquist et al., J. Lab.
Clin. Med., 1951, 38, 95). Although urinary excre-
tion is increased following ingestion of folic acid,
only about 0.1 per cent of the dose is recovered
in this form (Sauberlich, /. Biol. Chem., 1949,
181, 467). The liver of animals deficient in folic
acid shows a marked decrease in the concentration
of CF but retains the ability (in vitro) to convert
folic acid to CF (Nichol and Welch, Proc S. Exp.
Biol. Med., 1950, 74, 52). In vitro the folic acid
antagonist Aminopterin (Lederle) inhibits con-
version of folic acid to citrovorum factor and
in vivo decreases urinary excretion of CF. As
noted in the schema of Wright et al. (Arch. Int.
Med., 1953, 92, 357), discussed under cyanoco-
balamin, ascorbic acid is essential in the conver-
sion of folic acid to CF. The administration of
ascorbic acid alone does not increase urinary CF
but simultaneous ingestion of ascorbic acid and
folic acid results in a marked rise in urinary CF
(Welch et al, Pharmacol, 1951, 103, 403). In
patients with scurvy only traces of CF are found
in the urine and there is no increase after inges-
tion of folic acid, alone or with ascorbic acid.
In vitro, however, ascorbic acid increases con-
version of folic acid to citrovorum factor. In
promoting growth of L. citrovorum on synthetic
media other reducing agents, such as glutathione
and thioglycollic acid, were as effective as ascorbic
acid but in promoting conversion of folic acid to
folinic acid only ascorbic acid or glucoascorbic
acid was effective. An increase in the amount of
folic acid in the liver follows ingestion of ascorbic
acid, presumably by an action on intestinal bac-
teria (Dietrich et al, J. Biol. Chem., 1949, 181,
915).

A megaloblastic anemia was produced in mon-
keys, comparable to cases observed in human
infants using certain prepared feeding formulas,
by feeding a milk diet low in both ascorbic acid
and folic acid (May et al, Am. I. Dis. Child.,
1951, 82, 282). Since CF was much more effective

than folic acid in correcting this anemia (I. Lab.
Clin. Med., 1950, 36, 963), it was suggested that
the anemia arose from lack of conversion of folic
acid to CF in this ascorbic acid deficiency state.
The tendency of patients with pernicious anemia
to relapse during seasons of low ascorbic acid
intake in the diet is mentioned in the discussion
of Liver Extract Injection. In tissue cultures of
bone marrow from patients with pernicious ane-
mia, Callender and Lajtha (/. Clin. Path., 1951,

4, 204) reported that 0.1 microgram per ml. of
CF caused conversion from megaloblastic to
normoblastic marrow, whereas the same amount
of folic acid failed to produce this change in
cellular characteristics. Megaloblastic anemia in
scurvy may be due to a deficiency of CF but
neither folic acid nor CF benefit other manifes-
tations of ascorbic acid deficiency. Cyanoco-
balamin also probably plays a role in the con-
version of folic acid to CF (Dietrich et al, Proc.

5. Exp. Biol Med., 1949, 181, 915) but the
mechanism remains to be elucidated. In experi-
mental deficiency of folic acid and cyanocobala-
min, the latter increases the conversion of folic
acid to CF in the liver. The administration of
thyroid to normal rats, but not folic acid-deficient
rats, increases the urinary excretion of CF (Drys-
dale et al, Arch. Biochem., 1951, 33, 1), sug-
gesting an increased requirement for the vitamin
in hyperthyroidism. Macrocytic anemia is found
in some patients with myxedema.

The greater activity of CF, as compared with
folic acid, in reversing the antimetabolite effect
of anti-folic acid compounds suggests that the site
of antimetabolite action is the conversion of folic
acid to CF. This has been observed with L. citro-
vorum (Sauberlich, Arch. Biochem., 1949, 24,
224), other bacteria, insects (Goldsmith and
Harnly, Cancer Res., 1951, 11, 251), mice and
rats (Burchenal and Babcock, Proc. S. Exp. Biol.
Med., 1951, 76, 382), chickens (Cravens and
Snell, ibid., 1950, 75, 43) and monkeys (May
et al, J. Lab. Clin. Med., 1950, 36, 963). CF is
most effective in this respect when administered
simultaneously with the anti-folic acid congener.
Aminopterin is most effective against rapidly
growing cells — embryo and carcinoma (Karnofsky
et al, Proc. S. Exp. Biol. Med., 1949, 71, 447;
Thiersch and Philips, ibid., 1950, 74, 204). In
chick embryos, thymidine reverses Aminopterin
action while thymine and hypoxanthine do not
(Snell and Cravens, ibid., 87). Desoxyribonucleic
acid partially corrects the toxicity of Aminopterin
in mice (Skipper et al, Cancer, 1951, 4, 357).
The several anti-folic compounds seem to be anti-
citrovorum factor rather than anti-folic in action
(Karnofsky, Merck Rep., 1951, 60, 4). Both in-
terference with conversion of folic acid to CF
and competition with CF in biochemical reactions
seem probable (Greenspan et al, Cancer, 1951,
4, 619; Nichol and Welch, Proc. S. Exp. Biol.
Med., 1950, 74, 403). Oxytetracycline neutralizes
the toxicity of Aminopterin in rats (Waisman
et al, ibid., 1951, 76, 384) and Schwarz (Fed.
Proc, 1951, 10, 394) reported a marked increase
of CF in the contents of the colon of such animals.

Clinical Applications of Citrovorum Fac-
tor.— In general those megaloblastic anemias

588

Folic Acid

Part I

which respond to folic acid also respond to CF.
In pernicious anemia, Ellison et al. (Proc. S. Exp.
Biol. Med., 1951, 76, 366) found 1.5 mg. daily,
administered intramuscularly, to be insufficient.
Meyer et al. (ibid., 86) and also Jarrold et al.
(Science, 1951, 113, 688) reported an incomplete
response to 3 mg. daily, although some cases re-
sponded to 1.5 mg. A single intramuscular dose
of 12 mg. produced an incomplete response
(Davidson and Girdwood, Lancet, 1951, 1, 722).
Spies et al. (South. M. J., 1950, 43, 1076) re-
ported response in some cases with a dose of
3 mg. daily for 10 days. In cases with neuro-
logical manifestations hematological improvement
occurred with 6 mg., but not with 3 mg., given
intravenously daily (Meyer and Diefenbach, Am.
J. Clin. Path., 1951, 21, 1054). A good response
with 10 mg., but not with 5 mg., administered
orally daily was observed by Moore et al. (N. Y .
State J. Med., 1951, 51, 2645). Watson et al.
(Am. J. Med., 1954, 17, 17) concluded that citro-
vorum factor, like folic acid, was contraindicated
in primary pernicious anemia because of the fail-
ure to prevent progression of neurological damage
but that megaloblastic anemias in patients able
to secrete gastric hydrochloric acid, which often
fail to respond to cyanocobalamin, are usually
corrected by CF therapy. In pernicious anemia
Thedering and Tiethmuller (Deutsche vied.
Wchnschr., 1953, 78, 1470) reported good long-
term results with 40 micrograms of cyanoco-
balamin and 13 mg. of CF intramuscularly every
2 weeks. A specific deficiency of CF, rather than
of folic acid, has not been recognized, unless it
be the megaloblastic anemia of scurvy since as-
corbic acid is required for normal conversion of
folic acid to CF. In the megaloblastic anemia of
infancy, Woodruff et al. (Proc. S. Exp. Biol. Med.,
1951, 77, 16) found 75 micrograms daily, given
parenterally, to be effective. In sprue, Romero
et al. (Am. J. Med. Sc, 1952, 224, 9) reported
incomplete response to daily intramuscular doses
of 0.1 or 0.4 mg. but complete clinical and he-
matological response occurred with 1 mg. daily
for 12 days; CF, like folic acid, controlled the
diarrhea and other gastrointestinal symptoms as
well as the megaloblastic anemia in contrast to
the lack of effect of cyanocobalamin on the gastro-
intestinal disorder of this syndrome.

In correcting the toxic effects, particularly
ulcerative stomatitis, during Aminopterin therapy
of leukemia. CF has proven very effective (Earle
et al., J. Pediatr., 1951, 39, 560; Schoenbach
et al., J.A.M.A., 1950, 144, 1558). Doses of 1.5
to 9 mg. daily, orally or intramuscularly adminis-
tered, were employed.

Toxicology. — The most significant untoward
effect of folic acid is the development of neuro-
logical damage during its administration to un-
diagnosed cases of primary pernicious anemia.
Prolonged use in non-anemic and non-diabetic
older persons caused no symptoms and no changes
in the blood (Poliakoff et al., Proc. S. Exp. Biol.
Med., 1949, 72, 392). An instance of hyper-
sensitivity to the intravenous injection has been
reported (Mitchell et al., Ann. Int. Med., 1949,
31, 1102).

Dose. — The usual dose of folic acid is 10 mg.

(approximately Va grain) daily, orally or paren-
terally, with a range of 5 to 10 mg. A maximum
safe dose has not been established; as much as
100 mg. has been given intravenously, slowly and
well diluted.

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S. P.

FOLIC ACID CAPSULES. U.S.P.

"Folic Acid Capsules contain not less than 90
per cent and not more than 115 per cent of the
labeled amount of C19H19N7O6." U.S.P.

Usual Size. — 5 mg.

FOLIC ACID INJECTION. U.S.P.

"Folic Acid Injection is a sterile solution of
folic acid in water for injection prepared with the
aid of sodium hydroxide or sodium carbonate. It
contains not less than 95 per cent and not more
than 110 per cent of the labeled amount of
C19H19N7O6." U.S.P.

Solution Sodium Folate. Solution Sodium Folvite (Lederle).

Description. — "Folic Acid Injection is a
clear, yellow to orange-yellow, alkaline liquid.
The pH of Folic Acid Injection is between 8 and
11." U.S.P.

Usual Size.— 15 mg. in 1 ml.

FOLIC ACID TABLETS. U.S.P.

"Folic Acid Tablets contain not less than 90
per cent and not more than 115 per cent of the
labeled amount of C15H15N7O6." U.S.P.

Usual Size. — 5 mg.

FORMALDEHYDE SOLUTION.
U.S.P. (B.P., LP.)

[Liquor Formaldehydi]

"Formaldehyde Solution contains not less than
37 per cent of HCHO, with methanol added to
prevent polymerization." U.S.P. The B.P. recog-
nizes Solution of Formaldehyde as an aqueous
solution, with a variable amount of ethyl alcohol
or methyl alcohol or both. It contains not less
than 37 per cent w/v and not more than 41
per cent w/v of CH2O. The LP. requires not less
than 35.0 per cent and not more than 36.5 per
cent w/w, or not less than 38.0 per cent and not
more than 40.0 per cent w/v of formaldehyde
(CH2O) and polymers with a variable amount of
methanol.

B.P. Solution of Formaldehyde. LP. Solutio Formalde-
hydi. Formol; Formalin (Schering & Glatz). Formalde-
hydum Solutum; Formaldehyd Solutus; Solutio Formal-
dehydi. Fr. Solute officinale de formaldehyde; Formaline.
Ger. Formaldehydlosung. It. Soluzione di aldeide formica ;
Formolo; Formalina. Sp. Solucion de formaldehido.

Formaldehyde was first prepared in 1868 by
Hofmann by passing a mixture of air and methyl
alcohol vapor over heated platinum, and it is still
commercially obtained chiefly from the oxidation
of methyl alcohol in the presence of various
catalysts, such as copper gauze, mixed iron and
molybdenum oxides, vanadium pentoxide, etc.
Solutions containing 30, 35, or 40 per cent of
formaldehyde are thus prepared, the remainder
consisting chiefly of water and methyl alcohol.

Part I

Formaldehyde Solution 589

Formaldehyde has also been prepared by reduc-
tion of formic acid. Anhydrous formic acid vapors
are conducted over asbestos mixed with zinc oxide
and powdered zinc. The methyl formate thereby
obtained is subsequently decomposed into methyl
alcohol and formaldehyde. Other methods which
have been used to prepare formaldehyde involve
oxidation of methane, or hydrogenation of carbon
monoxide.

Formaldehyde, a colorless gas at ordinary tem-
peratures and pressures, has a pronounced tend-
ency to polymerize, forming solid compounds of
indefinite molecular weight, the mixture of which
is known as paraformaldehyde. The aqueous so-
lution of formaldehyde probably contains some
paraformaldehyde, and some unconverted methyl
alcohol is always present which is allowed to
remain because of the effect it has of retarding
polymerization. This change, which sometimes
occurs in solutions of formaldehyde when exposed
to low temperatures, is accompanied by the depo-
sition of a white precipitate.

Description. — "Formaldehyde Solution is a
clear, colorless or nearly colorless liquid, having
a pungent odor. The vapor from Formaldehyde
Solution irritates the mucous membrane of the
throat and nose. On long standing, especially in
the cold. Formaldehyde Solution sometimes be-
comes cloudy, due to the separation of paraform-
aldehyde. Formaldehyde Solution is miscible with
water and with alcohol." U.S.P. The B.P. gives
the weight per ml., at 20°, as from 1.076 to 1.091.

Standards and Tests. — Identification. — (1)
Metallic silver, either as a finely divided, gray
precipitate, or as a bright, metallic mirror, is pro-
duced on adding 1 ml. of silver ammonium nitrate
T.S. to 2 ml. of formaldehyde solution diluted
with 10 ml. of water. (2) A permanent, deep red
color forms on adding 2 drops of formaldehyde
solution to 5 ml. of sulfuric acid containing 20
mg. of salicylic acid and warming gently. Acidity.
— Not more than 1 ml. of 1 N sodium hydroxide
is required to neutralize a mixture of 20 ml. of
formaldehyde solution and 20 ml. of water, using
bromothymol blue T.S. as indicator. U.S.P.

The B.P. identity test specifies addition to 10
ml. of a 1:1000 dilution of solution of formalde-
hyde 2 ml. of freshly prepared 1 per cent w/v
aqueous solution of phenylhydrazine hydrochlo-
ride, 1 ml. of solution of potassium ferricyanide,
and 5 ml. of hydrochloric acid: a brilliant red
color results.

Assay. — About 3 ml. of formaldehyde solu-
tion is weighed into water, mixed with an excess
of 1 N sodium hydroxide solution, and the form-
aldehyde oxidized to formic acid by heating with
hydrogen peroxide T.S. The excess of alkali is
determined by titration with 1 N sulfuric acid,
using bromothymol blue T.S. as indicator. Each
ml. of 1 N sodium hydroxide represents 30.03 mg.
of CH2O. U.S.P.

In the B.P. assay, which utilizes the same reac-
tion as does the U.S.P., phenolphthalein is used
as the indicator.

The B.P. also specifies that: "The use of the
name Formalin as a synonym for Solution of
Formaldehyde is limited to Great Britain and
Northern Ireland. In parts of the British Empire

in which the word Formalin is a trade mark it
may be used only when applied to the product
made by the owners of the trade mark."

Formaldehyde possesses the property of mak-
ing gelatin and glue insoluble in water, and is
thus used in many technical applications, such as
tanning. It has the same use for waterproofing
wool and textiles made from animal staples. Its
reaction with phenol in the production of plastics
and synthetic resins utilizes large amounts of
formaldehyde. As a reducing agent it is especially
useful in certain dyeing operations. It has also
been used as an alcohol denaturant.

Because of the possible use of formaldehyde
as a preservative of milk and other food products
the detection of small amounts of it is a matter
of great importance. Several of the tests pro-
posed are primarily applicable to milk only, being
based on reactions which take place in the pres-
ence of milk proteins, so that if these tests are
to be applied in testing other liquids for the pres-
ence of formaldehyde, the material must be mixed
with an equal quantity of milk which has been
shown previously to be free from formaldehyde.

Paraformaldehyde. — Under this title the
U.S.P. X recognized " trioxy methylene," a polymer
of formaldehyde. More properly this should be
referred to as a mixture of polyoxymethylenes,
for there are generally many more than three
formaldehyde groups involved in the polymeriza-
tion; from ten to one hundred molecules may be
polymerized.

Paraformaldehyde is always produced to a
greater or less extent when solutions of formalde-
hyde are allowed to evaporate. The change from
the ordinary into the polymeric form also takes
place at low temperatures, especially when the
solution is free from methyl alcohol. Sulfuric acid
also induces polymerization.

It occurs in white friable masses, or a white
powder, having a slight odor of formaldehyde.
Paraformaldehyde is very slowly soluble in cold
water, more readily soluble in hot water with the
formation of formaldehyde; insoluble in alcohol
and in ether; soluble in solutions of fixed alkali
hydroxides. Paraformaldehyde, when heated, is
partly converted into formaldehyde and partly
sublimed unchanged. For other tests and assay
see U.S.D., 21st ed., p. 816.

Paraformaldehyde is employed as a convenient
form for generating small quantities of formalde-
hyde gas for disinfecting purposes. It may be used
for this purpose in the proportions of 1 to 2 Gm.
for each cubic yard of air space.

On distilling formaldehyde from a 60 per cent
solution containing 2 per cent sulfuric acid it
polymerizes to a crystalline cyclic trimer trioxane,
entirely different from paraformaldehyde, which
may be extracted from the distillate with methyl-
ene chloride. The trimer may be depolymerized
by heating, and represents a convenient source of
anhydrous, gaseous formaldehyde for synthetic
reactions.

Uses. — Disinfectant. — The use of formalde-
hyde was introduced by Trillat in 1888. Its solu-
tions are approximately equivalent, in germicidal
activity, to those containing the same percentage
concentrations of phenol. Burgess found that a

590 Formaldehyde Solution

Part I

2 per cent solution of formaldehyde kills E. coli
communis in five minutes; Slater and Rideal
found that a one per cent solution destroys vari-
ous nonsporulating organisms in 50 minutes. In
sufficient concentration it is an effective germi-
cide against all organisms, the higher the concen-
tration the more rapid being the effect. Its bac-
teriostatic action is marked; in Slater and Rideal's
experiments a 1:5000 solution absolutely inhib-
ited, and a 1:20,000 solution greatly retarded,
the growth of bacteria.

Because of its local irritant effect formaldehyde
is rarely used for disinfection of body tissues.
Excreta may be disinfected by application of an
equal volume of a 10 per cent solution; articles
of clothing, and surgical instruments and gloves,
may be soaked for one-half to one hour in a 5 or
10 per cent solution of formaldehyde. An inter-
esting use of formaldehyde has been the applica-
tion of a 5 per cent solution for sterilization of
the eggs of flesh flies employed to obtain sterile
maggots for surgrcal use; 1 per cent of sodium
hydroxide is used in the solution to prevent agglu-
tination. Formaldehyde solution is also an effec-
tive deodorizer.

Fumigant. — In the past formaldehyde vapor
was extensively used for disinfection of rooms
and other closed spaces. Various methods of effect-
ing vaporization of the substance were employed,
these including (1) spontaneous evaporation of
a solution sprinkled or sprayed about the space,
(2) heating of the official solution, (3) evolution
of the gas through the heat generated by the
oxidation of a portion of formaldehyde by potas-
sium permanganate, sodium dichromate. chlori-
nated lime, and (4) heating of paraformaldehyde.
The efficiency of the fumigation is dependent not
only on concentration of formaldehyde, but also
on time of exposure, temperature and humidity.
For a study of the chemical efficiency of the sev-
eral oxidation methods for generating formalde-
hyde and of the humidity required and attainable
in the several processes see Horn and Osol {Am.
J. Pharm., 1929. 101, 741). Depending on the
several variables of the fumigation process, from
1 to 2 pints of the official formaldehyde solution
is required for the disinfection of each 1000 cubic
feet of space. Formaldehyde is rarely used in this
manner today, room fumigation being by many
authorities considered of questionable value.

Action ox Protein. — Formaldehyde reacts
with proteins by a complex process involving at
least the amino groups and resulting in the hard-
ening and precipitation of the proteins. Thus,
gelatin capsules may be hardened and their dis-
integration thereby delayed after treatment with
formaldehyde; this hardening effect, which is
accompanied by decreased solubility in aqueous
media, progressively increases after the treat-
ment. The use of formaldehyde as a fixing fluid
in histological studies involves the same reaction.
Formaldehyde is employed in embalming fluids
but Weed and Baggenstoss (Proc. Mayo, 1952,
27, 124) reported that embalming does not de-
stroy all virulent bacteria in tissues. Another
practical application of the reaction between
formaldehyde and protein is in the Sprensen
"formol titration" in which the basic effect of

amino groups is suppressed through combination
with formaldehyde while permitting neutralization
of acidity due to carboxyl groups, such as are
formed in the hydrolysis of proteins (see the
assay of Aminoacctic Acid Elixir and the B.P.
assay for trypsin in Pancreatin). Still another
useful property of formaldehyde which may de-
pend on this same reaction is its detoxifying
action in converting toxins, as that of diphtheria,
into toxoids, and the killing of viruses, without
changing their antigenic power significantly, for
preparing vaccine (see Poliomyelitis Vaccine, in
Part IIj.

Topical Use. — Various skin diseases have been
treated by local applications of formaldehyde.
One per cent of the official solution, in a vehicle
of an aqueous jelly prepared from starch, has
been applied to dry eczema; dusting powder con-
taining formaldehyde has been used for weeping
eczemas. Applied 1 to 2 times daily for 1 or more
weeks as full strength solution, or in suspension
in collodion, or 3 to 6 ml. per 15 Gm. Aquaphor,
it has been used to remove warts, corns, moles,
etc. (Lynch and Karon. Arch. Derm. Syph., 1950,
62, 803). Ringworm has been claimed to be cured
by one application of solution. A 1 to 2 per cent
paint has been found useful in treating tonsillitis,
ozena, and tubercular laryngitis; aphthous ulcer-
ation of the mouth has been treated with stronger
solutions dispersed in collodion. Preliminary ap-
plication of local anesthetic is necessary when
stronger solutions are employed. A 1:1000 to
1 : 500 solution has been used in purulent oph-
thalmia and trachoma as an eye wash; such appli-
cation is very painful. Dilute solutions of formalde-
hyde have also been employed as a vaginal douche
and as an application to ivy poisoning. Diluted
with 1 to 3 volumes of water, the official solution
has found use as a skin hardener and irt the treat-
ment of hyperhidrosis.

Inhalations of formaldehyde vapor have been
employed in the treatment of pulmonary dis-
orders, notably phthisis, with the aim of direct
destruction of bacteria; the treatment is so irri-
tant to mucous membranes that it probably does
more harm than good. |vj

Toxicology. — Although its physiological ac-
tion is comparatively slight, formaldehyde solu-
tion, when swallowed, is a dangerous poison be-
cause of its local irritant effects. Symptoms of
poisoning include immediate severe abdominal
pains with blood-stained vomiting, and albumi-
nous, bloody or suppressed urine. Following ab-
sorption, formaldehyde depresses the central nerv-
ous system; vertigo, depression and coma may be
observed. Severe acidosis may result through
oxidation of formaldehyde to formic acid. Out
of 10 cases collated by McLoughlin (Cleveland
M. J., 1909) three ended fatally. The smallest
fatal dose of which we have knowledge is that of
the case reported by Eli (J. A.M. A., 54). in which
"a few drops of 40 per cent solution of formalde-
hyde" killed a three-year-old child with symptoms
of edema of the larynx. About one fluidounce of
the official solution may be fatal to an adult.
Diagnosis is usually easy through detection of the
odor of formaldehyde in the vomitus. Treatment
consists of immediate evacuation of the stomach,

Part I

Gallamine Triethiodide

591

administration of dilute ammonia water as an
antidote, followed by demulcents. If depression
of the central nervous system is severe, stimu-
lants should be given; shock therapy may be
necessary.

As a disinfectant from 10 per cent of the offi-
cial solution to the full strength solution is used
on inanimate objects. For external use on the skin
or mucous membranes 0.5 to 20 per cent concen-
trations of the official solution are used.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not below 15°." U.S. P.

BASIC FUCHSIN. N.F.

"Basic Fuchsin is a mixture of rosaniline and
pararosaniline hydrochlorides." N.F.

Basic Magenta.

When a mixture of equimolecular quantities of
aniline, o-toluidine and p-toluidine is oxidized,
there is produced the triphenylmethane dye called
rosaniline; simultaneously there is produced some
pararosaniline, which represents the reaction prod-
uct of two moles of aniline and one mole of
^-toluidine. The hydrochloride of the mixed reac-
tion product is basic fuchsin. This substance is
not to be confused with acid fuchsin, which is a
mixture of sodium and ammonium salts of ros-
aniline disulfonic acid and rosaniline trisulfonic
acid.

Description. — "Basic Fuchsin occurs as a
dark green powder or greenish glistening crystal-
line fragments having a bronze-like luster, and
not more than a faint odor. Basic fuchsin is solu-
ble in water, in alcohol, and in amyl alcohol. It is
insoluble in ether." N.F.

Standards and Tests. — Identification. — (1)
Acidification of a 1 in 1000 solution of basic
fuchsin with hydrochloric acid produces a yellow
color (distinction from acid fuchsin). (2) A red
precipitate is produced on adding tannic acid T.S.
to a 1 in 500 solution of basic fuchsin. (3) A solu-
tion of basic fuchsin alkalinized with ammonia is
decolorized with zinc dust; when a few drops of
the decolorized solution is placed on a filter paper,
adjacent to some dilute hydrochloric acid, a red
color develops at the zone of contact. Loss on
drying. — The limit is 5 per cent, when dried at
105° to constant weight. Residue on ignition. —
Not over 0.3 per cent. Alcohol-insoluble sub-
stances.— Not over 1 per cent. Arsenic. — 200 mg.
meets the requirements of the official test. Lead. —
200 mg. meets the requirements of the official
test. N.F.

Uses. — Basic fuchsin is officially recognized
because of its use as an ingredient of carbol-
fuchsin solution (Castellani's paint), which is em-
ployed as an antifungal topical application.

According to May (J.A.M.A., 1913, 90) fuchsin
is a powerful germicide comparable to phenol in
efficiency; like many other dyes it also stimulates
granulation and epithelization. Favorable reports
concerning the usefulness of basic fuchsin in
treating varicose ulcers, burns and granulating
wounds of various kinds have appeared. Good
results have been reported from its use in various
skin diseases, especially impetigo. It is used in a

concentration of about 1 per cent, either as an
ointment or an aqueous solution.

Deschiens and Lamy (Compt. rend. soc. biol.,
1944, 138, 203) reported that a 1:1000 solution
of basic fuchsin killed Endamceba dysenteries in-
cubated in it at 37° for 4 days. They also gave
basic fuchsin, in doses of 5 to 10 mg. per Kg.
daily for 10 consecutive days, in treatment of
oxyuris infestation in humans; the course of
treatment was repeated, if necessary, once or
twice.

Storage. — Preserve "in well-closed contain-
ers." N.F.

GALLAMINE TRIETHIODIDE. LP.

Gallamini Triaethiodidum

C6H3[0(CH2)2N+ (C2H5)3]3.3I-

"Gallamine Triethiodide is 1 ,2 ,3-tri ( (3-diethyl-
aminoethoxy) benzene triethiodide. It contains not
less than 97.6 per cent of C30H60O3N3I3." I. P.
The drug is also recognized in the N.N.R.

Flaxedil (Lederle, May & Baker).

Gallamine triethiodide may be prepared by
treating pyrogallol with l-chloro-2-diethylamino-
ethane hydrochloride in the presence of sodium
hydroxide, then reacting the product with ethyl
iodide.

Description. — Gallamine triethiodide is a
white or faintly yellowish, amorphous or granular
powder; it is slightly hygroscopic. It is odorless
and has a faintly bitter taste. Gallamine tri-
ethiodide melts at about 234°. It is very soluble
in water, slightly soluble in dehydrated alcohol
and in acetone, and practically insoluble in ben-
zene, ether, and chloroform. LP.

Standards and Tests. — (1) On warming gal-
lamine triethiodide with sulfuric acid violet
vapors of iodine are released. (2) On adding
0.1 N iodine to a 1 per cent w/v solution in water
the solution becomes cloudy and then yields a
brown precipitate. (3) A 1 per cent w/v solution
yields with trinitrophenol T.S. a golden-yellow
crystalline precipitate, with 0.1 N potassium per-
manganate an orange precipitate, with silver ni-
trate T.S. a yellowish-white precipitate which is
insoluble in nitric acid. LP.

Assay. — About 500 mg. of gallamine trieth-
iodide is dissolved in water, 25 ml. of 0.1 N
silver nitrate and nitric acid are added, the mix-
ture is heated to boiling to coagulate the precipi-
tate and, after cooling, the excess silver nitrate
is titrated with 0.1 N ammonium thiocyanate
using ferric ammonium sulfate T.S. as indicator.
Each ml. of 0.1 N silver nitrate represents 29.72
mg. of C30H60O3N3I3. LP.

Uses. — Gallamine triethiodide is used to pro-
duce muscular relaxation during anesthesia. It
was developed by Bovet {Compt. rend. acad. set.,
1947, 225, 74; Arch, internat. pharmacodyn.
therap., 1949, 80, 172) in the course of a sys-
tematic study of the relation of structure to
curare-like (curarimimetic) action of quaternary
ammonium compounds. It may be noted from the
formula given above that this compound contains
three choline-like moieties in ether linkage to a
benzene ring. It could be considered somewhat of

592

Gallamine Triethiodide

Part I

an isostere of acetylcholine, which is the acetyl
ester of choline. Actually, gallamine does not ap-
pear to have an acetylcholine-like (cholinergic)
action, but instead is an inhibitor of the effect of
acetylcholine, particularly on skeletal neuromus-
cular transmission (somatic anticholinergic effect).
In this respect its action resembles that of <i-tubo-
curarine in that both agents are said to reduce
the response of the end plate at the neuromuscu-
lar junction to the depolarizing action of acetyl-
choline (Feldberg. Brit. M. J., 1951, 1, 967 J. On
the other hand, this action of gallamine may be
contrasted with that of decamethonium (see
monograph on Curarimimetic Agents and Their
Antagonists, in Part II).

The above similarity in mode of action be-
tween gallamine and d-tubocurarine can be dem-
onstrated quite simply in the laboratory. Both
compounds are capable of blocking the stimu-
latory effect of acetylcholine on the isolated frog
rectus abdominis muscle (Winter and Lehman,
/. Pharmacol, 1950, 100, 489). Likewise, the
curarizing action of gallamine can be antagonized
or reversed by the administration of cholinesterase
inhibitors (Winter and Lehman, loc. cit.). This
compound differs particularly from d-tubocurarine
in that it does not produce a fall in blood pres-
sure. Indeed, both blood pressure and heart rate
are more apt to increase following its administra-
tion (Wien, Arch, internat. pharmacodyn. therap.,
1948, 77, 96; Roux, Presse mid., 1949, 57, 12;
Wilson and Gordon, Lancet, 1949, 2, 504).
Whereas d-tubocurarine is said to induce the re-
lease of histamine from the tissues, Mushin et al.
{Lancet, 1949, 1, 726) reported gallamine to have
only a minimally detectable histamine-like action.
This compound when administered in dosages
sufficient to produce relaxation of the skeletal
musculature has no consistent effect on the cen-
tral nervous system with respect to pain threshold,
consciousness, or cerebration (Unna et al.,
J.A.M.A., 1950, 144, 448). Apparently the com-
pound has little effect on transmission in sympa-
thetic ganglia or on synaptic transmission in the
spinal cord (Van Den Ostende, Arch, internat.
pharmacodyn. therap., 1951, 86, 439; Baisset
et al, Toulouse Med., 1949, 50, 521). Gallamine
has an unusually high dosage; in other words, it
is substantially less active in laboratory animals
and in man than is J-tubocurarine. However, its
duration of action is of about the same length or
somewhat longer than d-tubocurarine or deca-
methonium in man and in laboratory animals
(Unna et al., J. Pharmacol, 1950, 100, 201).

Therapeutic Applications. — Clinically, gal-
lamine has been employed as an adjuvant in gen-
eral anesthesia, for intubation, and in electro-
shock (Thompson and Norton. Brit. M. J., 1951,
1, 857) therapy. It is more rapid in onset than
decamethonium and more nearly resembles d-tubo-
curarine in its type of induction. That is to say,
the compound does not produce fasciculation or
cramping, such as occasionally occurs during the
induction or recovery from decamethonium
(Doughty, Lancet, 1950, 1, 899; Ruddell, ibid.,
1950, 1, 953). Like d-tubocurarine, the dose of
gallamine required for relaxation is less when
combined with ether anesthesia than when ad-

ministered with cyclopropane or with intravenous
barbiturate anesthesia (Foldes et al, J.A.M.A.,
1952, 150, 1559). One of the first clinical studies
on gallamine was that of Mushin et al. (Lancet,
1949, 1, 726). They considered a dose of 80 mg.
of gallamine to be equivalent in curarizing ac-
tivity to 15 mg. of d-tubocurarine chloride.
Lamoureux and Bourgeois-Gavardin (Un. med.
Can., 1949, 78, 1164) reported it to facilitate
laryngeal intubation in 50 operations of various
types. Since the earlier reports there have been
a number of articles documenting the general
utility of this agent. Foldes et al. (Anesth. &
Analg., 1954. 33, 122) reported on the combined
administration of gallamine with thiopental so-
dium and nitrous oxide-oxygen for the production
of muscular relaxation for intra-abdominal sur-
gery on 339 unselected patients. This compound
is compatible with thiopental sodium and the two
can be administered simultaneously. With the ex-
ception of tachycardia, no unwanted side effects
accompanied its use. They do not recommend the
agent for patients with hyperthyroidism or for
cardiac patients, because of the propensity of the
agent to produce some elevation of pulse rate and
blood pressure. This appears to be a conservative
position on their part.

Toxicology. — Untoward reactions to the com-
pound are few and are for the most part overt
manifestations of its pharmacodynamic action. In
an early paper Gillespie (Endotracheal Anesthe-
sia, 1948, 2nd Ed., p. 126) warned that severe
laryngeal spasm may follow intubation under very
light anesthesia in the presence of gallamine. In
one degree or another this involved about 4 per
cent of the patients. Doughty (loc. cit.) refers to
one instance wherein it was felt that an antidote
was required during administration. In this in-
stance, injection of neostigmine in a dosage of
2.5 mg. with 0.6 mg. of atropine sulfate effectively
restored full respiratory activity within a minute.
Respiratory arrest following overdosage of such
an agent cannot be considered a toxic manifesta-
tion in most instances, since it can be controlled
by manual artificial respiration. The increase in
heart rate may be alarming in some cases, but
that effect, together with the increase in blood
pressure, ordinarily does not contraindicate the
use of this agent except perhaps in cardiac or
thyrotoxic patients.

Dose. — The usual dose of gallamine trieth-
iodide is an initial injection of 80 mg. intra-
venously. This may last for an average of 20 min-
utes. Further administration of amounts up to
40 or 80 mg. may be given intravenously. In some
of the cases it may be necessary for the anes-
thetist to assist respiration if the larger dosage is
repeated. This compound, like other curarimimetic
agents, should be administered only by a trained
anesthetist and under circumstances where equip-
ment for the maintenance of adequate oxigena-
tion under artificial respiratory conditions can be
assured.

Storage. — Preserve gallamine triethiodide in a
tightly-closed container. LP.

Usual Size. — In vials, containing 200 mg. in
10 ml. of aqueous solution.

Part I

Gamboge 593

GAMBOGE. N.F.

Cambogia

"Gamboge is the gum-resin obtained from
Garcinia Hanburyi Hooker filius (Fam. Gutti-
ferce)." N.F.

Pipe Gamboge; Cambodia; Gambogia. Gummi Gutta;
Gutti; Gummiresina Gutti; Gumbi Gambse; Gummi Gambae.
Fr. Gomme-gutte. Ger. Gummigutt; Gommegutt. It.
Gomme gotta. Sp. Gomo-resina guta; Gutagamba.

The name Cambogia (of which Gamboge is
a corruption) appears to have been derived from
the fact that it originally came from the kingdom
of Cambodia, formerly a part of French Indo-
China. Many years ago Hanbury, who had received
from Singapore specimens of the gamboge plant
cultivated in that island, and derived from Siam,
found that the plant approached very near to the
Garcinia Morella of Desrousseaux, from which it
could be distinguished only by its pedicellate
flowers and classified it as G. Morella, var. pedi-
cellata. Sir Joseph Hooker, however, determined
(/. Linn. Soc, 14, 480) that the var. pedicellata
is a distinct species, differing from G. Morella in
having not only its flowers pedicellate, but also its
leaves more ovate and much larger, and its fruit
larger; he very properly gave it the specific name
of Hanburyi.

G. Hanburyi is a tree reaching a height of SO
feet found in a limited district including Cam-
bodia, southern Cochin China and the islands
and seacoast of the Gulf of Siam, where it is
known as "Ton Rong."

The oleo-gum-resin constituting gamboge occurs
as a yellowish emulsion in schizogenous resin
canals found in the cortex, pith, leaves, flowers
and fruits. It is collected from trees not less than
10 years of age by making long spiral incisions in
the bark from the base of the trunk upward to
the lower branches. The exuding juice is usually
collected in the hollow internodes of large bamboo
stems, allowed to harden for a month, after which
the bamboo stem segments are heated and the
gamboge removed. This is the best gamboge and
termed pipe gamboge. An inferior variety called
cake or lump gamboge is said to be procured in
Cochin China by breaking off the leaves and
shoots of the tree; the juice, which is contained in
resin canals in the bark, issues in drops, and being
received in suitable vessels, gradually thickens,
and at length becomes solid.

Although the medicinal properties of this gum
were known to the Chinese as far back as the
thirteenth century, it was first brought to Europe
by the Dutch, about the middle of the seven-
teenth century. We import it from Bangkok and
Saigon through Singapore.

Indian gamboge, formerly recognized by the
B.P. Add. under the name of Cambogia Indica,
is obtained from the Garcinia Morella Desrouss.
Ceylon gamboge, derived from G. pictoria Roxb.,
is procured by incisions, or by cutting away a
portion of the bark, and scraping off the juice
which exudes. The specimens sent to Christison
were in flatfish or round masses, eight or nine
inches in diameter, apparently composed of ag-
gregated irregular tears, with cavities which are
lined with a grayish and brownish powdery in-

crustation. It resembled coarse gamboge, and was
identical in composition. In Ceylon it is used as
a pigment and purgative.

New Caledonian gamboge, derived from Gar-
cinia collina Vieil, is described by Heckel and
Schlagdenhauffen {Rep. de Pharm., 1893) as very
similar in its appearance and reactions to ordi-
nary gamboge; its color is, however, deep orange.
A white crystalline compound, which when heated
beyond 235° produced pyrocatechin, was found
in it, and marked the point of difference between
it and other varieties of gamboge.

Description. — "Unground Gamboge occurs as
cylindrical pieces, frequently hollow at the center,
from 2 to 5 cm. in diameter and up to 20 cm. in
length; longitudinally striate, weak reddish brown
to dark orange in color. The brittle, conchoidal
fracture presents a smooth, rather dull, surface.
Gamboge is odorless and has an acrid taste.

"Powdered Gamboge is moderate yellowish
orange. When mounted in chloral hydrate T.S.,
nearly all the particles slowly dissolve, leaving
but a few fragments of vegetable tissues and very
few or no starch grains." N.F.

By virtue of the brilliance of its color, gamboge
is highly esteemed as a pigment.

Standards and Tests. — Identification. — An
emulsion of strong yellow color is obtained on
triturating gamboge with water; on adding am-
monia T.S. the emulsion becomes darker, reddish,
and finally almost clear. Starch. — Not even a
transient green color is produced on adding iodine
T.S. to an emulsion of gamboge. Foreign organic
matter. — Not over 1 per cent. Acid-insoluble ash.
— Not over 1 per cent. Alcohol-soluble extractive.
— Not less than 65 per cent. N.F.

Constituents. — Gamboge contains 70 to 80
per cent of resin, 15 to 20 per cent of gum and
4 or 5 per cent of water. The gum is quite soluble
in water, but is not identical with gum arabic.
The resin of gamboge, formerly known as gam-
bogie acid, is soluble in alkaline solutions — from
which it may be precipitated by acids — in alcohol,
ether and other organic solvents. From it have
been separated a-, P-, and y-garcinolic acids.

The seeds of several species of Garcinia fur-
nish oils which have been used as foodstuffs;
that from the G. indica is known as goa butter,
kokum butter or margosteen oil. From the G.
Morella is obtained the so-called gamboge butter,
also called murga or gurgi fat.

Adulterants. — The chief adulterants of gam-
boge have been rice and wheat starches, sand
and vegetable fragments, all of which can be
readily detected by microscopic examination. The
inferior kinds of gamboge may be known by their
greater hardness and coarser fracture; by the
brownish or grayish color of their broken surface,
which is often marked with black spots; by their
obvious impurities, and by the green, or even blue,
color which their decoction, after cooling, gives
with iodine tincture (starch). When pure, the
gum-resin is completely dissolved by the suc-
cessive action of ether and water, so that the
amount of residue left by any specimen treated
in the manner just spoken of indicates approxi-
mately the measure of the adulteration.

Uses. — Gamboge is a powerful, drastic, hydra-

594 Gamboge

Part I

gogue cathartic; as it may produce nausea and
vomiting and much griping, when given in full
dose, it is almost always employed only in com-
bination with other cathartics. In large quantities
it is capable of causing fatal effects, and death has
resulted from taking 60 grains of it. Its cathartic
action is conditioned on the presence of bile in
the intestines, probably because the alkalinity of
this fluid renders the resin soluble. It was for-
merly employed as a hydragogue cathartic in
anasarca, and for the evacuation of intestinal
worms, but is now infrequently employed.

The N.F. gives a dose of 125 mg. (approxi-
mately 2 grains) for humans and 15 Gm. (ap-
proximately Yi ounce) for cattle. 12

Off. Prep. — Compound Mild Mercurous Chlo-
ride Pills, N.F.

BIVALENT GAS GANGRENE
ANTITOXIN. N.F.

[Antitoxinum Gas-gangraenosum Bivalens]

"Bivalent Gas Gangrene Antitoxin is a sterile
solution of antitoxic substances obtained from
the blood of healthy animals, which have been
immunized against Clostridium perfringens and
Clostridium septicum toxins. Each package of
Bivalent Gas Gangrene Antitoxin contains not
less than 10,000 antitoxic units of each of the
component antitoxins. Bivalent Gas Gangrene
Antitoxin complies with the requirements of the
National Institutes of Health of the United States
Public Health Service." N.F.

For a discussion of gas gangrene see Pentava-
lent Gas Gangrene Antitoxin. Bivalent gas gan-
grene antitoxin contains antitoxic antibody for
the toxins of Clostridium perfringens and Clos-
tridium septicum. These two organisms are the
ones most frequently isolated from cases of gas
gangrene. Moreover, these organisms are fre-
quently found in symbiotic association in infected
wounds, so it is reasonable to have a single dosage
form consisting of antitoxins against the toxins
of both organisms.

The methods of preparation of bivalent gas
gangrene antitoxin are essentially those outlined
under Pentavalent Gas Gangrene Antitoxin ex-
cept that only toxins of CI. prefringens and CI.
septicum are used.

Description. — "Bivalent Gas Gangrene Anti-
toxin is a transparent or slightly opalescent liquid,
of a faint brownish, yellowish, or greenish color,
nearly odorless or having an odor due to the
presence of a preservative; it may have a slight
granular deposit. It must be free from harmful
substances detectable by animal inoculation and
must not contain an excessive proportion of pre-
servative (not more than 0.5 per cent of phenol
or 0.4 per cent of cresol, if either of these is
used)." N.F.

Uses. — Bivalent gas gangrene antitoxin is used
in the prophylaxis and therapy of gas gangrene.
It is used as an adjunct to surgical debridement
in cases of traumatic wounds in order to reduce
the frequency of gas gangrene. It is also used
in the therapy of gas gangrene, such use being
limited to cases in which the infecting organisms

are known to be either CI. perfringens, CI. septi-
cum or both. For a further discussion of the use
of gas gangrene antitoxin see Pentavalent Gas
Gangrene Antitoxin.

Dosage. — The initial dose of bivalent gas gan-
grene antitoxin is the contents of one container
or more. For therapeutic action, the dose may
be repeated at 3- to 8-day intervals (see Pentava-
lent Gas Gangrene Antitoxin).

Regulations. — "The potency of the Antitoxin
shall be expressed in antitoxic units and the units
shall be those of the Perfringens Antitoxin and
the Vibrion septique Antitoxin prescribed by the
National Institutes of Health of the United States
Public Health Service. The outside label must
indicate the minimum number of antitoxic units
of each antitoxin in the package, the manufac-
turer's lot number of the Antitoxin, the name,
address, and license number of the manufacturer,
the genus of animal employed when other than
the horse, and the date beyond which the mini-
mum potency of the contents, as declared on the
label, may not be maintained." N.F.

Storage. — 'Preserve Bivalent Gas Gangrene
Antitoxin at a temperature between 2° and 10°,
preferably at the lower limit. It must be dispensed
in the unopened glass container in which it was
placed by the manufacturer." N.F.

TRIVALENT GAS GANGRENE
ANTITOXIN. N.F. (B.P.)

[Antitoxinum Gas-grangraenosum Trivalens]

"Trivalent Gas Gangrene Antitoxin is a sterile
solution of antitoxic substances obtained from
the blood of healthy animals which have been
immunized against the toxins of Clostridium per-
fringens, Clostridium septicum and Clostridium
cedematiens (Novyi). Each package of Trivalent
Gas Gangrene Antitoxin contains not less than
10,000 units of Clostridium perfringens and Clos-
tridium septicum antitoxins and 1500 units of
Clostridium cedematiens (Novyi) antitoxin. Tri-
valent Gas Gangrene Antitoxin complies with
the requirements of the National Institutes of
Health of the United States Public Health Serv-
ice." N.F.

The B.P. recognizes this product under the title
Mixed Gas-Gangrene Antitoxin; it may be native
serum, or a preparation from native serum, and
may be liquid or dried. If liquid the preparation
must have a potency of not less than 1000 Units
each of CI. welchii (perfringens) and CI. cedema-
tiens antitoxins and 500 Units of CI. septicum
antitoxin per ml. If dried it must have a potency
of not less than 5000 Units each of CI. welchii
(perfrigens) and CI. cedematiens antitoxins and
2500 Units of CI. septicum antitoxin per Gm.
The B.P. also recognizes separately the mono-
valent antitoxins, under the titles Gas-Gangrene
Antitoxin ( (Edematiens ) , Gas-Gangrene Anti-
toxin (Septicum), and Gas-Gangrene Antitoxin
(Welchii). The LP. recognizes only the individual
antitoxins, naming these, respectively. Anti-gas-
gangrene (Oedematiens) Serum, Anti- gas- gangrene
(Septicum) Serum, and Anti-gas-gangrene (Per-

Part I

Gas Gangrene Antitoxin, Pentavalent 595

fringens) Serum; they may be liquid or dried
preparations.

For a discussion of gas gangrene see Pentava-
lent Gas Gangrene Antitoxin. Trivalent gas gan-
grene antitoxin contains antitoxic antibody for
the toxins of CI. perfringens, CI. septicum and
CI. cedematiens, these three organisms being the
ones most frequently isolated from cases of gas
gangrene. This product differs from bivalent gas
gangrene antitoxin by the addition of CI. cedema-
tiens antitoxin and, therefore, has a wider cover-
age than this antitoxin. The organisms listed
above are sometimes found in symbiotic associa-
tion in infected wounds so it is reasonable to have
a single dosage form consisting of antitoxins
against the toxins of all three organisms. In
many geographical areas CI. bifermentans and
CI. histolyticum are rarely isolated and, therefore,
it is not considered necessary to have the wide
coverage represented in pentavalent gas gangrene
antitoxin.

The methods of preparation of trivalent gas
gangrene antitoxin are essentially those outlined
under Pentavalent Gas Gangrene Antitoxin ex-
cept that only the toxins of CI. perjringens, CI.
septicum and CI. cedematiens are used in its
preparation.

Description. — "Trivalent Gas Gangrene Anti-
toxin is a transparent or slightly opalescent liquid,
of a faint brownish, yellowish, or greenish color,
nearly odorless or having an odor due to the pres-
ence of a preservative; it may have a slight granu-
lar deposit. It must be free from harmful sub-
stances detectable by animal inoculation and must
not contain an excessive proportion of preserva-
tive (not more than 0.5 per cent of phenol or
0.4 per cent of cresol, if either of these is used)."
N.F.

Uses. — Trivalent gas gangrene antitoxin is used
in the prophylaxis and therapy of gas gangrene.
It is used as an adjunct to surgical debridement
in cases of traumatic wounds in order to reduce
the risk of the development of gas gangrene. It is
also used in the therapy of gas gangrene, its
therapeutic use being limited to cases in which the
infecting organisms are known to be the Clostridia
used in the preparation of the antitoxin. For
further discussion of the use of gas gangrene anti-
toxin see Pentavalent Gas Gangrene Antitoxin.

The usual initial dose of Trivalent Gas Gan-
grene Antitoxin is the contents of one container
or more. When this product is used for prophy-
lactic purposes a single dose is frequently used.
However, in the therapy of gas gangrene, doses
may be repeated at 3- to 8-day intervals. See
Pentavalent Gas Gangrene Antitoxin for further
discussion of dosage and for precautions concern-
ing the use of this product.

Regulations. — "The potency of the Antitoxin
shall be expressed in antitoxic units and the units
shall be those of the Perfringens, Vibrion septique
and CEdematiens Antitoxins prescribed by the
National Institutes of Health of the United States
Public Health Service. The outside label must
indicate the minimum number of antitoxic units
of each antitoxin in the package, the manufac-
turer's lot number of the Antitoxin, the name,

address, and license number of the manufacturer,
the genus of animal employed when other than
the horse, and the date beyond which the mini-
mum potency of the contents, as declared on the
label, may not be maintained." N.F.

Storage. — "Preserve Trivalent Gas Gangrene
Antitoxin at a temperature between 2° and 10°,
preferably at the lower limit. It must be dis-
pensed in the unopened glass container in which
it was placed by the manufacturer." N.F.

PENTAVALENT GAS GANGRENE
ANTITOXIN. N.F.

[Antitoxinum Gas-gangraenosum Pentavalens]

"Pentavalent Gas Gangrene Antitoxin is a
sterile solution of antitoxic substances obtained
from the blood of healthy animals which have
been immunized against the toxins of Clostridium
perfringens, Clostridium septicum, Clostridium
cedematiens (Novyi), Clostridium bifermentans
(Sordelli), and Clostridium histolyticum. Each
package of Pentavalent Gas Gangrene Antitoxin
contains not less than 10,000 units each of Clos-
tridium perfringens and Clostridium septicum
antitoxins, 3000 units of Clostridium histolyticum
antitoxin, and 1500 units each of Clostridium
cedematiens (Novyi) and Clostridium bifermen-
tans (Sordelli) antitoxins. Pentavalent Gas Gan-
grene Antitoxin complies with the requirements
of the National Institutes of Health of the United
States Public Health Service." N.F.

Gas gangrene, while recognized for many years,
remained a little-known infection until the First
World War, when it resulted in large numbers of
fatalities following war wounds which would not
otherwise cause death. In the majority of these
wounds it was possible to isolate Clostridium per-
fringens but usually other anaerobic spore-form-
ing bacilli such as CI. septicum, CI. cedematiens
(Novyi), CI. bifermentans (Sordelli) and CI.
histolyticum were also found. Subsequent studies
extending through World War II have indicated
that the frequency with which these various
Clostridia are found in contaminated wounds
varies remarkably from one area to another.
Inasmuch as it is usually impossible to determine
the species of organism present in a contaminated
wound in time to use this knowledge in prophy-
laxis and therapy, it has become the practice to
employ multivalent antitoxins wherever possible.

All of the Clostridia mentioned above elaborate
exotoxins which are partially responsible for their
pathogenicity. Although the antitoxins have no
antibacterial action, the neutralization of the
toxins of the bacteria makes the control of the
infection itself somewhat easier.

Antitoxins against the toxins of the organisms
causing gas gangrene are produced commercially
by methods analogous to those used for other
antitoxins (see Diphtheria Antitoxin) . Certain of
these antitoxins are produced singly in horses
while others are produced, for multivalent prepa-
rations, by the simultaneous immunization of the
animals to two or more toxins. The latter proce-
dure is preferable because it simplifies the subse-

596 Gas Gangrene Antitoxin, Pentavalent

Part I

quent purification of the antitoxin and produces a
final product of greater potency per volume.

In the immunization of horses for the produc-
tion of gas gangrene antitoxins, the use of tox-
oids is not as satisfactory as in the case of diph-
theria and tetanus toxoids, and the animals are
usually given injections of fully active toxin as
soon as the latter can be tolerated. The actual
procedure for immunization varies in different
laboratories.

When satisfactory antitoxin titers may be dem-
onstrated in the sera of horses on immunization
they are bled and the plasma is collected. This
plasma is concentrated and purified by ammo-
nium sulfate precipitation or enzymatic digestion.
After purification, sera containing various anti-
toxins may be blended to give the individual
potencies required for the pentavalent antitoxin.

Description. — "Pentavalent Gas Gangrene
Antitoxin is a transparent or slightly opalescent
liquid, of a faint brownish, yellowish, or greenish
color, nearly odorless or having an odor due to
the presence of a preservative; it may have a
slight granular deposit. It must be free from
harmful substances detectable by animal inocula-
tion and must not contain an excessive propor-
tion of preservative (not more than 0.5 per cent
of phenol or 0.4 per cent of cresol, if either of
these is used)." N.F.

Standardization. — Pentavalent gas gangrene
antitoxin is tested for potency by comparison
with the individual standard glycerinated anti-
toxins supplied by the National Institutes of
Health. These tests are all carried out in mice but
the individual antitoxin titrations are made by
slightly different methods. In general, the anti-
toxin to be tested is mixed in varying dilutions
with a constant quantity of test toxin. After incu-
bation at room temperature or 37°, the mixture
is injected into mice. The route of injection varies
with the antitoxin being tested. Similar tests are
made with the standard antitoxin and the unitage
of the unknown antitoxin is determined by com-
parison with the standard. The survival of mice
is the criterion used to determine the endpoint of
the test.

Uses. — Pentavalent gas gangrene antitoxin is
used for the prophylaxis and treatment of gas
gangrene. The possibility of the development of
gas gangrene exists chiefly in instances of trau-
matic accidents where clothing and soil have
gained access to the injury (see review by Alte-
meier and Furste, Surg. Gynec. Obst., 1947, 84,
507). The Clostridia causing gas gangrene do not
readily infect healthy tissue and are usually found
to cause infections either in wounds which have
not received prompt medical attention or which
have not been adequately cleansed and debrided
of devitalized tissue. The most important factor
in the prevention of gas gangrene is the complete
surgical removal of all traces of dead and de-
vitalized tissue even to the extent of amputating
an extensively infected extremity. However,
Spring and Kahn (Arch. Int. Med., 1951, 88,
373) have pointed out that crepitus in infected
tissue does not necessarily mean clostridial infec-
tion, particularly in a patient with diabetes mel-
litus and arteriosclerosis obliterans. They found

other gas-forming organisms in some of these
cases, including E. coli, nonhemolytic streptococci
and B. melaninogetiicus. In such cases, multiple
incisions for drainage and appropriate antibiotic
therapy usually result in healing. The prophylactic
action of the gas gangrene antitoxin is not very
great and, therefore, these agents are recognized
as being only an adjunct to the surgical and anti-
biotic management of traumatic wounds poten-
tially infected with Clostridia.

During wars the problem of gas gangrene be-
comes quite serious because of the frequency of
traumatic injuries and the unavoidable delays in
obtaining adequate surgical treatment. In normal
times, however, severe traumatic injuries gen-
erally receive rather prompt treatment and the
danger of gas gangrene is lessened materially.

Dowdy et al. (N. Y. State J. Med., 1944, 44,
1890), finding penicillin to be effective against all
Clostridia, recommend it as the chemotherapeutic
agent of choice; they consider both penicillin
and antitoxin to be powerful therapeutic agents.
Herrell et al. (J.A.M.A., 1944, 125, 1003) be-
lieve that antitoxin must be used along with peni-
cillin on the basis that the neutralizing effect of
the antitoxin is essential. A dose of 1 to 2 million
units of penicillin, intramuscularly, is indicated.
Oxytetracycline or chlortetracycline, in a dose of
2 Gm. intravenously daily, may be used. Sulfona-
mides are less effective.

Dose. — The usual dose of antitoxin, adminis-
tered intramuscularly, is the contents of one or
more packages. Sometimes a portion of the dose is
injected at multiple points around the area of
injury. Since this antitoxin is derived from animal
serum (almost invariably horse serum) adequate
precautions must be taken to prevent serum
reactions.

In the treatment of gas gangrene an attempt
should always be made to identify the causative
organisms and to use antitoxins specific for the
infection. In the absence of this knowledge,
pentavalent gas gangrene antitoxin may be used
(MacLennan and Macfarlane, Lancet, 1945, 2,
301). Dosage is repeated at 3- to 8-day intervals
for therapy, and the indicated surgical procedures
should be carried out. Sulfonamide treatment is
also combined with antitoxin therapy.

Regulations. — "The potency of the Antitoxin
shall be expressed in antitoxic units and the units
shall be those of the Perfringens, Vibrion sep-
tique, (Edematiens, Sordelli, and Histolyticum
Antitoxins prescribed by the National Institutes
of Health of the United States Public Health
Service. The outside label must indicate the mini-
mum number of antitoxic units of each antitoxin
in the package, the manufacturer's lot number of
the Antitoxin, the name, address, and license num-
bers of the manufacturer, the genus of animal
employed when other than the horse, and the date
beyond which the minimum potency of contents,
as declared on the label, mav not be maintained.''
N.F.

Storage. — "Preserve Pentavalent Gas Gan-
grene Antitoxin at a temperature between 2° and
10°, preferably at the lower limit. It must be dis-
pensed in the unopened glass container in which
it was placed by the manufacturer." N.F.

Part I

Gauze, Petrolatum

597

ABSORBENT GAUZE. U.S.P.

Gauze, Plain Gauze, Non-sterilized Absorbent Gauze,
[Carbasus Absorbens]

"Absorbent Gauze consists of well-bleached
cotton cloth of plain weave." U.S.P.

Tela Depurata; Tela Hydrophila. Fr. Gaze hydrophile
pour pansements. Ger. Verbandmull ; Verbandgaze;
Hydrophiler Mull. It. Garza idrofila. Sp. Gasa hidrofila;
Gasa absorbente.

Description. — "Absorbent Gauze is white cot-
ton cloth of various thread counts and weights.
The following table gives the commercial desig-
nations in type and in terms of thread-count and
the standard weight in grams per linear yard. It
also gives the width of the gauze in inches. A
variation of ±.l/i inch shall be allowed in width."
U.S.P. For other standards, and tests, see U.S.P.
XV.

Threads per

Standard Weight,

Width

Type

25.4 mm. (1 Inch)

Gm. per Linear
Yard

Warp Filling

Inches

44 36

44.S

38.5

32 28

31.3

III

28 24

27.0

24 20

23.2

22 18

21.S

20 16

18.8

VII

20 12

17.2

Storage and Labeling. — "Preserve Absorb-
ent Gauze in well-closed containers. The type,
thread count, length, and width of the Gauze are
stated on the container, and the designation 'un-
sterilized' or 'not sterilized' appears prominently
thereon." U.S.P.

STERILE ABSORBENT GAUZE.

U.S.P.

Sterile Gauze, [Carbasus Absorbens Sterilis]

"Sterile Absorbent Gauze is absorbent gauze
which has been rendered sterile and protected
from contamination." U.S.P.

Sp. Gasa Absorbente Esteril.

Description and Tests. — "Sterile Absorbent
Gauze complies with the definition, description,
and tests under Absorbent Gauze. Sterile Ab-
sorbent Gauze may be supplied in various lengths
and widths, and in the form of rolls or folds.
Dimensions. — The dimensions of Sterile Absorb-
ent Gauze shall be not less than 98 per cent of
the labeled dimensions of the Gauze. Sterility. —
Sterile Absorbent Gauze meets the requirements
of the Sterility Tests for Solids." U.S.P.

Sterilized gauze is most frequently sold in pack-
ages of from one yard to ten yards long and up-
wards. There are also available packages contain-
ing several small pieces individually wrapped so
that one may have a dressing for a small wound
without soiling the whole roll; it must be remem-
bered that once the gauze is exposed to air it can
no longer be regarded as sterile.

Storage and Labeling. — "Each Sterile Ab-
sorbent Gauze unit is so packaged individually
that the sterility of the unit is maintained until
the package is opened for use. Sterile Absorbent

Gauze is sterilized in the package. The package
bears a statement to the effect that the sterility
of the Gauze cannot be guaranteed if the package
bears evidence of damage or has been previously
opened. The length, width, and type of the gauze
are stated upon the package." U.S.P.

GAUZE BANDAGE. U.S.P.

Roller Gauze Bandage, [Ligamentum Carbasi
Absorbentis]

Sp. Venda de Gasa Absorbente.

Description. — "Gauze Bandage is prepared
from Type I absorbent gauze in various widths
and lengths, and sterilized. Each bandage is in
one continuous piece, tightly rolled, and sub-
stantially free from loose threads and ravelings."
U.S.P. For standards and tests see U.S.P. XV.

Gauze bandage is used for surgical purposes.

Storage and Labeling. — "Each Gauze Band-
age is so packaged individually that the sterility
of the product is maintained until the package is
opened for use. Gauze Bandage is sterilized in the
package. The package bears a statement to the
effect that the sterility of the Bandage cannot be
guaranteed if the package bears evidence of dam-
age, or if the package has been previously opened.
The width and length of the bandage, and the
name of the manufacturer, packer, or distributor
are stated on the package." U.S.P.

PETROLATUM GAUZE. U.S.P.

"Petrolatum Gauze is absorbent gauze saturated
with white petrolatum. The weight of the petro-
latum in Petrolatum Gauze is not less than 4
times the weight of the gauze. Petrolatum Gauze
is sterile." U.S.P.

Petrolatum gauze may be prepared as fol-
lows: Place 20 Gm. of absorbent gauze, in strips
of suitable length and width, plain or folded, in
suitable containers, and sterilize in an autoclave
at 121° in an atmosphere of steam for 30 minutes.
Place 85 Gm. of white petrolatum in a beaker,
insert a thermometer in the petrolatum, heat to
a temperature of 170° and maintain the tempera-
ture between 165° and 170° for 2 hours. Cover
the petrolatum, allow it to cool to about 100°,
then aseptically pour it upon the gauze in such
manner as to cover the entire mass of gauze, and
immediately tightly close the container. U.S.P.

Standards and Tests.— The petrolatum re-
covered in the assay conforms to the description
and meets the requirements of the test for color
and other tests under White Petrolatum. The con-
ditioned gauze obtained in the assay meets the
requirements of the tests for thread count and
weight under Absorbent Gauze, and for width
and length under Gauze Bandage. Petrolatum
gauze meets the sterility requirements of the
U.S.P.

Assay. — Not less than 20 units of gauze are
weighed and then placed in a heated glass funnel
to allow the petrolatum to melt and drain from
the gauze, the remaining petrolatum being re-
moved by washing with warm benzene. The gauze,
freed from petrolatum, is conditioned in a stand-
ard atmosphere (65 per cent relative humidity,

598

Gauze, Petrolatum

Part I

21° C.) and then weighed. The difference in
weight represents the weight of petrolatum. U.S.P.
Uses. — Petrolatum gauze is widely employed
as a bland, emollient dressing, packing or drain
for burns, wounds, ulcers, fractures and in many
different surgical situations. Nasal bleeding, and
even hemorrhage, may generally be controlled by
a firm packing of petrolatum gauze. It is nontoxic
and nonirritating, does not adhere to the tissue
with which it is in contact and, when it contains
the quantity of petrolatum directed to be used in
the U.S. P. formula, does not cause maceration of
tissue. An excessive amount of petrolatum is to
be avoided because of the danger of tissue macer-
ation. The wide utility of the gauze may be
inferred from the recommendation of Vorhaus
and Weihe (Illinois M. J., 1951, 99, 81) that
sterile petrolatum gauze always be carried in the
physician's bag. Single sterile petrolatum gauze
dressings, packaged in properly sealed sterile con-
tainers to ensure maintenance of sterility until
the gauze is used; are commercially available. A
comprehensive review of the more recent litera-
ture pertaining to petrolatum gauze and its uses,
and also of the problems arising in its preparation
and sterilization, has been published by Gershen-
feld (Am. J. Pharm., 1954, 126, 112). Additional
experimental data concerning preparation and
sterilization of the gauze, obtained by Gershenfeld
and his associates, are reported in Drug Stand-
ards, 1954, 22, 205, 210.

Labeling. — "The package label bears a state-
ment to the effect that the sterility of the Petro-
latum Gauze cannot be guaranteed if the package
bears evidence of damage or has been opened
previously. The package label states the width,
length, and type or thread count of the Gauze and
the name of the manufacturer, packer, or dis-
tributor." U.S.P.

Storage. — "Each Petrolatum Gauze unit is so
packaged individually that the sterility of the
unit is maintained until the package is opened
for use." U.S.P.

GELATIN. U.S.P.,

[Gelatinum]

B.P.

"Gelatin is a product obtained by the partial
hydrolysis of collagen derived from the skin,
white connective tissue, and bones of animals.
Gelatin derived from an acid-treated precursor
exhibits an isoelectric point between pH 7 and
pH 9, known as Type A, while Gelatin derived
from an alkali-treated precursor has an isoelectric
point between pH 4.7 and pH 5, known as Type
B." U.S.P. The B.P. defines gelatin as the protein
obtained by extraction from collagenous material.

Gelatina Officinalis; Gelatina Alba. Fr. Gelatine offi-
cinale; Grenetine. Ger. Weiszer Leim; Weisze Gelatine.
It. Gelatina officinale. Sp. Gelatina; Grenetina.

The collagens are a class of albuminoids abun-
dant in bones, skin, tendons, cartilage and simi-
lar tissues of animals. These collagens may be
hydrolyzed by water at high temperatures pro-
ducing compounds known respectively as gelatin
or glue, which differ from each other mainly in
the character and quality of the raw stock from
which they are manufactured and also in the rela-

tive amounts of glutin and chondrin which they
contain. Glutin is present in higher proportions in
glue, to which it imparts its great adhesive power,
while chondrin gives to gelatin its greater gela-
tinizing power.

Edible gelatin is prepared chiefly from three
carefully selected raw materials: clean bones,
fresh frozen porkskins, and calfskins. Bone stock
is first treated with hydrochloric acid which re-
moves the acid-soluble calcium salts, chiefly the
phosphate, leaving a substance known as ossein.
Following this step the treatment of ossein and
calfskin is essentially the same. They are sub-
jected to a prolonged liming treatment which re-
moves many lime-soluble, extraneous protein sub-
stances. The excess lime is then removed by
washing, leaving practically pure collagen. The
acidity is then adjusted to a pH of about 5 or 6
and the collagen extracted with water, at an
elevated temperature in a cooking kettle, forming
gelatin. This weak gelatin solution is then concen-
trated and clarified by the use of a filter press or
a Kiefer filter. This concentrated solution is gela-
tinized by chilling, and the resulting gel is cut
into slabs which are placed on wire net frames
which pass through a carefully regulated drying
oven. The surface of sheet gelatin is covered with
lozenge-shaped marks due to impressions left by
the netting upon which it is dried.

In the case of porkskins, the fresh skins are
"acid-plumped" with hydrochloric acid, then well
washed with water and finally extracted with
water at a pH of 3.5 to 5.0 in kettles as already
described. The melted fats rise to the surface
whereas the gelatin solution, by reason of its
greater density, is drawn off at the bottom.

The physico-chemical properties of gelatin are
widely different, dependent upon the nature of its
precursor and consequently it is frequently nec-
essary to know definitely the source of the gelatin
at hand in order to adjudge its suitability for a
specific purpose. One of the major points of dif-
ference between the two types of gelatin — i.e.,
that made by a preliminary liming of the precur-
sor and that made by acid hydrolysis not pre-
ceded by a liming treatment — is the region of
their isoelectric points, as evidenced by the pH
at which they exhibit maximum turbidity in a 2
per cent gel. The former has an isoelectric point
at approximately pH 4.7 whereas that of the
latter is in the region pH 7 to 9.

The gel strength of gelatin is commercially
specified in terms of "Bloom Rating," the higher
the Bloom the greater being the power of gel
formation. The determination of Bloom Rating
is made by the use of the Bloom gelometer, a
device developed by the industry for this purpose.
In the absence of such an apparatus the Bloom
rating may be approximately estimated by the
following simple test. Weigh out five portions of
the gelatin as follows: 0.9 Gra., 1.0 Gm., 1.1 Gm.,
1.2 Gm., and 1.3 Gm.; to each add sufficient water
to make 100 Gm. of solution. Soak for 15 minutes
and then place the containers in a water bath at
60° until the gelatin has dissolved. Put 10 ml. of
each solution into each of five 12 by 120 mm. test
tubes and places these tubes in an ice bath, mak-
ing certain that the whole of the gelatin solution

Part I

Gelatin

599

is well below the level of the bath mixture. The
ice bath and the immersed tubes are then placed
in a refrigerator and the bath maintained at 0°
for six hours. At the end of this period remove
the tubes and determine the minimum amount of
gelatin required to produce a gel so firm that no
perceptible movement of it occurs when the tube
is inverted. The approximate Bloom rating will
be found from the following table:

Minimum

Bloom Rating

Per Cent

for Gelatin from

to Produce

Acid-Treated

Alkali-Treated

Firm Gel

Precursor

1.3

100

1.2

150

100

1.1

200

150

1.0

250

200

0.9

above 250

250

Note: The U.S. P. test for gel strength is based
on this method except that conformity to a mini-
mum value only is determined.

Various forms of gelatin are supplied, including
the sheet gelatin already mentioned, shred gelatin
which is made by cutting sheet gelatin into very
narrow shreds by a shearing machine, and granu-
lated gelatin made by grinding the broken sheets
into coarse granules. The latter variety is by far
the most desirable from the standpoint of ease
of handling and use.

In preparing a solution of gelatin it should first
be allowed to hydrate in cold water and thereafter
the temperature raised and maintained until solu-
tion is effected. The prolonged heating of a gelatin
solution will cause it to lose its power of gelation
in the cold, such power being completely lost if
the hydrolysis is continued beyond a certain point.
A solution of high grade gelatin can, however,
be sterilized in an autoclave without losing its
ability to gel.

Description. — "Gelatin occurs in sheets,
flakes, shreds, or as a coarse to fine powder. It is
faintly yellow or amber in color, the color varying
in depth according to the particle size. It has a
very slight, characteristic bouillon-like odor. It is
stable in air when dry, but is subject to microbic
decomposition when moist or in solution. Gelatin
is insoluble in cold water, but swells and softens
when immersed in it, gradually absorbing from
5 to 10 times its own weight of water. It is soluble
in hot water, in acetic acid, and in a hot mixture
of glycerin and water. It is insoluble in alcohol,
in chloroform, in ether, and in fixed and volatile
oils." U.S.P.

Standards and Tests. — Identification. — (1)
A 1 in 100 solution of gelatin yields a precipitate
with acidified dichromate solution, and with trini-
trophenol T.S. (2) A 1 in 5000 solution of gela-
tin is at once rendered turbid by tannic acid T.S.
Residue on ignition. — Not over 20 mg. from 1
Gm. of gelatin. Odor and water-insoluble sub-
stances.— A hot solution of gelatin (1 in 40) is
free from disagreeable odor, and is only slightly
opalescent when viewed in a layer 2 cm. thick.
Sulfite. — The limit is 40 parts per million. Arsenic.
— The limit is 1 part per million. Heavy metals. —

The limit is 50 parts per million. Gel strength. —

1 Gm. of gelatin, when tested as described above
under Bloom Rating, produces a gel showing no
movement when inverted. Bacterial count. — The
total bacterial count does not exceed 10,000 per
Gm. and coliform bacteria are not present in 10
mg. or less. U.S. P.

"Note. — Gelatin to be used in the manufacture
of capsules in which to dispense medicines, or for
the coating of pills, may be colored with a certi-
fied color, may contain not more than 0.15 per
cent of sulfur dioxide and may have a lower gel
strength. For the special Gelatin to be used in the
preparation of emulsions, see Emulsions." U.S.P.

The B.P. specifications provide for limits of

2 parts per million of arsenic, 30 p. p.m. of copper,
7 p.p.m. of lead, 100 p.p.m. of zinc, 1000 p.p.m.
of sulfur dioxide, 16.0 per cent loss on drying at
105°, and 3.25 per cent of ash.

Uses. — Pharmaceutical. — Gelatin has many
uses in pharmacy. Its most frequent use is in the
manufacture of both hard and elastic capsules,
the gelatin for the latter containing a plasticizing
substance characterized by the presence of hy-
droxyl groups, i.e., a polyhydric compound. Many
formulations of dermatologic agents in a plastic
gelatin base, which can be melted so as to permit
application of the preparation to the skin, have
been devised and several continue to be used;
one such preparation which is official is Zinc Gela-
tin, which is described elsewhere in Part I. The
British Pharmacopoeia provides a formula for
preparing Lamellce, which are small discs contain-
ing gelatin in which are incorporated various
medicinal agents intended for application to the
eye. Gelatin is commonly used as the principal
base ingredient of many pastilles or troches, also
of suppositories. Its use in emulsions is discussed
under that title. Finally, it finds an important
application in delaying absorption of certain drugs
which are used parenterally, thereby prolonging
their action; epinephrine and heparin are among
the medicinal agents the duration of action of
w:hich has been thus modified.

Nutritional Aspects. — Gelatin is often of
service as an adjuvant protein food. It is not a
complete protein, lacking especially the essential
amino acid trytophan, but its ease of digestion
and freedom from carbohydrate and fat some-
times make it a valuable dietary component in
various forms of malnutrition. Its protective col-
loid function has led to the addition of 1 or 2 per
cent of gelatin in preparing modified milk for-
mulas for infant feeding; Berggren (/. Dairy
Science, 1938, 21, 463) demonstrated that it
appreciably lowers the curd tension of cow's milk.
Its amphoteric action makes it especially valuable
as a food in cases of gastric hyperacidity or peptic
ulcer (see Andresen, Surgery, 1939, 5, 535;
Matzner et al., J. Lab. Clin. Med., 1941, 26, 682).

In certain non-mycotic disturbances of the
nails, the oral administration of gelatin daily has
been reported to be of value in restoring the
normal growth and appearance of the nails
(Tyson, /. Invest. Dermat., 1950, 14, 323).

Intravenous Uses. — In 1896 Dastre and
Floresco (Compt. rend. soc. biol., 1896) called
attention to the fact that intravenous injection

600

Gelatin

Part I

of gelatin solutions greatly accelerated coagula-
tion of blood and used such solutions in the treat-
ment of internal hemorrhages. Solutions of gela-
tin are difficult to sterilize and a number of cases
of tetanus followed such use in the early days.
Quick (Wisconsin M. J., 1940. 39, 517) revived
this use of gelatin, especially for hemorrhagic
conditions associated with hepatic injury. Now
there is available a gelatin, specially prepared
from refined beef bone collagen, from which
sterile, pyrogen-free, nonantigenic solutions may
be prepared. Under the title Gelatin Solution,
Special Intravenous, the X.X.R. recognizes a 6
per cent solution of such gelatin in isotonic
sodium chloride solution; it is intended for use
as an infusion colloid. The solution is odorless,
clear, amber colored and slightly viscous at tem-
peratures above 29° ; it gels at ordinary room
temperature. The pH of the solution is between
6.95 and 7.40. It is used as a plasma extender
(see also under this title in Part II ) in the treat-
ment of shock. The disadvantage of this solution
is that it gels at room temperature and must be
warmed to about 50° before injection and kept
warm for prolonged administration, as by the drip
method (see Ravdin. J.A.M.A., 1952. 150, 10).

To be suitable for use as a plasma extender the
molecular weight of gelatin should be in the range
of 20.000 to 70,000. Different preparations of
gelatin may van* widely in their properties.
Osseous gelatin composed of relatively long mo-
lecular chains is not excreted from the kidney as
quickly as the more degraded and shorter chain
skin gelatins. After testing many types of skin
and bone gelatins Levenson (Surg. Gyn. Obst.,
1947, 84, 925) concluded that there was no
marked superiority of any particular gelatin over
the others when a sufficient concentration and
volume of solution were used.

Gelatin being an incomplete protein it would
appear that it can be utilized by the body as a
protein only if any missing amino acid, notably
trytophan. is supplied (Brunschwig, ibid., 1946,
82, 25). Since this is not provided when gelatin
is given as a plasma extender it is probably not
metabolized (Robscheit-Robbins. /. Exp. Med.,

1944. 80, 145); this, however, is no disadvantage.
It is not stored by the reticuloendothelial system
but is excreted in the urine. At the end of 24
hours from 60 to 100 per cent of injected gelatin
has been found in the urine (Jacobsen. Arch. Int.
Med., 1944. 74, 254). Injected intravenously as
a 6 per cent solution, osseous gelatin causes a
hemodilution maximum 3 to 4 hours later, the
blood volume increase amounting to 70 per cent
of the injected volume (Fletcher. /. Clin. Inv.,

1945. 24, 405). Accompanying the hemodilution
is a decreased hematocrit and a decrease in plasma
proteins. Levenson (loc. cit.) believed that the
red cell mass was decreased, but this has not been
confirmed. The sedimentation rate is increased
and pseudoagglutination occurs, as it does with
all macromolecular solutions used as plasma ex-
tenders; this does not interfere with blood typing
and crossing (Koop. Am. J. Med. Sc, 1945. 209,
28), the pseudoagglutination being abolished by
the addition of 1 per cent of glycine solution to
the red cell serum suspension. It was thought at

first that gelatin increased the bleeding and clot-
ting time (Amberson, Biol. Rev., 1937, 12, 48;
Haimovici. New Eng. J. Med., 1945, 233, 8);
this may have been due to the high calcium con-
tent of the preparations used, for Koop (Surg.,

1944. 15, 839) found no changes in the clotting
mechanism. No changes in liver or renal function
have been observed (Michie et al., J. Applied
Physiol, 1952, 4, 677).

Gelatin, effective as a plasma extender in 4 to
6 per cent solution, can be used in the treatment
of shock due to trauma, burns, and vasodilation.
Koop (Surg. Clinics A '. America, 1944. 24, 1300)
found it effective in the treatment of the early
stages of hemorrhagic shock in 100 patients. On
the basis of use in over 400 patients, Seldon
(Proc. Mayo, 1945. 20, 468) recommended its
use in patients with minimal bleeding, in elderly
patients whose blood pressure tends to fall and
who need more intravenous fluid but not blood.
Kozoll (Am. J. Med. Sc, 1944. 208, 141) and
Evans (Am. J. Surg., 1945, 121, 478) found it
satisfactory in treating bum shock.

A 10 per cent solution has been given to pa-
tients with edema due to hypoproteinemia in
chronic renal and liver disease; significant diuresis
occurred in a few patients (Scott, Am. J. Med.
Sc, 1951. 222, 686).

To obviate the disadvantage that gelatin solu-
tions have of setting to a gel. attempts have been
made to modify gelatin so that it will remain
fluid in solutions intended for intravenous use.
Most such modifications yield, as a result of
hydrolysis of the gelatin, particles of such small
molecular dimensions that they are rapidly lost
from the circulation and thus do not have the
required efficiency for treatment of shock. One
product, more efficient than the others, is called
oxy poly gelatin and was introduced by Pauling in
1946. It consists of particles with a molecular
weight ranging from 10.000 to 100.000. but hav-
ing an average weight of 31.000; solutions of it
remain fluid at temperatures above 18°. When
tested in animals and man it compared favorably
with other plasma extenders (McCarthy et al.,
Am. J. Physiol, 1947. 150, 428; Chen et al.,
U. S. Armed Forces Med. J., 1952. 3, 1479;
Campbell et al, Texas Rep. Biol. Med., 1951, 9,
235). Higgins (J. Applied Physiol, 1952, 4, 776 i
observed 75 per cent retention of it at the end
of an infusion and 9 per cent at the end of 24
hours; 50 per cent appeared in the urine in 8
hours. Earlier preparations produced proteinuria,
tubular damage and uremia in the rat. Higgins
(loc. cit.) found no proteinuria in man; he did
observe, however, itching, erythema, and joint
swelling in 5 of 42 patients.

Topical Hemostatic. — An absorbable sponge,
composed chiefly of gelatin, has been demon-
strated to be a useful hemostatic in operative pro-
cedures and in the treatment of wounds; it is
official as Absorbable Gelatin Sponge (see under
this title for further information).

Toxicology. — Patients receiving gelatin are
remarkably free of toxic reactions (Ravdin. Am.
J. Surg., 1950. 80, 744; Seldon. Proc. Mayo,

1945, 20, 468). Although Skinsnes (Surg. Gyn.
Obst., 1947, 85, 563) reported changes in the

Part I

Gelatin Sponge, Absorbable 601

renal tubule, a "gelatin nephrosis," Koop (Arch.
Surg., 1949, 59, 185) felt that these changes were
merely indicative of some substance being vigor-
ously reabsorbed or excreted by the proximal
tubule and that they did not indicate damage.
Mitchie (Am. J. Applied Physiol., 1952, 4, 677)
found no measurable changes in tubular function.
Vascular lesions in dogs have been reported by
Heuper (Am. J. Path., 1942, 18, 895) but this
has not been confirmed (Brook, /. Lab. Clin.
Med., 1947, 32, 1115).

Dose. — As a plasma extender in the treat-
ment of shock, the usual dose of the 6 per cent
special intravenous gelatin solution is 500 ml.,
given intravenously at rates of injection up to
30 ml. per minute if indicated that rapidly; the
gel should be liquefied by warming to about 50°
and kept warm for prolonged administration by
the drip method. As much as 3000 ml. has been
given. It should be used cautiously in the pres-
ence of cardiac impairment lest the excessive fluid
volume prove burdensome to the circulation; it
is considered inadvisable to use it in the crush
syndrome or in extensive third-degree burns
because of possible renal damage. The solution
is supplied in 500-ml. bottles (Knox Gelatine
Company).

Storage. — Preserve "in well-closed containers
in a dry place." U.S.P.

Off. Prep. — Zinc Gelatin; Glycerinated Gela-
tin Suppositories (in Part II), U.S. P.; Gelatin of
Zinc; Lamellae; Suppositories of Glycerin, B.P.

ABSORBABLE GELATIN SPONGE.
U.S.P.

[Spongia Gelatini Absorbenda]

"Absorbable Gelatin Sponge is a sterile, absorb-
able, water-insoluble gelatin-base sponge." U.S.P.

Gelfoam (Upjohn).

In 1945 Correll and Wise (Proc. S. Exp. Biol.
Med., 1945, 58, 233) described a gelatin sponge,
made by foaming a solution of partially denatured
gelatin with air and then drying the foam in an
oven, which possessed hemostatic action when
applied to wounds or used in surgical procedures.
The hemostatic action of the sponge depends in
part on its action as a tampon and in part on the
liberation of thromboplastin from damaged plate-
lets which become traumatized by contact with
the walls of the interstices of the foam structure.
Though the gelatin sponge is water-insoluble it
will absorb about 50 times its weight of water or
about 45 times its weight of blood. Following
application to bleeding tissue it undergoes enzymic
digestion as healing progresses and in two to four
weeks the gelatin is usually completely "ab-
sorbed." The use of partially denatured gelatin
prevents its solution before healing takes place.
It is non-antigenic.

Description. — "Absorbable Gelatin Sponge is
a light, nearly white, nonelastic, tough, porous
matrix. It shows no tendency to disintegrate even
with relatively rough handling. A piece of Absorb-
able Gelatin Sponge may be rapidly wetted by
kneading it vigorously with moistened fingers.
A 10-mm. cube of Absorbable Gelatin Sponge

weighing approximately 9 mg. will take up ap-
proximately fifty times its weight of water or
forty-five times its weight of well-agitated oxa-
lated whole blood. Absorbable Gelatin Sponge will
withstand dry heat at 150° for 4 hours. Absorb-
able Gelatin Sponge is insoluble in aqueous media,
but is absorbable in body tissues. It is completely
digested by a solution of Pepsin." U.S.P.

Standards and Tests. — Residue on ignition.
— Not over 2 per cent. Digestibility. — The aver-
age digestion time of absorbable gelatin sponge in
a 1 in 100 solution of pepsin in 0.1 N hydro-
chloric acid is not more than 75 minutes. Sterility.
— The substance meets the requirements of the
Sterility Tests for Solids. U.S.P.

Uses. — Absorbable gelatin sponge has found
many applications as a hemostatic, for example in
neurosurgery (Light and Prentice, Neurosurgery,
1945, 2, 433), in gynecologic surgery (Huffman,
Quart. Bull. Northwest. U. Med. Sch., 1948, 22,
53), in traumatic rupture of the liver (Papen and
Mikal, New Eng. J. Med., 1948, 239, 920), in
liver repair surgery (Scott, Am. J. Surg., 1951,
81, 321), in numerous otorhinolaryngologic sur-
gical procedures (Senturia et al., Laryn., 1949,
59, 1068), in proctologic removals (Rosser, South.
M. J., 1950, 43, 26), and in epistaxis (Cope, Eye,
Ear, Nose & Throat Monthly, 1947, 26, 417).

On the basis of animal experimentation it ap-
pears that gelatin foam can be used effectively to
fill the pleural cavity after pneumonectomy
(Small et al, Proc. Mayo, 1947, 22, 585). Scott
(loc. cit.) used it as a space filler in liver surgery.
Use of gelatin foam packing enhanced the results
of thoracoplasty (Hedberg, Am. Rev. Tuberc,
1950, 61, 193).

Powdered Gelfoam, followed by thrombin solu-
tion, has been administered orally in successful
management of massive gastrointestinal hemor-
rhage; aluminum hydroxide gel was given to pre-
vent digestion of the clot (Cantor et al., Am. J.
Surg., 1951, 82, 23; McClure, Surgery, 1952,
32, 630).

An insolubilized gelatin film (Gelfilm) has been
used to repair dura and traumatized cortex
(Scheuerman et al., J. Neurosurg., 1951, 8, 608).

A gelatinized bone mass composed of ground
bone (fresh or preserved), blood, and powdered
Gelfoam has been used to repair skeletal defects
and traumatized bone about the face and ex-
tremities (Swanker and Winfield, Am. J. Surg.,
1952, 83, 332).

A sponge biopsy technic for diagnosis of cancer,
in which a suspected lesion is wiped with a Gel-
foam sponge so as to transfer living cells directly
to the sponge surface for subsequent microscopic
examination for evidence of malignancy, has been
developed (Gladstone, New Eng. J. Med., 1949,
241, 48, and Cancer, 1949, 2, 604). Gelfoam has
also been applied to the biopsy site following ex-
cision of a tissue block by the round cutaneous
punch, providing hemostasis and facilitating the
healing process.

The commercially available sponges are small,
dry, crisp, rectangular sheets, which may be cut
into any desired shape with a scalpel, or molded
easily with the fingers. Before use the sheets are
compressed to expel air; they may then be soaked

602 Gelatin Sponge, Absorbable

Part I

in either isotonic sodium chloride solution or a
solution of bovine thrombin and then applied
where required. Sometimes they are applied in the
dry state, blood serving to moisten the sponge.

Storage and Labeling. — Preserve "in a her-
metically sealed or other suitable light-resistant
container in such manner that the sterility of the
product is maintained until it is opened for use.
The package bears a statement to the effect that
the sterility of Absorbable Gelatin Sponge cannot
be guaranteed if the package bears evidence of
damage, or if the package has been previously
opened. The label bears the name and address of
the manufacturer, packer, or distributor, and a
lot number which will reveal the processing his-
tory of the product." L.S.P.

GENTIAN. X.F.. B.P.

Gentian Root. [G«ntiana]

"Gentian is the dried rhizome and roots of
Gentiana lutea Linne (Fam. Gentianacece). Gen-
tian yields not less than 30 per cent of water-
soluble extractive.'" X.F. The B.P. recognizes the
dried fermented rhizome and root of the same
origin, and requires not less than 33.0 per cent of
water-soluble extractive.

Yellow Gentian Root; Bitter Root; Felwort. Radix
Gentianae. Fr. G«ntiane ; Racine de gentiane; Gentiane
jaune. Ger. Enzianwurzel ; Bitterwurzel; Roter Enzian;
Gelber Enzian: Fieberwurzel; Hochwurzel. It. Genziana.
Sp. Genciana; Raiz de genciana.

Gentiana lutea or yellow gentian is among the
most remarkable of the species which compose
this genus, because of its beauty and large size.
From its perennial rhizome — which is thick, long
and branching — an erect, round stem rises to the
height of 3 or 4 feet, bearing opposite, sessile,
ovate, acute, five- to seven-nerved leaves of a
bright-green color, and somewhat glaucous. The
flowers are large and beautiful, of a yellow color,
and arranged in axillary cymes along the upper
part of the stem. The calyx is gamosepalous.
membranous, yellowish, and semi-transparent,
splitting when the flower opens, and reflected
when it is fully expanded: the corolla is rotate,
and deeply divided into five or six lanceolate,
acute segments; the stamens are five or six. and
shorter than the corolla. The fruit is an ovate
capsule containing winged seeds. The plant grows
among the Apennines, the Alps, the Pyrenees, the
Juras and Vosges. and in other mountainous or
elevated regions of Europe and Asia Minor. The
drug is collected, in the summer months, from
plants two to five years old and usually prepared
by placing the rhizomes and roots in heaps which
are allowed to he on the ground for some time and
ferment. These are then washed, dried in the
open, then in sheds, and cut into variable lengths.
During the process of fermentation the white
internal color of the drug changes to an orange
brown, some of the original bitterness is lost and
the characteristic odor is acquired.

Gentian comes to the United States from vari-
ous European countries. In 1952 a total of 246. 65S
pound were imported into the U.S.A. from Yugo-
slavia, France and Spain.

Several other species are used like the official
drug. The roots of G. purpurea L., and G. punc-

tata L.. inhabiting the same regions as G. lutea,
and of G. pannonica Scopoli. growing in Austria,
are said to be often mixed with the official species.
All of these are usually smaller than the official
article, the G. purpurea rhizomes being crowned
with a number of aerial stem bases with scaly
remains of leaves attached. The German Pharma-
copoeia permits the use of the rhizome and roots
of these three species.

One indigenous species. G. Catesbcei (now G.
Elliottii Chapm. ». growing in the southern States,
formerly was recognized in the secondary list of
the U.S. P.. and is reputed to be but httle inferior
to the official species. This plant, popularly called
blue gentian, has a perennial, branching, some-
what fleshy root, and a simple, erect, rough stem,
rising eight or ten inches in height, and bearing
opposite ovate-lanceloate leaves and pale blue
flowers, crowded, nearly sessile, and axillary or
terminal. It grows in the grassy swamps from
Virginia to Florida, where it flowers from Sep-
tember to December. It may be given in powder
in doses of 1 to 2 Gm.. or in the form of extract,
infusion, wine or tincture.

Description. — "Unground Gentian occurs in
nearly cylindrical pieces, sometimes branched,
entire or longitudinally split, from 5 to 40 mm. in
thickness ; the rhizome portions are annulate from
leaf scars and frequently end in a bud; the rhi-
zome and roots are longitudinally wrinkled, some-
times twisted, moderate brown to weak brown
externally. Gentian is brittle when dry, tough and
flexible when damp; internally yellowish brown
to dusky yellowish orange, with a bark from 0.5
to 2.5 mm. in thickness, separated from a porous
wood by a dark cambium zone and radiate in
appearance, especially in the region of the cam-
bium. The odor is strong and characteristic. The
taste is slightly sweet at first, then strongly and
persistently bitter." X.F. For histology see X.F. X.

''Powdered Gentian is yellowish brown to yel-
lowish orange. It consists chiefly of parenchyma
cells containing oil globules, with fragments of
reticulate and scalariform vessels and tracheids;
fragments of cork and collenchyma: occasional
clumps of minute prismatic crystals of calcium
oxalate in angles of parenchyma cells: starch
grains few or absent. Stone cells and fibers are
absent." X.F.

Standards and Tests. — Water. — Not over
15 per cent. Foreign organic matter. — Not over 2
per cent. Identification. — On microsublimation
powdered gentian yields pale, greenish yellow,
acicular crystals which are insoluble in water, in
alcohol, and in ether, but soluble in chloral hy-
drate and potassium hydroxide solutions. The
crystals are mostly 10 to 150 ji in length, straight
to slightlv curved, and isolated or in small clus-
ters. X.F.

Assay. — Proceed as directed under Water-
soluble extractive. X.F.

Constituents. — Kromayer. in 1862, first ob-
tained the bitter principle of gentian as a pure
substance and gave it the name of gentiopicrin.
This principle has been found in many other
species of the genus Gentiana and seems to be a
characteristic constituent of the genus. It is a
glycoside, crystallizing in colorless needles, which

Part I

Gentian Tincture, Compound 603

readily dissolve in water. It is soluble in 95 per
cent alcohol, but dissolves in absolute alcohol only
on heating; it does not dissolve in ether. Sodium
hydroxide forms with it a yellow solution. Dilute
acids hydrolyze gentiopicrin into a sugar and an
amorphous, yellowish-brown neutral substance
named gentiogenin. Fresh gentian roots yield, ac-
cording to Tanret (Pharm. J., 76, 87), about 1.5
per cent of gentiopicrin but dried roots only about
0.1 per cent of gentiopicrin. Asahina, however,
states (Ber., 1939, 72B, 1534) that gentiogenin
is a polymer of the true aglycone which he calls
protogentiogenin. The proportion of gentiopicrin
in the root apparently diminishes on aging (Bridel,
/. pharm. chim., 1920, 22, 411).

Other constituents which have been reported in
gentian include: a second glycoside gentiin, which
forms yellow crystals insoluble in water; gentia-
marin, which is soluble in either water or alcohol
and appears to be related to the tannins, giving a
black precipitate with ferric chloride; gentisin
(also called gentianin or gentianic acid), which
is the 3-monomethyl ether of 1,3,7-trihydroxy-
flavone and forms yellow crystals which are al-
most insoluble in either water or alcohol and is
apparently physiologically inert (see Shinoda,
/. Chem. S., 1927, 130, 1983); gentisic acid (2,5-
dihydroxybenzoic acid) and gentianose, a tri-
saccharide. For further review of the chemistry
of gentian see Redgrove (Pharm. J., 1929, 122,
324).

Adulterants. — The unground drug has been
mixed with rhizomes of Rnmex alpinus which give
the anthraquinone test. Powdered gentian has
been adulterated with ground olive stones, ground
peanut shells, and even quassia root. These are
all readily detected by means of their lignined
tissues, which may be seen through the use of the
microscope.

Uses.— Gentian has been known from earliest
antiquity and is said to have derived its name
from Gentius, a king of Illyria. Many of the com-
plex preparations handed down from the Greeks
and Arabians include it as an ingredient. The
usual preparations of gentian are, however, almost
without physiological properties except for a local
effect on the mucous membrane of the alimentary
tract. Moorhead (/. Pharmacol., 1915, 7, 577)
offered a scientific rationale for the ancient em-
pirical belief in the bitters, by showing that
gentian markedly increased gastric secretions in
cachetic dogs. As a stimulant to gastric digestion,
gentian was perhaps the most popular of all bitters
in the treatment of atonic dyspepsia, anorexia,
and similar complaints. In overdose it acts as a
local irritant and may cause nausea or vomiting.
According to Tanret (Bull. gen. therap., 1905,
p. 730) gentiopicrin is highly poisonous to the
Plasmodium and, in doses of 1.3 to 2 Gm. (ap-
proximately 20 to 30 grains), is useful in malarial
fevers (it might be pointed out in this connection
that it would require between four and five pounds
of dried gentian root to produce one dose of
gentiopicrin). [v]

Dose of gentian, 1 to 2 Gm. (approximately
15 to 30 grains).

Storage. — Preserve "against attack by in-
sects." N.F.

Off. Prep. — Compound Gentian Tincture,
N.F., B.P.; Gentian Fluidextract ; Glycerinated
Gentian Elixir, N.F.; Concentrated Compound
Infusion of Gentian; Compound Infusion of
Gentian, B.P.

GLYCERINATED GENTIAN ELIXIR.

N.F.

[Elixir Gentianae Glycerinatum]

Dissolve 200 Gm. of sucrose in 200 ml. of puri-
fied water, add 400 ml. of glycerin, a mixture of
100 ml. of alcohol and 15 ml. of sweet orange
peel tincture, 10 ml. of gentian fluidextract, 15 ml.
of taraxacum fluidextract, 60 ml. of compound
cardamom tincture, 60 ml. of raspberry syrup, 5
ml. of phosphoric acid, 1 ml. of ethyl acetate, and
sufficient purified water to make 1000 ml. Mix
well and filter, if necessary, until the product is
clear. N.F.

Alcohol Content. — From 12 to 15 per cent,
by volume, of C2H5OH. N.F.

Glycerinated gentian elixir possesses no thera-
peutic action except such as might be due to the
alcohol, but is a useful vehicle for certain "tonic"
drugs. It will discolor when mixed with iron salts.

Storage. — Preserve "in tight containers." N.F.

GENTIAN FLUIDEXTRACT.

[Fluidextractum Gentianae]

N.F.

Prepare the fluidextract from gentian, in moder-
ately coarse powder, by Process A (see under
Fluidextracts) using diluted alcohol as the men-
struum. Macerate the drug during 48 hours, and
percolate at a moderate rate. N.F.

Alcohol Content. — From 33 to 39 per cent,
by volume, of C2H5OH. N.F.

Gentian fluidextract is occasionally prescribed
as a simple bitter in doses of 1 ml. (approximately
15 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

Off. Prep. — Glycerinated Gentian Elixir, N.F.

CONCENTRATED COMPOUND INFU-
SION OF GENTIAN. B.P.

Infusum Gentianae Compositum Concentratum

Concentrated Compound Infusion of Gentian
is made by macerating gentian, bitter orange peel
and lemon peel with 25 per cent alcohol. It repre-
sents approximately 10 per cent w/v of gentian.

When diluted with seven volumes of distilled
water the product is the B.P. Compound Infusion
of Gentian.

The dose of the concentrated infusion is 2 to 4
ml. (approximately 30 to 60 minims) ; that of the
diluted infusion is 15 to 30 ml. (approximately
]/z to 1 fluidounce).

COMPOUND GENTIAN TINCTURE.

N.F. (B.P.)

[Tinctura Gentianae Composita]

B.P. Compound Tincture of Gentian. Sp. Tintura de
Genciana Compuesta.

Prepare a tincture from 100 Gm. of gentian, 40
Gm. of bitter orange peel, and 10 Gm. of carda-

604 Gentian Tincture, Compound

Part I

mom seed, all in moderately coarse powder, by
Process P (see under Tinctures), using first a
menstruum of 100 ml. of glycerin, 500 ml. of alco-
hol and 400 ml. of water, then percolating with
diluted alcohol. Macerate the drugs during 12 to
16 hours, and percolate at a moderate rate. N.F.

The B.P. prepares the tincture by maceration
of 100 Gm. of gentian. 37.5 Gm. of bitter orange
peel, and 12.5 Gm. of cardamom seed with 45
per cent alcohol.

There is generally more or less precipitate in
this tincture; glycerin has been included in an
attempt to prevent precipitation but it does not
entirely avoid it.

Alcohol Content. — From 43 to 47 per cent,
by volume, of C2H0OH. U.S.P.

This tincture is still occasionally employed as a
bitter in treating gastric atony and anorexia.

Dose, from 4 to 8 ml. (approximately 1 to 2
fluidrachms).

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat.'' N.F.

GINGER. X.F., B.P.

Zingiber

"Ginger is the dried rhizome of Zingiber offi-
cinale Roscoe (Fam. Zingiberacece) known in
commerce as Jamaica Ginger, African Ginger,
and Cochin Ginger. The outer cortical layers are
often either partially or completely removed."
X.F. The B.P. recognizes the scraped and sun-
dried rhizome of the same species, specifying "un-
bleached Jamaica Ginger."

Ginger Rhizome. Rhizoma Zingiberis. Fr. Gingembre ;
Racine de gingembre. Ger. Ingwer; Ingber. It. Zenzero.
Sp. Jengibre.

The genus Zingiber includes about 70 species
of perennial herbs, having horizontal tuberous
rhizomes, all native to tropical countries, most
of the commercial ginger being obtained from
Zingiber officinale. This species is a native of
tropical Asia, but now extensively cultivated in
tropical countries of both the Eastern and West-
ern Hemispheres. It has been introduced into
southern Florida, where it thrives in rich soil and
partial shade.

The ginger plant has a perennial, creeping rhi-
zome, and an annual stem, which rises two or
three feet in height, is solid, cylindrical, erect,
and enclosed in an imbricated membranous sheath.
The leaves are sessile, lanceolate or linear-
lanceolate, acute, smooth, up to eight inches long
by about three-quarters of an inch in breadth,
and stand alternately on the sheaths of the stem.
The flower-stalk rises by the side of the stem
from six to twelve inches high without foliage
leaves, and terminates in an ellipsoidal, obtuse,
bracteal, imbricated spike. The flowers are of a
greenish-yellow color with a purple lip spotted
with yellow and appear two or three at a time
between the bracteal scales. The fruit is an oblong
capsule. The plants mature in from nine to ten
months. The rhizome of the ginger is lifted from
the soil by a single thrust of a fork at the time
when the stems of the plant turn white, before
the rhizome has begun to get tough and fibrous.

It is prepared in different ways for the market,
which is an important factor in determining the
appearance of the several varieties. When simply
deprived of roots, and washed, it constitutes the
green ginger which is used for condimental pur-
poses. When, in addition, it is scalded in boiling
water and rapidly dried, it is known as black
ginger. There are other varieties, however, which
after washing are either peeled and bleached,
sometimes with chlorine or sulfurous acid, or
coated with lime. All of the medicinal gingers are
dried before marketing.

In Jamaica, the so-called unbleached Jamaica,
or white ginger, is produced by carefully peeling
the washed fresh rhizomes so that the cork and
outer part of the cortex are removed. These are
washed repeatedly and bleached by exposure to
the sun. The peeled pieces are macerated some-
times in water and sometimes in lime juice, and
not rarely the color of the ginger is improved by
finally coating it with chalk. An inferior white
ginger is produced in the East Indies. The thor-
oughness of desiccation is a matter of commercial
importance. The moisture in ginger should not
exceed 10 per cent, but in the poorer specimens
may constitute one-fourth of the whole weight.
In China the fresh ginger is sometimes rasped
into a powder and as such dried. Formerly East
Indian ginger was imported into the United States
from Calcutta, while the Jamaica or West Indian
ginger came usually through London. At present
the cultivation of ginger is spread almost over the
whole sub-tropical world, and the drug is produced
in Jamaica, St. Lucia. Dominica. Nigeria, West
Indies, Honduras, Mexico, British West Africa.
India. Cochin China, Japan, etc.

The chief varieties of ginger grown in India
are the Cochin and the Calicut, of which the
Cochin is reputed to be the better grade. This
occurs in three forms, viz.. the whitewashed and
bleached, scraped and the unbleached. These
gingers are sent chiefly from the ports of Cochin
and Calicut of Madras to Bombay whence they
are exported to England and America.

In Martinique a ginger is said to be obtained
by the cultivation of Zingiber Zerumbet Rose.
The ginger of Thailand is said to be produced by
Alpinia Galanga Willd. (Galanga, Part II). The
large, ordinary, preserved ginger of China is.
according to C. Ford (Kew Bulletin, 1891). also
the product of the same plant. Preserved ginger
from the West Indies is made from the official
plant. According to Hartwich and Swanlund. the
rhizome of the Zingiber Mioga Roscoe. which is
cultivated in China and Japan, has a taste less
pungent than that of the official ginger, and dis-
tinctly recalling bergamot. Its volatile oil differs
from Jamaica ginger in physical properties.

In commerce the varieties of ginger are known
by the place of their production. African and
Cochin ginger on an average yield more resin
than the other varieties; the African also yields
more volatile oil than the Jamaican.

The recent rhizome, known in commerce as
"green ginger." is from one to four inches long,
somewhat flattened on its upper and under sur-
face, knotty, obtusely and irregularly branched
or lobed, externally of a light ash color with cir-

Part I

cular rugae, internally yellowish-white and fleshy.
It sometimes begins to grow when kept in a damp
atmosphere. The black ginger is of the same gen-
eral shape, but has a dark ash-colored, wrinkled
epidermis, which, being removed in some places,
exhibits patches of an almost black color, appar-
ently the result of exposure. Beneath the epi-
dermis is a brownish cork and a resinous, almost
horny cortical portion. The interior parenchyma
is whitish, the cells being filled with starch with
scattered cells containing resin and oil. The pow-
der is of a light yellowish-brown color. The un-
bleached Jamaica ginger is pale yellowish-buff on
the outside. The pieces are rounder and thinner,
and afford when pulverized a pale yellowish
powder.

The uncoated ginger of the East Indies re-
sembles the Jamaica, but is darker, being gray
rather than pale yellow. As the Jamaica com-
mands a much higher price than even the un-
coated East India production, the latter is occa-
sionally altered to simulate the former. This is
sometimes done by coating the exterior with cal-
cium sulfate or carbonate, sometimes by bleaching
with the fumes of burning sulfur or in other ways,
by which not only the exterior but also the in-
ternal parts are rendered whiter than in the un-
prepared root.

Commercial gingers are known as "scraped,"
"decorticated," and "coated." The "scraped"
gingers are those from which the cortex has been
removed in whole or in part by peeling, as seen
in the Jamaica, and in some Cochin and Japanese
varieties. In the "coated" gingers a portion of the
outer natural layers is retained as in the African,
Calcutta and Calicut varieties. "Bleached" and
"unbleached" gingers are also distinguished, the
former being lighter in color due to careful wash-
ing or special treatment. The African is the most
pungent of the gingers.

During 1952 imports of unground ginger
amounted to 3,974,375 pounds, chiefly from
Jamaica, India, Cuba. Nigeria, O.B.M. Africa,
Taiwan, and Hong Kong.

Description. — "Unground Jamaica Ginger
shows a horizontal rhizome laterally compressed
and irregularly branched, from 4 to 16 cm. in
length and from 4 to 20 mm. in thickness with
the cork wholly removed. It is weak orange to
weak yellowish orange externally. The rhizome is
longitudinally striate showing ends of branches
with depressed stem-scars. The fracture is short,
fibrous, starchy, and resinous, and internally yel-
lowish brown to yellowish orange. The odor is
agreeably aromatic and the taste aromatic and
pungent.

"Unground African Ginger occurs with the cork
partly removed on the flattened sides, leaving
light brownish areas, and showing portions with
cork longitudinally or reticulately wrinkled and
grayish brown. Internally it is light yellow to
brown. The taste is aromatic and strongly pun-
gent. Otherwise it resembles Jamaica Ginger.

"Unground Cochin Ginger occurs with the cork
partially or wholly removed on the flattened sides.
It is fight brown to yellowish gray. The fracture
is shorter, less fibrous, and more starchy than the
other varieties. Internally it is weak yellow to

Ginger 605

medium yellow. The odor is aromatic and the
taste is pungent." N.F. For histology see N.F. X.

"Powdered Ginger is weak yellowish orange
(Jamaica Ginger), light yellowish brown to mod-
erate yellow (African and Cochin Ginger). Starch
grains are numerous, from 5 to 40 n in diameter,
occasionally up to 60 \i in the long axis, nearly
spherical, ovoid, ellipsoidal or pear-shaped, fre-
quently with a characteristic beak, slightly lamel-
lated, the hilum is near the smaller end. The
fibers are long, with rounded, pointed or notched
ends, thin-walled, non-lignified or slightly lignified,
with oblique pits and, where they join the paren-
chyma, distinctly undulate. Long fiber-like cells
with suberized walls and brown to dark brownish
red, resin-like contents are occasionally present.
The vessels are spiral, reticulate or scalariform
and frequently non-lignified. Numerous greenish
yellow to reddish brown secretion cells with vola-
tile oil or resin content are present. Yellowish or
brownish cork cells, thin-walled, occur occasion-
ally in Jamaica Ginger and in scraped Cochin
Ginger, and are fairly numerous in unscraped
Cochin Ginger and in African Ginger." N.F.

Those pieces of ginger which are very fibrous,
light and friable, or worm-eaten, should be re-
jected. The aromatic taste of ginger gradually
lessens, and eventually disappears, on exposure.

For an article on the microscopic and chemi-
cal properties of different varieties of ginger, see
Kraemer and Sindall (Am. J. Pharm., 1908, 80,
303). Kimura and Watanabe have made a com-
parative pharmacognostic investigation of Japa-
nese ginger, Z. Mioga, with special attention to
the starch grains (/. Pharm. Soc. Japan, 1929,
49, 62).

Standards and Tests. — Water-soluble ex-
tractive.— Not less than 12 per cent. Ether-soluble
extractive. — Not less than 4.5 per cent. N.F. The
B. P. requires not less than 4.5 per cent of alcohol
(90 per cent) -soluble extractive, not less than
10.0 per cent of water-soluble extractive, not less
than 1.7 per cent of water-soluble ash, and not
more than 6.0 per cent of ash.

Constituents. — Garnet and Grier isolated a
pungent constituent from ginger which Thresh
named gingerol. This was later investigated by
Nomura, who identified it as (4-hydroxy-3-
methoxyphenyl) ethyl methyl ketone, and named
it zingerone. Its composition is C11H14O3 and it
is a crystalline solid melting at 40° to 41°.
Nomura also reported the presence of shogaol
(from shoga, the Japanese name for ginger). This
is an unsaturated ketone, homologous with zin-
gerone and having the formula C17H24O3. Its re-
actions and synthesis have been worked out by
Nomura and co-workers (Chem. Abst., 1930, 24,
2445).

Zingerone has a sweet odor and an extremely
pungent taste; it is chemically related to vanillin
and to capsaicin. The pungency of ginger, in con-
trast to that of capsicum, is destroyed by heating
with alkali hydroxides.

Clevenger (/. A. Ph. A., 1928, 17, 630), exam-
ining African and Jamaica ginger, found that from
1 to 3 per cent of volatile oil may be expected;
the oil should have a specific gravity from 0.876
to 0.885, and an optical rotation of —40° to —56°,

606 Ginger

Part I

both at 25°, and an index of refraction, at 20°,
from 1.490 to 1.493. Japanese ginger is said to
yield a dextrorotatory oil. The oil from official
ginger consists largely of a mixture of terpenes,
camphene, phellandrene and the sesquiterpene
zingiberene. There is also some citral, cineol and
borneol in the oil.

Ginger root contains also a considerable pro-
portion of starch.

Adulterants. — Powdered ginger is sometimes
adulterated with rice starch, wheat flour, wheat
middlings, powdered flaxseed, or, most frequently,
with powdered ginger which has been exhausted
in making preparations. The loss of pungency is
masked by the addition of capsicum or mustard
and turmeric is added to match the color of the
genuine drug. The detection of spent ginger (the
residue of the drug which has been exhausted in
the preparation of essence), without assay of
some sort, is almost impossible, unless so much
is present as sensibly to alter the taste of the
powder. The tests useful to detect spent ginger
are determinations of ash and the cold water ex-
tract. The presence of capsicum may be detected
by a test specified for the formerly official tinc-
ture (see U.S.D., 21st ed., p. 1117) and based on
the fact that the pungency of capsicum is not
destroyed by heating with alkali hydroxides, as
is the case with ginger (see under Constituents).

Uses. — Ginger is an agreeable stimulant and
carminative, and was formerly often administered
in dyspepsia and flatulent colic. In serous diarrhea,
resulting from relaxation of the bowel, it may be
of service but should not be employed in the
presence of inflammatory conditions. A hot in-
fusion, called "Ginger Tea," was at one time
highly popular for its diaphoretic effect in "colds,"
the infusion being prepared by adding half an
ounce of the powdered or bruised root to a pint
of boiling water, and given in doses of one or two
fluidounces (30 to 60 ml.).

Under the name of "Essence of Ginger" alco-
holic preparations of ginger were formerly sold
and used as intoxicants. A number of cases of
blindness produced by such use have been re-
corded, the amblyopia having been due to the
use of methyl alcohol in the making of these
"essences." Another group of poisonings by im-
pure essence of ginger have been caused by the
presence of tricresyl phosphate. S

Dose, 0.6 to 1.3 Gm. (approximately 10 to
20 grains).

Off. Prep. — Ginger Fluidextract, N.F.; Com-
pound Powder of Rhubarb; Strong Tincture of
Ginger, B.P.

GINGER FLUIDEXTRACT. N.F.

Fluidextractum Zingiberis
Sp. Extracto Fluilo de Jengibre.

Prepare the fluidextract from ginger, in mod-
erately coarse powder, by Process A (see under
Fluidextracts) , using a menstruum of 9 volumes
of alcohol and 1 volume of water. Macerate the
drug overnight, and percolate at a moderate rate.
N.F.

Assay. — A 20-ml. portion of fluidextract is
evaporated on a water bath until the odor of alco-

hol is no longer apparent; the residue is macerated
with several portions of ether, which are filtered
into a tared beaker, the ether evaporated and this
residue dried over sulfuric acid for 18 hours. The
weight of the residue is not less than 900 mg. N.F.

Alcohol Content. — From 69 to 76 per cent,
by volume, of C2H5OH. N.F.

This fluidextract is representative of ginger and
may be used for the same purposes.

Dose, from 0.3 to 1 ml. (approximately 5 to
15 minims).

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." N.F.

GINGER OLEORESIN. N.F.

[Oleoresina Zingiberis]

"Ginger Oleoresin yields not less than 18 ml.
and not more than 35 ml. of volatile ginger oil
from each 100 Gm. of oleoresin." N.F.

Extract the oleoresin from ginger, in moder-
ately fine powder, by percolation with acetone,
alcohol or ether. Recover the greater part of the
solvent by distillation, transfer the residue to a
suitable container, and allow the remainder of the
solvent to evaporate spontaneously. N.F.

Assay. — The volatile oil in 10 Gm. of oleo-
resin is determined by Process A for volatile oil
determinations. N.F.

Ginger oleoresin finds some use as a carmina-
tive and in the treatment of atonic gastrointestinal
conditions.

Dose, from 30 to 120 mg. (approximately Yz
to 2 grains).

Storage. — Preserve "in tight containers." N.F.

Off. Prep. — Aloin, Belladonna, Cascara and
Podophyllum Pills, N.F.

SYRUP OF GINGER.

Syrupus Zingiberis

B:P.

The B.P. preparation is made by mixing 50 ml.
of strong tincture of ginger (B.P.) with sufficient
syrup to make 1000 ml.

The N.F. IX Ginger Syrup was made as fol-
lows: Mix 30 ml. of ginger fluidextract with 20
ml. of alcohol, and triturate the liquid with 10 Gm.
of magnesium carbonate and 60 Gm. of sucrose.
To this gradually add 430 ml. of distilled water
and triturate until the sucrose has dissolved. Filter
the solution, dissolve in it 760 Gm. of sucrose,
warming slightly to facilitate solution, and strain
the syrup. When it is cold, add distilled water,
through the strainer, to make 1000 ml. of syrup.
Mix well. N.F. IX.

Alcohol Content. — From 3.5 to 4.5 per cent,
by volume, of C2H5OH. N.F. IX.

This syrup is occasionally employed as a warm
stomachic addition to tonic and purgative mix-
tures, and sometimes as a flavoring agent.

Dose, 2 to 8 ml. (B.P.) ; the N.F. IX gave the
usual dose as 10 ml.

Storage. — Preserve "in tight containers, and
avoid excessive heat." N.F. IX.

STRONG TINCTURE OF GINGER.
B.P.

Essence of Ginger, Tinctura Zingiberis Fortis

Strong Tincture of Ginger is prepared by per-

Part I

Globulin, Immune Serum

607

colating 50 per cent w/v of ginger with 90 per
cent alcohol. Alcohol content, 82 to 88 per cent,
by volume.

Dose, 0.3 to 0.6 ml. (approximately 5 to 10
minims).

Off. Prep. — Syrup of Ginger; Weak Tincture
of Ginger, B.P.

WEAK TINCTURE OF GINGER. B.P.

Tinctura Zingiberis Mitis

Tinctura Zingiberis (Ger.). Tincture of Ginger; Tinc-
ture of Jamaica Ginger. Fr. Teinture de gingembre. Ger.
Ingwertinktur. It. Tintura di zenzero.

Weak Tincture of Ginger is prepared by diluting
strong tincture of ginger with 4 volumes of 90 per
cent alcohol.

The tincture is a carminative, often being added
to tonic and purgative mixtures in debilitated
states of the alimentary canal.

Dose, from 2 to 4 ml. (approximately 30 to
60 minims).

ANTIHEMOPHILIC GLOBULIN.

U.S.P.

Antihemophilic Globulin (Human), [Globulinum
Antihemophilicum]

"Antihemophilic Globulin is a sterile prepara-
tion containing a fraction of normal human plasma
that is capable of shortening the spontaneous
clotting time of hemophilic blood when it is shed.
It is prepared by fractionation, and contains no
preservative." U.S.P.

Antihemophilic globulin is prepared from nor-
mal human plasma by the method of fractiona-
tion developed by Cohn; the procedure involves
careful control of such variables as alcohol con-
centration, pH, and ionic strength. For a dis-
cussion of plasma fractionation, see under Normal
Human Plasma. The factor required for anti-
hemophilic activity is found in fraction I, together
with several other substances.

Description. — "Antihemophilic Globulin is a
white or nearly white, amorphous substance dried
from the frozen state." U.S.P.

Standards and Tests. — Water. — It loses not
more than 2 per cent of its weight when dried at
room temperature over phosphorus pentoxide at
a pressure of not more than 1 mm. of mercury.
Other requirements. — The globulin complies with
the solubility, identity, pyrogen, safety, sterility
and potency tests and other requirements of the
National Institutes of Health, including the re-
lease of each lot individually before its distribu-
tion. U.S.P.

Uses. — Antihemophilic globulin is used to con-
trol the bleeding of hereditary hemophilia. Peri-
odic intravenous injection of this globulin prep-
aration appears to produce coagulation times that
are within the normal range (Patek and Stetson,
/. Clin. Inv., 1936, 15, 531; Pohle and Taylor,
ibid., 1937, 16, 741).

Hemophilia is an hereditary disease character-
ized by a bleeding tendency of variable degree,
from time to time, and a prolongation of the
coagulation time of venous blood uncontaminated
with tissue juice. The management of hemophilia
involves many procedures, such as prevention of
propagation by male patients and female carriers

of the hereditary trait, avoidance of trauma by
these patients, local anticoagulant and antibac-
terial treatment of wounds, and preoperative
transfusion of whole blood or plasma and careful
selection of the occasion for essential surgical
procedures. The defect in the conversion of pro-
thrombin to thrombin (prothrombin consumption
test, Quick, J.A.M.A., 1951, 145, 2) is an incom-
plete explanation of bleeding in many cases. An
antibody to the deficient globulin factor may be
present or may appear after the injection of anti-
hemophilic globulin or of whole blood or plasma
(Frommeyer et al., Blood, 1950, 5, 401) or an
anticoagulant may be present in the patient's
blood (Conley et al, J. Clin. Inv., 1950, 29, 1182 ;
Singer et al., Blood, 1950, 5, 1135; Alexander
et al., J. Clin. Inv., 1950, 29, 881). Treatment
with this globulin should be employed only in
acute situations, since antibodies form readily
and the globulin loses its beneficial action.

The usual dose, administered intravenously, is
200 mg., with a range of 200 to 600 mg., the latter
generally not being exceeded in 24 hours. The
dose is usually determined for individual patients
by a titration relating the amount of globulin
administered and the therapeutic response it
produces.

Labeling. — "The package label bears the name
Antihemophilic Globulin {Human) ; the contents
in mg. of protein; the lot number and the expira-
tion date, which is not more than 1 year after
date of manufacture; the manufacturer's name,
license number, and address; and the statement,
'Keep preferably at 2° to 10° C. (35.6° to
50° F.).'" U.S.P.

Storage. — Preserve "at a temperature between
2° and 10°, preferably at the lower limit. Dispense
it in the unopened container in which it was
placed by the manufacturer." U.S.P.

IMMUNE SERUM GLOBULIN. U.S.P.

Immune Serum Globulin (Human) (U.S.P. XIV)

"Immune Serum Globulin is a sterile solution
of globulins which contains those antibodies
normally present in adult human blood. It con-
tains a suitable antibacterial agent. Each lot of
Immune Serum Globulin is derived from an orig-
inal plasma or serum pool which represents at
least 1000 individuals. Not less than 90 per cent
of the total protein of Immune Serum Globulin
is globulin." U.S.P.

Measles Prophylactic.

The serum or plasma used for the preparation
of immune serum globulin may be obtained from
the donor either by collection of blood by veni-
puncture or by collection of blood incidental to
the expulsion of the human placenta at the time
of childbirth, or from the placenta itself. Regard-
less of the source of the blood the plasma or
serum is separated and from it the globulins are
concentrated by the alcohol method of Cohn et al.
(see Plasma Fractionation under Normal Human
Plasma). Other methods of refining may be used
providing not less than 90 per cent of the total
protein recovered is in the form of globulin as
demonstrated electrophoretically. Immune serum

608

Globulin, Immune Serum

Part I

globulin was originally prepared by the same
method used for diphtheria antitoxin (McKhann
et al, J. Infect. Dis., 1933, 52, 268); later work,
however, demonstrated the superiority of the al-
cohol method (see Greenburg et al., J.A.M.A.,
1944, 126, 944 and Sweet and Hickman,
/. Pediatr., 1946, 28, 566).

There is no laboratory method to accurately
standardize human immune globulin. However,
since it is now recognized that the antibody
against measles is present in the gamma globulin
fraction of serum, which also contains diphtheria
antitoxin, anti-influenzal antibody and many other
antibodies, the laboratory demonstration of the
presence of these other antibodies in a prepara-
tion of human immune globulin is accepted as
presumptive evidence of the presence of the
measles antibody.

Description. — "Immune Serum Globulin is a
transparent or slightly opalescent liquid, either
colorless or of a brownish color due to denatured
hemogloblin. It is nearly odorless ; it may develop
a slight, granular deposit on aging." U.S. P.

Standards and Tests. — Total solids. — Not
more than 25 per cent, when dried to constant
weight at 105°. Other requirements. — The globu-
lin complies with the identity, pyrogen, safety,
sterility and potency tests and other requirements
of the National Institutes of Health, including
the release of each lot individually before its
distribution.

Uses. — Immune serum globulin is indicated
for the prevention or modification of measles in
susceptible contacts. It is particularly useful in
the control of the disease in hospitals and insti-
tutions for children and in patients already ill,
where a natural attack of measles is likely to
further jeopardize health. Complete protection
may be expected in about 70 per cent of indi-
viduals and modification in 20 to 30 per cent.
Immune serum globulin should be administered
within the first six days after initial exposure.
Some effect, with increased dose, may be expected
up to the tenth day. Modification of the disease
is usually desired to complete prevention because
it results in lasting immunity. Modification does
not appear to affect the infectiousness of the
disease so that susceptible persons exposed to
treated cases may contract the disease (see also
Measles Immune Serum, in Part II). Immune
serum globulin may also be used as a source of
other antibodies as, for example, in the prophy-
laxis and treatment of infectious hepatitis.

Dose. — For prophylaxis or complete preven-
tion of measles the usual dose, subcutaneously or
intramuscularly, is 0.22 ml. per Kg. of body
weight; for modification, 0.045 ml. per Kg. of
body weight is administered, either subcutaneously
or intramuscularly. For prophylactic use in infec-
tious hepatitis the U.S. P. gives the dose as 0.1
ml. per Kg. Immune serum globulin is not
for intravenous use. Local tenderness and stiff-
ness of the muscles may develop and persist for
several hours. The occurrence of hypersensitiza-
tion with repeated injections of globulin should
be borne in mind (J.A.M.A., 1953, 151, 1272).
Immune serum globulin should not be confused
with Poliomyelitis Immune Globulin, Human (see

Part II). Immune serum globulin is not recom-
mended for use in the prevention of poliomyelitis.

Labeling. — "The package label bears the name
Immune Serum Globulin (Human); the lot num-
ber; the expiration date, which is not more than
2 years after date of manufacture or date of
issue; the manufacturer's name, license number,
and address; and the statements, 'Contains . . .
mg. of globulin per ml.,' 'Keep preferably at 2°
to 10° C. (35.6° to 50° F.)' and 'Do not give
intravenously.' " U.S.P.

Storage. — "Preserve Immune Serum Globu-
lin at a temperature between 2° and 10°, prefer-
ably at the lower limit. Dispense it in the un-
opened container in which it was placed by the
manufacturer." U.S.P.

Usual Sizes. — 2 and 10 ml.

LIQUID GLUCOSE. U.S.P., B.P.

Glucose, [Glucosum Liquidum]

"Liquid Glucose is a product obtained by the
incomplete hydrolysis of starch. It consists chiefly
of dextrose (r>glucose. C6H12O6), with dextrins,
maltose, and water," U.S.P. The B.P. recognizes
liquid glucose as obtained by the hydrolysis of
starch, and consisting of a mixture of dextrose,
maltose, dextrin and water.

Syrupy Glucose; Starch Syrup. Glucosum. Cer. Starke-
sirup. Sp. Glucosa Liquida.

Liquid glucose is the product of the acid hy-
drolysis of starch (which see) at elevated tem-
peratures and, generally, under pressure. Follow-
ing hydrolytic action, the product is neutralized
with soda ash or limestone, filtered, decolorized
with bone-char, and concentrated in evaporators
to the desired specific gravity. The proportions
of the various hydrolysis products — dextrose,
maltose and dextrins — in liquid glucose depend
on many variables of the manufacturing process,
chief of which are concentration of the starch
suspension, temperature and pH.

In the United States, corn starch is generally
employed as the raw material; in some countries
of Europe, potato starch is utilized. The name
corn syrup is properly applied only to liquid glu-
cose produced by the hydrolysis of corn starch. In
commerce it is offered in three different "purities"
— low, regular, and high — the term purity refer-
ring to the percentage of reducing sugars, expressed
as dextrose, in the syrup, calculated on a dry sub-
stance basis. The "regular" purity of 43 to 44
forms the bulk of the commercial production.
Liquid glucose is available on the market with
specific gravities ranging from 41° to 46° Baume.
Syrups with a gravity of 41° to 42° Be. are usu-
ally called mixing syrups because of their use in
the manufacture of mixed table syrups; confec-
tioners' syrup, used in candy manufacture, is the
term applied to liquid glucose having a gravity
of 43° to 46° Be.

The reducing property of liquid glucose is use-
ful in some manufacturing operations as, for ex-
ample, in the reduction of indigo to the colorless
derivative, indigo-white. Another useful property
of liquid glucose is that of being able to undergo
alcoholic fermentation, hence its use in the brew-

Part I

Glutamic Acid Hydrochloride 609

ing industry. It is a frequent ingredient in the
manufacture of confectionery, jellies, etc.

It is possible to make glucose not only from
starch but also from many related carbohydrates,
such as cellulose; it is possible, for example, to
prepare it from sawdust.

Glucose is not as sweet as cane sugar and is
more slowly soluble in cold water. Paul {Chem.
Ztg., 1921, 45, 705) evaluated the sweetening
power, compared to sucrose as unity, of dextrose
as 0.52, levulose as 1.03, and lactose as 0.28.

Description. — "Liquid Glucose is a colorless
or yellowish, thick, syrupy liquid. It is odorless,
or nearly so, and has a sweet taste. Liquid Glu-
cose is miscible with water, but is sparingly
soluble in alcohol." U.S.P.

Standards and Tests. — Identification. — A
copious, red precipitate of cuprous oxide forms
on heating a mixture of 5 ml. of hot alkaline
cupric tartrate T.S. and a few drops of a 1 in 20
solution of liquid glucose (distinction from su-
crose). Acidity. — Not more than 0.6 ml. of 0.1 iV
sodium hydroxide is required to neutralize 5 Gm.
of liquid glucose mixed with 15 ml. of water, using
phenolphthalein T.S. as indicator. Water. — Not
over 21 per cent. Residue on ignition. — Not over
0.5 per cent. Sulfite. — A blue color forms on add-
ing 0.2 ml. of 0.1 N iodine followed by starch
T.S. to a solution of 5 Gm. of liquid glucose in
50 ml. of water. Arsenic. — The limit is 1.3 parts
per million. Heavy metals. — The limit is 10 parts
per million. Starch. — No blue color forms on add-
ing 0.2 ml. of 0.1 N iodine to a solution of 5 Gm.
of liquid glucose in 50 ml. of water, the solution
having previously been boiled for 1 minute, then
cooled. U.S.P.

The B.P. requires that liquid glucose be dextro-
rotatory and that the refractive index be not
less than 1.490 at 20°; limits of 1 part per mil-
lion for arsenic, 2 parts per million for lead, and
450 parts per million for sulfur dioxide are
specified.

Uses. — Dextrose is frequently administered
intravenously, but liquid glucose should never be
so used.

This syrupy glucose is used in medicine for
three purposes: First, for its food value by
either oral or rectal administration; secondly, for
its local dehydrating effect, and thirdly, as a
pharmaceutical agent. Like lactose, its taste is
less sweet than that of sucrose. In cases in which
it is undesirable to administer food by the stom-
ach, rectal enemata of 180 to 250 ml. (approxi-
mately 6 to 8 fluidounces) of a 10 per cent solu-
tion of glucose, every four hours, have been em-
ployed. In acidosis, especially that type seen
after prolonged anesthesia, the administration of
large amounts of carbohydrates usually exercises
a most beneficial action. The administration of
glucose immediately before the production of
anesthesia has been recommended as a preventa-
tive for vomiting, especially in children. It is
widely employed as the source of added carbo-
hydrate in feeding formulas for infants; an ap-
propriate amount is added to the diluted cow's
milk prior to terminal sterilization; Karo corn
syrup is a familiar commercial preparation in
the United States.

When given in doses of about 180 ml. (ap-
proximately 6 fluidounces) per day in the form
of the concentrated syrup, it is claimed that glu-
cose acts as a diuretic, and is useful in the treat-
ment of cardiac dropsy. If the kidneys are
healthy, the glucose is said not to appear in the
urine.

Locally, glucose has been used for its dehy-
drating effect, as in the treatment of gunshot
wounds. For this purpose gauze may be saturated
with solutions of glucose, either with or without
the addition of an antiseptic, and placed over the
wounds. It is claimed that this treatment stimu-
lates the flow of lymph and thereby tends to
diminish the severity of infection (see Lancet,
1915, 1, 851).

Pharmaceutical^, glucose is used in solid ex-
tracts and other preparations where a uniform,
moist consistence is desired, and as a diluent.

Off. Prep. — Aloin, Belladonna, Cascara and
Podophyllum Pills, N.F.

GLUTAMIC ACID HYDRO-
CHLORIDE. N.F.

Acidi Glutamici Hydrochloridum

[HOOC.CH2.CH2.CH(N+H3)COOH]Cl-
"Glutamic Acid Hydrochloride, dried at 80°
for 4 hours, contains not less than 99 per cent
and not more than 101 per cent of C5H9NO4.
HC1." N.F.

Acidoride (Abbott), Acidulin (Lilly), Aclor (Cole),
Gastuloric (Warren-Teed), Glutan H-C-L (Lederle) ,
Glutasin (McNeil), Hydrionic (Upjohn), Muriamic (Pit-
man-Moore).

Glutamic acid, first isolated by Ritthausen
from the sulfuric acid hydrolysate of wheat
gluten, in 1866, has been shown to be a product
of the hydrolysis of many proteins, both of plant
and animal origin. Gliadin, a protein of wheat,
contains about 47 per cent of this amino acid,
while casein contains about 23 per cent. Although
it is a nonessential amino acid, it is one of the
important constituents of body proteins, and also
occurs free in many tissues.

The acid, which is 2-aminopentanedioic acid,
has been synthesized by several methods; levu-
linic acid is used as the starting material in one
process but the method of Marvel and Stoddard
(/. Org. Chem., 1938-9, 3, 198) involving addi-
tion of phthalimidomalonic ester to methyl ac-
rylate appears to be the best of the synthetic
methods. Commercial supplies of the acid are ob-
tained from natural sources, as by hydrolysis of
wheat gluten, corn, soybean protein, and also as
a by-product of beet sugar manufacture. The
product obtained from natural sources is dextro-
rotatory, and is properly designated l(+) -glu-
tamic acid.

Glutamic acid occurs in white crystals, spar-
ingly soluble in water, and practically insoluble in
alcohol, ether, and acetone. Being an amino acid
it is amphoteric; the official hydrochloride is
obtained by interaction with hydrochloric acid,
while a monosodium salt may be prepared by in-
teraction with sodium hydroxide.

Description. — "Glutamic Acid Hydrochloride
occurs as a white crystalline powder. Its solution

610 Glutamic Acid Hydrochloride

Part I

is acid to litmus. One Gm. of Glutamic Acid
Hydrochloride dissolves in about 3 ml. of water.
It is almost insoluble in alcohol and in ether."
N.F.

Standards and Tests. — Identification. — (1)
Barium glutamate precipitates when alcohol is
added to a solution containing glutamic acid hy-
drochloride and barium hydroxide. (2) An in-
tense violet-blue color is produced on boiling a
mixture containing glutamic acid hydrochloride,
ninhydrin T.S. and sodium acetate. Specific rota-
tion.— Between +23.5° and +25.5°, when deter-
mined in 3 N hydrochloric acid solution contain-
ing 125 mg. of dried glutamic acid hydrochloride
in each ml. Loss on drying. — Not over 0.5 per
cent, when dried at 80° for 4 hours. Residue on
ignition. — Not over 0.1 per cent. Readily car-
bonizable substances. — A solution of 500 mg. of
glutamic acid hydrochloride in 5 ml. of sulfuric
acid is colorless. Sulfate. — Not over 0.1 per cent.
Heavy metals. — The limit is 20 parts per million.
N.F.

Assay. — About 300 mg. of glutamic acid hy-
drochloride, dried at 80° for 4 hours, is titrated
with 0.1 N sodium hydroxide to neutralize the
hydrochloric acid released by the salt; bromothy-
mol blue T.S. is used as indicator. Each ml. of
0.1 A7 sodium hydroxide represents 9.180 mg. of
C5H9NO4.HCI. N.F.

Action. — Metabolically, glutamic acid is one
of the most reactive of amino acids, being in-
volved in various deamination, transamination,
and amination reactions in the body. It partici-
pates, for example, in the conversion of ornithine
to citrulline in the Krebs-Henseloit cycle of urea
formation; by a reversible process of oxidative
deamination it is converted to a-ketoglutaric acid,
thereby serving as a link between the metabolism
of proteins and of carbohydrates; it is metaboli-
cally related also to histidine. The amide of glu-
tamic acid, known as glutamine, serves as a stor-
age form of ammonia and also as an intermediate
in the removal of ammonia from animal organ-
isms; it is the source not only of urea but the
major part of urinary ammonia as well. Both the
free acid and glutamine are involved in the
metabolism and functioning of nervous tissue;
the concentration of the acid in the brain is
greater than in any other tissue, with the possible
exception of the spleen. Since the brain is com-
monly considered to utilize principally carbohy-
drate for its requirement of energy, and to lack
the nitrogen-catabolizing powers of the liver and
kidney, glutamic acid thus occupies a unique
position among amino acids. The amine, but not
the acid, is believed to cross the blood-brain
barrier. The role of the glutamic acid-glutamine
system in the brain appears to involve neutrali-
zation of ammonia and removal of ammonium ion
from the brain, an important role in view of the
toxicity of ammonia and its salts to cells in gen-
eral and nervous tissue in particular.

Uses. — Glutamic acid and its hydrochloride
have been investigated as possible therapeutic
agents for the treatment of petit mal type of epi-
lepsy. Reports of their value in reducing the fre-
quency of seizures in this disease have appeared.

along with the interesting observation that im-
provement in mental and physical alertness oc-
curred in patients thus treated. Although origi-
nally it was assumed that the acidifying property
of racemic glutamic acid hydrochloride was re-
sponsible for the beneficial effect, later experi-
ments appear to have established that the L-form
of the acid is the sole therapeutic agent (Waelsch
and Price, Arch. Neurol. Psychiat., 1944, 51,
393). A number of investigations seeking to de-
termine the effect of glutamic acid on the intelli-
gence of mentally retarded human patients have
been undertaken. Reports of an intelligence-
enhancing effect have appeared (Albert et al.,
J. Nerv. Ment. Dis., 1951. 114, 471; Zimmerman
et al, Am. J. Psychiat., 1948, 104, 593; 1949,
105, 661; Ewalt and Bruce, Texas Rep. Biol.
Med., 1948, 6, 97), along with reports that no
effect whatsoever of this nature could be found
(Oldfelt, /. Pediatr., 1952, 40, 316; Nutrition
Rev., 1951, 9, 113; Milliken and Standen, /.
Neurol. Neurosurg. Psychiat., 1951, 14, 47;
Kantor and Boyes, Science, 1951, 113, 681; Phil-
lips, Fed. Proc, 1954, 13, 112). Whether or not
glutamic acid is useful in improving human intel-
ligence remains in dispute.

Other uses of L-glutamic acid include that of
restoring consciousness to schizophrenic patients
in hypoglycemic coma following insulin treat-
ment, the substance being injected intravenously
in a dose of 20 Gm. of the sodium salt (Mayer-
Gross and Walker, Biochem. J., 1949, 44, 92;
Braitinger and Zeise, Munch, med. Wchnschr.,
1952, 94, 834). It has been recommended for
treatment of muscular dystrophies (Tripoli and
Beard, J. A.M. A., 1934, 103, 1595). It is also of
interest that patients with malignant tumors have
a higher plasma glutamic acid concentration than
normal individuals or those with benign tumors
(Beaton et al., Fed. Proc, 1954, 13, 319).

Acidifying Action of Hydrochloride. — By
virtue of its releasing hydrochloric acid in aque-
ous solution, the hydrochloride is employed as
a means of administering the mineral acid in the
treatment of subchlorhydria, pernicious anemia,
and other conditions of deficient acidity of the
stomach. A dose of 300 mg. (approximately 5
grains) of glutamic acid hydrochloride is equiva-
lent in acidulating power to 0.6 ml. (approxi-
mately 10 minims) of the official diluted hydro-
chloric acid. Rabinowitch {Am. J. Digest. Dis.,

1949, 16, 322) and others reported improved
response to iron therapy when glutamic acid hy-
drochloride was administered simultaneously.
Studies with dogs (Whipple and Robscheit-
Robbins, J. Exp. Med., 1940, 71, 569) and rats
(Fitzhugh et al, J. Biol. Chem., 1933, 103, 617)
have indicated that glutamic acid stimulates
hemoglobin formation. Orr (/. Oklahoma M. A.,

1950, 43, 451) reported relief of nausea and
vomiting during the first trimester of pregnancy
with a glutamic acid hydrochloride and ferrous
sulfate preparation.

Monosodium Glutamate. — This salt, repre-
senting glutamic acid in which one of the carboxyl
groups has been neutralized with sodium, im-
parts a saline, beef-broth-like flavor which many

Part I

Glycerin 61 1

persons find attractive as a seasoning of foods.
The salt occurs as a white or nearly white crystal-
line powder, very soluble in water.

Dose. — Glutamic acid, for the uses described
above, is given in amounts of 6 to 20 Gm. (ap-
proximately \l/i to 5 drachms) daily, divided into
three or four equal doses. The dose of the hydro-
chloride, for achlorhydria, is 0.3 to 1 Gm. (ap-
proximately 5 to 15 grains), during or immedi-
ately after meals.

Storage. — Preserve "Glutamic Acid Hydro-
chloride in well-closed, light resistant containers."
N.F.

GLUTAMIC ACID HYDROCHLORIDE
CAPSULES. N.F.

"Glutamic Acid Hydrochloride Capsules con-
tain not less than 93 per cent and not more than
107 per cent of the labeled amount of C5H9NO4.-
HC1." N.F.

Usual Size.— 300 mg. (approximately 5
grains).

GLYCERIN. U.S.P., B.P. (IP.)

Glycerol, [Glycerinum]
CH2OH.CHOH.CH2OH

"Glycerin contains not less than 95 per cent
of C3H8O3." U.S.P. The B.P. defines it as pro-
pane-1 :2 :3-triol, containing not less than 98.0
per cent of C3H8O3. The LP. requires not less
than 97.0 per cent of QHsO:}. Under the title
Dilute Glycerol (Glycerolum Dilutum) the LP.
recognizes a mixture of propanetriol and water
containing not less than 86.4 per cent and not
more than 88.3 per cent of C3H8O3.

I. P. Glycerol; Glycerolum. Glycerine. Glycerina. Fr.
Glycerine officinale. Gcr. Glyzerin ; Glycerin. It. Glicerina.
Sp. Glicerina.

Discovered in 1779 by Scheele, who called it
the sweet principle of fats, glycerin has its most
important source in oils and fats, in which it
occurs in the form of esters of fatty acids called
glycerides, and from which it may be obtained
by saponification. In time of peace, adequate
amounts of glycerin may be produced as a by-
product in the manufacture of soap. It is found
in the spent lyes from soap; the lye solution is
treated with iron or aluminum salts to precipi-
tate impurities and the filtrate from the mixture
is concentrated to yield crude glycerin, from
which the pure substance may be obtained by
distillation with steam under reduced pressure,
and subsequent evaporation of water.

Glycerin may also be obtained by fermentation
of various carbohydrate substances, the yield
being materially increased by the inclusion of an
acetaldehyde fixative such as sodium sulfite. Nor-
mally, fermentation processes cannot compete
with the soap-producing industry, but in times of
war the increased demand for glycerin is such
as to require utilization of every manufacturing
process that is available.

In 1938 synthesis of glycerin from propylene,
occurring in petroleum, began. In the process
propylene is chlorinated to allyl chloride, then

converted to trichloropropane and finally hydro-
lyzed to glycerin; conversion of the allyl chlo-
ride to allyl alcohol and then, by addition of
HOC1, to alpha-monochlorohydrin, from which
glycerin is obtained by hydrolysis, is an alterna-
tive process.

During World War II German chemists de-
veloped a process for making glycerin by hydro-
genating invert sugar at about 200° and 400
atmospheres pressure. After filtering the reaction
product, treating it with charcoal, and drying
under vacuum, the residue consisted of a mixture
of 40 per cent glycerin, 40 per cent propylene
glycol, and 20 per cent hexahydric alcohol; by
fractionation the glycerin may be separated, al-
though for explosives manufacture the mixture
may be employed.

Description. — "Glycerin is a clear, colorless,
syrupy liquid, having a sweet taste. It has not
more than a slight, characteristic odor, which is
neither harsh nor disagreeable. When exposed
to moist air, it absorbs water. Its solutions are
neutral to litmus paper. Glycerin is miscible with
water and with alcohol. It is insoluble in chloro-
form, ether, and in fixed and volatile oils. The
specific gravity of Glycerin is not less than 1.249,
indicating not less than 95 per cent C3H8O3."
U.S.P. The B.P. states that when kept for a con-
siderable time at a low temperature glycerin
may solidify to a mass of colorless crystals which
do not melt until the temperature reaches about
20°. The weight per ml., at 20°, is required to be
between 1.255 and 1.260, corresponding to 98.0
to 100.0 per cent of C3H8O3.

Exposed to the air glycerin gradually absorbs
moisture. Pure glycerin boils at 290° at atmos-
pheric pressure; under reduced pressure (12 mm.)
it boils at 170°. Cooled rapidly, it becomes more
viscid, without congealing, even when a tempera-
ture of — 40° is attained; but, if kept for some
time at a temperature not above about 0°, it
gradually forms hard but deliquescent crystals,
which melt at 17.9°.

Glycerin possesses extensive powers as a sol-
vent. For example, it dissolves bromine and
iodine, sulfur iodide, potassium and sodium chlo-
rides, the fixed alkalies, some of the alkaline
earths (it increases the solubility of lime in
water), the sodium derivatives of the sulfona-
mides, and even some of the sulfonamides them-
selves. It is a good solvent of pepsin.

Standards and Tests. — Color. — When viewed
downward against a white surface in a 50-ml.
Nessler tube the color of glycerin is not darker
than that of a standard prepared by diluting 0.4
ml. of ferric chloride C.S. to 50 ml. with water,
the standard being viewed similarly. Identifica-
tion.— Pungent vapors of acrolein are evolved on
heating several drops of glycerin with about 500
mg. of potassium bisulfate. Residue on ignition. —
On igniting 50 Gm. of glycerin in an open, shallow
dish, then igniting the residue in the presence of
sulfuric acid, not more than 5 mg. of ash is ob-
tained. Chloride. — The limit is 10 parts per mil-
lion. Sulfate. — No turbidity develops on adding
3 drops of diluted hydrochloric acid and 5 drops
of barium chloride T.S. to 10 ml. of a 1 in 10

612 Glycerin

Part I

solution of glycerin. Arsenic. — The limit is 2 parts
per million. Heavy metals. — The limit is 5 parts
per million. Readily carbonizable substances. — A
mixture of 5 ml. of glycerin and 5 ml. of sulfuric
acid, shaken vigorously for 1 minute and then
allowed to stand 1 hour, is not darker than match-
ing fluid H. Acrolein, glucose, and ammonium
compounds. — A mixture of 5 ml. of glycerin and
5 ml. of a 1 in 10 solution of potassium hydroxide
does not become yellow on heating at 60° for
5 minutes, nor does it evolve ammonia. Fatty
acids and esters. — On boiling 40 ml. (SO Gm.) of
glycerin with 5 ml. of 0.5 N sodium hydroxide
and 50 ml. of freshly boiled water for 5 minutes
not more than 1 ml. of 0.5 N alkali is consumed.
U.S.P.

The B.P. gives the following additional charac-
teristics and tests. On heating in the flame of a
Bunsen burner on a borax head it imparts a green
color to the flame. When strongly heated it ac-
quires a faintly yellow, but not pink, color, and
it eventually volatilizes and burns with little or
no charring, and without emitting an odor of
burnt sugar. The refractive index at 20° is be-
tween 1.4696 and 1.4726. The arsenic and lead
limits are 2 parts and 1 part per million,
respectively.

Incompatibilities. — The addition of glycerin
to solution containing borax renders such solu-
tions incompatible with carbonates because of
development of acidity in the former (see under
Boric Acid and Sodium Borate). Oxidizing agents
such as chlorinated lime, chromates, hydrogen
peroxide, or manganese dioxide convert glycerin
to oxalic acid and carbon dioxide. When triturated
with dry oxidizing agents an explosion may take
place. Potassium permanganate decomposes dilute
solutions of glycerin.

Uses. — Pharmaceutical. — The pharmaceu-
tical uses of glycerin are many and varied. Next
to water it is probably the most widely used
vehicle for medicinal substances, whether these
are for internal or external use.

Glycerin is a good solvent for many inorganic
and organic substances. But its value as a vehicle
depends not only on its solvent properties, but
also on one or more of such properties as its high
viscosity, its water-absorbing property, its ability
to lower the surface tension of water, its osmotic
effect, its miscibility with water and alcohol, and
its sweetness. Many official preparations utilize
glycerin in their formulation; a class of prepara-
tions, known as glycerites, use it exclusively as
the solvent. In many medicinal preparations
which contain water the inclusion of glycerin pre-
vents or retards hydrolytic decomposition of
therapeutically active ingredients. Thus a com-
bination of solvent action on tannins and retarda-
tion of their hydrolysis makes glycerin an im-
portant component of liquid dosage forms of
many tannin-containing drugs. Another advan-
tage of glycerin, as compared with syrup, is its
non-fermentability. Its antiseptic action, however,
is so slight that it is hardly useful for this pur-
pose, unless it is present in sufficient concentra-
tion to dehydrate bacteria. Ruediger (J.A.M.A.,
1915, 64, 1529) found that 50 per cent glycerin

destroyed certain-non-sporulating bacteria only
after four days' exposure while spore-forming
bacteria were not destroyed even after fifteen
days of exposure; Goodrich {Pharm. J., 1917, 98,
453 ) stated that 50 per cent glycerin has hardly
more disinfectant action than pure water. On the
other hand its inclusion in a variety of medicinal
preparations for local application, as lotions and
ointments, often enhances their antibacterial
and or other therapeutic effects. It has been used
in the formulation of many preparations, for ex-
ternal application, of sulfonamides and antibiotics.

Sometimes glycerin is used as a plasticizing
agent, as in preserving elasticity in preparations
containing gelatin, such as glycerinated gelatin
suppositories and the gelatin base lamellae of the
British Pharmacopoeia. Similar plasticizing action
is utilized in certain film-producing dermatological
preparations made with methyl cellulose, poly-
vinyl alcohol, etc.

Medicinal. — When placed in contact with
mucous membranes glycerin absorbs moisture and
causes temporary irritation; such is the action
which is responsible for the effectiveness of glyc-
erin, when applied rectally in suppository form,
in producing fecal discharges in habitual consti-
pation (see Glycerin Suppositories) . When diluted
with water it is demulcent. Its emollient and
lubricant effects are variously utilized, as in some
preparations for treatment of coughs and others
for application to the skin.

In the treatment of various skin diseases glyc-
erin is most frequently employed for its emollient
effect. By virtue of its dehydrating and osmotic
actions it is sometimes used as a local application
to furuncles and other inflammatory processes.
Thus it is widely used, alone or as a vehicle for
other drugs, in inflammations of the external audi-
tory canal or the middle ear. In this connection
it is of interest that in cases of perceptive deaf-
ness the effect of instilling glycerin into the ex-
ternal auditory canal was to reduce hearing acuity
by at least 30 decibels (Suzuki and Hirose. Arch.
Otolaryng., 1952, 55, 465). Glycerin itself has
been used in treating burns of the hands and face
where tough film or eschar formation is to be
avoided (MacKenzie, Can. Med. Assoc. /., 1942,
47, 443); the dehydrating action of glycerin pre-
vents growth of bacteria. Glycerin pastes of solu-
ble sulfonamides have been used similarly.

Toxicology. — As has been shown by a num-
ber of investigators, when injected intravenously
glycerin causes hemolysis, hemoglobinuria, and
other toxic effects. When taken by mouth, how-
ever, it is completely innocuous unless the dose
is large enough to exert an osmotic effect (John-
son and Carlson, Am. J. Physiol., 1933, 103, 517).
Dogs fed 9 Gm. per Kg. of body weight daily for
a year showed no apparent ill effects; humans
who ingested 110 Gm. daily for 50 days showed
no evidence of changes in the blood or of kidney
irritation. Johnson and Carlson found further that
in moderate amounts glycerin is oxidized in the
svstem and can replace a part of carbohvdrate
food. Doerschuk (/. Biol. Chem., 1951, 193, 39)
employed radioactive carbon- 14-labeled glycerin
in his studies of the metabolism of the compound.

Part I

Glyceryl Monostearate 613

As might be expected, no difference between the
toxicity of natural and synthetic glycerin exists
(Anderson et al, J. A. Ph. A., 1950, 39, 583).

The average dose of glycerin, by mouth, might
be 4 ml. (approximately 1 fluidrachm), though it
is rarely if ever given as such.

Storage. — Preserve "in tight containers."
U.S.P.

GLYCERIN SUPPOSITORIES.

U.S.P. (B.P.)

[Suppositoria Glycerini]

B.P. Suppositories of Glycerin. Suppositoria cum Glyc-
erine Fr. Suppositoires a la glycerine. Ger. Glycerin-
suppositorien. It. Coni anali di glicerina solidificata. Sp.
Supositorios de Glicerina.

Heat 91 Gm. of glycerin in a porcelain or other
suitable container, on a suitable bath, to about
115° to 120°, add 9 Gm. of sodium stearate, and
stir the mixture gently with a glass rod while
maintaining the temperature until the sodium
stearate has dissolved. Then add 5 ml. of purified
water, mix thoroughly, and immediately pour
the hot liquid into suitable molds. Remove the
suppositories when cold. If preferred, the sodium
stearate may be prepared by the reaction of
stearic acid with sodium bicarbonate, sodium car-
bonate, or sodium hydroxide. U.S.P.

The B.P. prepares glycerin suppositories from
glycerinated gelatin containing 70 per cent of
glycerin and 14 per cent of gelatin, the remainder
being water.

Glycerin suppository has been official in the
U.S.P. since 1890. In the earlier processes of
manufacture sodium stearate was prepared from
sodium carbonate and stearic acid, but Prout
(J. A. Ph. A., 1936, 25, 1123) found that the
commercially available sodium stearate could be
used directly.

Uses. — Glycerin suppositories are used to pro-
duce fecal discharges in constipation. They act by
local irritation of the mucous membrane of the
rectum, and are often effective, though never
purgative. As an occasional remedy they are
useful, but their habitual employment is probably
injurious to the mucous membrane.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 25°." U.S.P.

COMPOUND GLYCEROPHOSPHATES
ELIXIR. N.F.

Compound Glycerophosphates Solution, [Elixir
Glycerophosphatum Compositum]

Dissolve 35 Gm. of sodium glycerophosphate
and 16 Gm. of calcium glycerophosphate in 400
ml. of purified water containing 20 ml. of lactic
acid. Dissolve 3 Gm. of ferric glycerophosphate,
2 Gm. of manganese glycerophosphate and 600
mg. of citric acid in 50 ml. of purified water with
the aid of heat and add to the first solution. Dis-
solve 125 mg. of strychnine nitrate in 10 ml. of
purified water. Dissolve 875 mg. of quinine hydro-
chloride in a mixture of 125 ml. of alcohol and
2 ml. of compound cardamom spirit, and add 350
ml. of glycerin to the solution. Mix the three
solutions, add enough purified water to make 1000
ml. and, if necessary, filter the mixture. N.F.

Alcohol Content. — From 10 to 12 per cent,
by volume, of C2H5OH. N.F.

It is too much to expect that each ingredient of
this "tonic" elixir will be of therapeutic value in
the dose of 8 ml. usually given. Each such dose
represents 280 mg. of sodium glycerophosphate,
128 mg. of calcium glycerophosphate, 24 mg. of
ferric glycerophosphate, 16 mg. of manganese
glycerophosphate, 7 mg. of quinine hydrochloride,
and 1 mg. of strychnine nitrate; the quantity of
the last ingredient approaches a therapeutic dose.

Dose, 8 ml. (approximately 2 fluidrachms).

Storage. — Preserve "in tight, light-resistant
containers." N.F.

GLYCERYL MONOSTEARATE. N.F.

Monostearin, [Glyceryl Monostearate]

It is possible to esterify one, two or all three
of the hydroxyl groups of glycerin with various
fatty acids; for example, glyceryl monostearate,
glyceryl distearate, and glyceryl tristearate may
be prepared. Moreover, depending on the position
of the hydroxyl groups to be esterified, two dif-
ferent glyceryl monostearates and two different
glyceryl distearates may be made.

The product known as glyceryl monostearate
is prepared by heating, under pressure and in the
presence of an alkaline catalyst, glycerin and
stearic acid. The product contains 30 to 40 per
cent of glyceryl monostearate, with variable
amounts of the distearate and tristearate and un-
reacted glycerin and stearic acid. One manufac-
turer, at least, concentrates the glyceryl mono-
stearate by molecular distillation to produce a
product containing at least 90 per cent of that
ester (Drug Standards, 1952, 20, 35). This ester
is esterified at the alpha hydroxyl group of glyc-
erin. Glyceryl esters may also be prepared by re-
action between the appropriate chlorohydrin and
sodium stearate; the reaction is not utilized
commercially.

Description. — "Glyceryl Monostearate occurs
as a white, wax-like solid or as white, wax-like
beads or flakes. It has a slight, agreeable, fatty
odor and taste. It is affected by light. Glyceryl
Monostearate dissolves in hot organic solvents
such as alcohol, mineral or fixed oils, benzene,
ether and acetone. It is insoluble in water but it
may be dispersed in hot water with the aid of a
small amount of soap or other suitable surface
active agent. Glyceryl Monostearate does not
melt below 55°." N.F.

Standards and Tests. — Residue on ignition.
— Not over 0.1 per cent. Acid value. — Not more
than 18. Saponification value. — Not less than 164
and not more than 170. Iodine value. — Not more
than 6. N.F. For data concerning properties of
commercial samples of glvceryl monostearate, see
Green (Bull. N.F. Com., 1946, 14, 160).

Uses. — The specific uses to which glyceryl
monostearate may be put depend to a large extent
on whether or not it contains, or there is added to
it in the process of compounding, soap or other
suitable surface active agent. Though the presence
of two hydroxyl radicals (hydrophilic groups) and
a long hydrocarbon chain (hyrophobic group)

614 Glyceryl Monostearate

Part I

confers on the substance some degree of surface-
active properties (see Surface-Active Agents, Part
II), such properties may need to be enhanced by
the addition of soap or other surface-active agent
(see the description above). Commercial products
often contain such added agents to make it dis-
persible in water; the ester is then described as
being self-emulsifying. Usually potassium stearate
is incorporated, to the extent of 5 or 10 per cent,
for this purpose, but other substances may be
used. It is apparent that an incomplete specifica-
tion of the composition of different samples of
glyceryl monostearate may lead to wide discrep-
ancies in the results of their use. The official arti-
cle should not contain added emulsifying aids.

Glyceryl monostearate has been employed in
the formulation of a variety of cosmetic creams
which are claimed not to crack at freezing tem-
peratures, as do ordinary stearate creams. It is
an ingredient of several dermatological prepara-
tions which are used to prevent industrial der-
matitis (for typical formulas see Klauder et al.,
Arch. Dermat. Syph., 1940, 41, 331; also Lesser,
Drug Cosmet. Ind., 1943, 53, 630). Sorg and
Jones (/. A. Ph. A., Prac. Ed., 1941, 2, 400) and
Fiero and Dutcher (/. A. Ph. A., 1945, 34, 56)
published formulas including it in several types of
bases — emulsified, non-emulsified and vanishing —
for use in preparing ointments. Some of these for-
mulas are reproduced in the review article by
Green (/. A. Ph. A., Prac. Ed., 1946, 7, 299).

Liquid emulsions for external use are some-
times stabilized by addition of 0.5 per cent of
glyceryl monostearate. When pure, or when con-
taining a harmless surface-active agent like potas-
sium stearate, glyceryl monostearate may be used
in the formulation of medicinal and food prod-
ucts for internal use. It has been suggested as a
coating for hygroscopic powders or tablets to pro-
tect them against atmospheric influences.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

GLYCERYL TRIACETATE.

Triacetin, [Glycerylis Triacetas]

(CHsCOCOsCsHs

N.F.

"Glyceryl Triacetate contains not less than 98.5
per cent of C9H14O6." N.F.

Sp. Triacetato de Glicerilo.

By heating glycerin with acetic acid or acetic
anhydride, mono-, di-, and tri-substituted acetate
esters may be obtained. The higher the reaction
temperature and the greater the concentration of
acid or anhydride, the larger the proportion of
triacetate produced. The official product contains
some monoacetate and diacetate as well.

Description. — "Glyceryl Triacetate is a color-
less, somewhat oily liquid with a slight, fatty odor,
and a bitter taste. Glyceryl Triacetate is soluble
in water. It is miscible with alcohol, with ether
and with chloroform, and is insoluble in carbon
disulfide. The specific gravity of Glyceryl Triace-
tate is not less than 1.154 and not more than
1.158." N.F.

Standards and Tests. — Distillation range. —
Not less than 95 per cent distils between 257° and

260°. Refractive index. — Not less than 1.4288
and not more than 1.4296. Identification. — (1)
Pungent vapors of acrolein are emitted on heating
a few drops of glyceryl triacetate with about 500
mg. of potassium bisulfate. (2) The solution re-
sulting from the determination of the saponifica-
tion value of glyceryl triacetate responds to the
test for acetate. Water. — Not more than 0.3 ml.
of water is obtained from 150 ml. of glyceryl
triacetate by the toluene distillation method.
Acidity. — Not more than 1 ml. of 0.02 N sodium
hydroxide is required for neutralization of 25 Gm.
of glyceryl triacetate. Unsaturated compounds. —
No turbidity or precipitate appears in a mixture
of 10 ml. of glyceryl triacetate with sufficient of
a 1 in 100 solution of bromine in carbon tetra-
chloride to produce a permanent yellow color, the
mixture being permitted to stand' in a dark place
for 18 hours. N.F.

Glyceryl triacetate has no recognized therapeu-
tic effect. It is official as a solvent for chloroazodin.

Storage. — Preserve "in tight containers, and
do not permit contact with metal." N.F.

Off. Prep. — Chloroazodin Solution, N.F.

GLYCERYL TRINITRATE TABLETS.

U.S.P. (B.P., LP.)

Nitroglycerin Tablets, Trinitrin Tablets, [Tabellae
Glycerylis Trinitratis]

"Glyceryl Trinitrate Tablets contain not less
than 80 per cent and not more than 112 per cent
of the labeled amount of glyceryl trinitrate
(C3H5N3O9)." U.S.P. The B.P. requires not less
than 81.0 per cent and not more than 121.0 per
cent of the labeled content of glyceryl trinitrate;
the corresponding LP. limits are 80.0 per cent
and 120.0 per cent.

B.P. Tablets of Glyceryl Trinitrate. I.P. Compressi
Glycerylis Trinitratis.

When glycerin is added gradually, in small por-
tions at a time, to a mixture of concentrated nitric
and sulfuric acids at reduced temperature it is
converted into the highly explosive liquid known
as nitroglycerin, also called glonoin and trinitrin.
Since the compound is the glyceryl ester of nitric
acid it is more properly referred to as glyceryl
trinitrate. It was discovered in 1847 by Sobrero,
of Turin, who called it pyroglycerin, but it did
not attract wide attention until 1867, when Alfred
Nobel, a Swedish engineer, suggested its use for
explosive purposes when mixed with inert sub-
stances such as kieselguhr or infusorial earth to
make dynamite.

Glyceryl trinitrate, C3H5(N03)3, is an almost
colorless or slightly yellow liquid having a specific
gravity of about 1.6; it is inodorous and of a
sweet, pungent, aromatic taste; very slightly solu-
ble in water, but readily soluble in ether, alcohol,
most immiscible solvents, and oils. It freezes at
about 13°, forming long needles which explode
violently even when broken gently. In the liquid
state contact with flame does not cause it to burn
or explode, but concussion does cause it to explode
with great force. The explosive force of nitro-
glycerin is much greater than that of gunpowder.
According to Nobel, one volume of nitroglycerin
releases on explosion about 10,000 volumes of

Part I

Glyceryl Trinitrate Tablets 615

gas, while one volume of gunpowder releases only
about 800 volumes of gas.

Besides the tablet dosage form for medicinal
use, there was formerly official Glyceryl Tri-
nitrate Spirit (N.F. IX), an alcohol solution con-
taining 1 per cent w/w of glyceryl trinitrate; this
was hardly a satisfactory form for dispensing and
administering the potent drug.

For pharmaceutical manufacturing use there is
supplied, by a manufacturer of nitroglycerin, a
10 per cent trituration of glyceryl trinitrate in
lactose. When stored in a closed container in a
cool place such trituration is very stable. It is
essential that this trituration not be mixed with
substances having an alkaline reaction, such as
magnesium oxide or magnesium carbonate, as
such substances quickly decompose nitroglycerin
even in the dry state. The B.P. recommends a
base of 15 parts of non-alkalized cocoa powder,
15 parts of sucrose, and 70 parts of lactose for
preparing the tablets.

Assay. — A portion of tablets representing
about 5 mg. of glyceryl trinitrate is mixed with
water and the active ingredient extracted with
ether. This solution is heated with alcoholic po-
tassium hydroxide, which reacts with the glyceryl
trinitrate as follows:

C3H5(N03)3 + 5NaOH -* 2NaN02 +

NaNOs + CH3COONa + HCOONa + 3H20

The nitrate and nitrite are subsequently reduced,
in alkaline solution, by Devarda's alloy, thereby
producing three molecules of ammonia for every
molecule of glyceryl trinitrate originally present.
Some alcohol is added and the ammonia is dis-
tilled into boric acid solution and titrated with
0.01 N sulfuric acid, using methyl red as indica-
tor. A blank test is performed on the reagents.
Each ml. of 0.01 N sulfuric acid represents 0.757
mg. of C3H5N3O9. U.S.P. This method is a slight
modification of the procedure of Cannon and
Heuermann (J.A.O.A.C, 1951, 34, 716), in which
alcohol is used in the distilling medium to elimi-
nate frothing; the method uses a considerably
smaller amount of sample, and requires much less
time to complete, than the method formerly
official.

In the B.P. assay a sample containing about
1 mg. of glyceryl trinitrate is shaken for one hour
with 5 ml. of glacial acetic acid and then filtered.
One ml. of the filtrate is mixed with 2 ml. of
phenoldisulfonic acid, allowed to stand 15 min-
utes, the solution mixed with about 8 ml. of water,
alkalinized with strong solution of ammonia,
cooled to 20°, and finally diluted to 20 ml. with
water. This solution, filtered if necessary, is placed
in a suitable colorimeter and the yellow color is
compared with the colors obtained with solutions
containing known amounts of potassium nitrate,
similarly treated. Since in this assay one molecule
of glyceryl trinitrate produces the same color as
three molecules of potassium nitrate, each Gm.
of the latter represents 0.7487 Gm. of C3H5N3O9.
The assay is based on the method of Meek (Quart.
J. P., 1935, 8, 375) for estimating nitrate. The
LP. uses this assay for tablets of glyceryl tri-
nitrate.

Uses. — Although nitroglycerin is a nitrate its

effects upon the body are essentially the same as
those of the nitrites (see Sodium Nitrite). It has
been generally taught that the organic nitrates are
reduced in the body to nitrites but Krantz et al.
(J. Pharmacol., 1940, 70, 323) presented evidence
which throws some doubt on this. They believe
that organic nitrates act by virtue of their own
structure and suggest that the difference in action
between organic nitrates and inorganic nitrites
involves a difference of their oil-water partition
coefficients. Whatever may be the explanation, the
fact is that the effects of nitroglycerin are indis-
tinguishable from those of sodium nitrite except
in their rapidity.

Action. — Nitroglycerin produces a direct vaso-
dilating effect on the arterioles and venules, re-
sulting in a fall in blood pressure within 2 or 3
minutes after ordinary oral dosage. There is flush-
ing of the face, dilatation of the meningeal vessels
accompanied by a throbbing headache, and in-
crease in cardiac rate induced by reflex effect from
the carotid sinus as the pressure falls. The entire
action is usually over within half an hour. It is
eliminated very rapidly, partly by oxidation.
Wegria et al. (Am. J. Med., 1951, 10, 414) studied
the effects on the cardiovascular system of nitro-
glycerin administered sublingually in 10 normal
persons, by means of the ballistocardiograph, con-
firmed in one instance by cardiac catheterization.
They found that cardiac output per minute, sys-
tolic output and heart rate increased, but there
was no change in the blood pressure. Their find-
ings suggest that the drug relieves the pain of
myocardial ischemia by increasing the coronary
flow relatively more than the work of the heart.
Because of the danger of producing shock, cau-
tion should be exercised, therefore, in adminis-
tering nitroglycerin to patients who may have
coronary occlusion rather than a simple myo-
cardial ischemia.

Indications. — Nitroglycerin is a volatile sub-
stance and unless evaporation is guarded against
its preparations lose potency. Glyceryl trinitrate
tablets are used in the same class of cases as
sodium nitrite, being employed where rapidity of
action is important, as in angina pectoris, threat-
ened apoplexy, asthma, and the like. Russek et al.
(J.A.M.A., 1953, 153, 207) compared the ability
of various drugs to modify the electrocardio-
graphic response to standard exercise (Master
two-step test) in carefully selected patients with
coronary artery disease. In every instance a strik-
ingly favorable effect was observed when 0.4 to
0.6 mg. (approximately Hso to Vioo grain) of
glyceryl trinitrate had been administered sub-
lingually 5 minutes prior to the test. Because of
the fugaciousness of its action and the rapidity
with which patients develop a tolerance (see
Crandall, /. Pharmacol, 1934, 48, 127) it is not
suited for conditions in which prolonged vascular
dilatation is desired. It has been misused as a
cardiac stimulant in various forms of collapse;
it should be remembered that its effect is always
to lower blood pressure and it can do no good in
any form of circulatory failure. It has been recom-
mended in hemoptysis, its action being attribut-
able to the dilatation of the abdominal and con-
traction of the pulmonary vessels.

616 Glyceryl Trinitrate Tablets

Part I

Nitroglycerin is used to relieve spasm of the
sphincter of Oddi induced by morphine in treat-
ing postcholecystectomy syndromes. It is effec-
tive in relieving night cramps in the legs (see
JAM. A., 1952, 150, 630). Kleckner et al. (Proc.
Mayo, 1950. 25, 657) found that in some patients
with Raynaud's disease benefit may be obtained
by the inunction of an ointment containing 2 per
cent glyceryl trinitrate in lanolin; the ointment
may become impotent because of the extreme
volatility of the glyceryl trinitrate.

Toxicology. — Workers in dynamite factories
are subject to chronic nitroglycerin poisoning
(Rabinowitch. Can. Med. Assoc. J., 1944. 50,
199). The most characteristic symptom of this
intoxication is throbbing headache, at times so
violent that the patient may become maniacal.
The pain is made worse by lying down and is not
alleviated by either acetphenetidin or morphine.
After some time the workers in these factories
appear to develop an immunity to the poison
which, however, is rapidly lost if they cease to be
exposed.

Bresler (Ind. Med., 1949. 18:12, 519) called
attention to the hazards experienced by workers
in the pharmaceutical industry in the handling of
this substance. In addition to headache in severe
cases of poisoning, there may be intense abdomi-
nal cramps with nausea and vomiting, psychic
disturbances ranging from dizziness and mental
confusion to maniacal manifestations. Respira-
tion may become labored and slow, the pulse
slows and becomes dicrotic, the skin is cold and
cyanotic. Paralysis occurs, followed by clonic
convulsions, death occurs after 4 to 7 hours from
respiratory failure. Toxic effects may result from
inhalation of the drug as dust, as well as by inges-
tion, and such effects will follow excessive absorp-
tion through the intact skin. Prolonged contact will
produce skin eruptions. Alcohol aggravates the
toxic svmptoms and a case of homicidal mania
was reported by Ebright (J.A.M.A., 1914. 62,
201) in a worker who drank some whisky to
alleviate nitroglycerin headache. Treatment of
nitroglycerin poisoning is unsatisfactory. De-
pressants and coal tar derivatives should not be
employed. Strong coffee is helpful and in severe
instances caffeine and sodium benzoate may be
administered intravenously. Ergotamine tartrate
may prove to be beneficial. S

Dose. — The usual sublingual dose is 0.4 mg.
(approximately M^o grain), up to 10 times a day,
as required, the range being 0.2 to 0.6 mg.

Storage. — Preserve "in well-closed contain-
ers." U.S.P. The B.P. adds that the tablets shall
be kept in a cool place, protected from light.

Usual Sizes. — 0.3. 0.4, 0.6 and 1.2 mg. (ap-
proximately }£oo, ^ioo, Hoo, and ^oo grain) hypo-
dermic tablets and tablet triturates.

GLYCOBIARSOL. N.F.

Bismuth N-Glycolylarsanilate

0 // \ °H

HOCH,CNH— ff \_As_0_BJ0

"Glycobiarsol yields, calculated on the anhy-

drous basis, not less than 97 per cent and not
more than 103 per cent of CsHoAsBiNOe." N.F.

Milibis (.li'inthrop-Stearns).

Glycobiarsol, a compound containing approxi-
mately 15 per cent of pentavalent arsenic and
39 per cent of trivalent bismuth, is the product
of the interaction of sodium p-N-glycolylarsanilate
and bismuth nitrate (for details of synthesis see
U. S. Patent 1,934.017).

Description. — "Glycobiarsol is an odorless,
yellowish white to flesh-colored, amorphous pow-
der. It decomposes when heated. Glycobiarsol is
very slightly soluble in alcohol and in water, and
practically insoluble in benzene, in chloroform,
and in ether." N.F.

Standards and Tests. — Identification. — (1)
A portion of an acid-hydrolyzed solution of glyco-
biarsol produces with sodium sulfide T.S. a heavy
dark brown precipitate; a second portion of the
solution responds to the test for arsenic. (2) A
third portion of the solution prepared for the
preceding test yields with bromine water a pre-
cipitate of 2,4,6-tribromoaniline. Loss on drying.
— Not over 3 per cent, when dried at 105° for 24
hours. Limit for arsenic. — Not less than 14.0 per
cent and not more than 16.0 per cent, calculated
on the anhydrous basis, the compound being de-
composed with nitric and sulfuric acids, in the
presence of starch, and the trivalent arsenic thus
produced titrated with 0.1 AT iodine after neu-
tralizing the solution and adding sodium bicar-
bonate in excess. Limit for free arsanilic acid. —
Not over 0.5 per cent, on the anhydrous basis,
determined by diazotization and coupling with
N-(l-naphthyl)ethylene diamine. Limit for bis-
muth.— Not less than 36 per cent and not more
than 42 per cent of Bi, the bismuth being precipi-
tated and weighed as BiPO-t. N.F.

Assay. — About 500 mg. of glycobiarsol is
hydrolyzed by heating with diluted hydrochloric
acid, which releases aniline, and the solution is
titrated with 0.1 M sodium nitrite, which quanti-
tatively diazotizes the aniline. Each ml. of 0.1 M
sodium nitrite represents 49.91 mg. of C&H9-
AsBiXOe. N.F.

Uses. — Bismuth glycolylarsanilate is widely
used in the treatment of intestinal amebiasis. By
virtue of its slight solubility and poor absorption
from the gastrointestinal tract it is well tolerated,
though these properties confine its usefulness to
the intestinal form of the disease. For cases of
extra-intestinal amebiasis or those with deep in-
testinal ulcers, it needs to be supplemented with
an absorbable amebacide.

In humans. McChesney and Hoppe (Proc. S.
Exp. Biol. Med., 1950, 73, 326) found no bismuth
and only 2 to 4 per cent of the ingested arsenic
in the urine. Insignificant quantities of either of
these elements were found in the tissues of rats
fed the compound. In Hansen's egg infusion
medium it was active against E. histolytica in a
dilution of 1 to 30.000. and in hamsters it was
more effective than either chiniofon or diiodo-
hydroxyquinoline but somewhat less effective than
carbarsone (Dennis et al., Am. J. Trop. Med.,
1949. 29, 683).
Only 3 of 103 human cases of amebiasis re-

Part I

Glycyrrhiza 617

lapsed after treatment with the drug was discon-
tinued, the average follow-up period being 287
days. Berberian et al. (ibid., 1950, 30, 613) re-
ported negative stool examinations in 25 of 28
cases over an average period of 322 days; the
3 other cases relapsed in 87 days. Radke (Mil.
Surg., 1951, 109, 620), however, in more chronic
cases found 62 per cent failure at 3 months with
the drug; Wilmot et al. (J. Trop. Med., 1951, 54,
161) experienced a similar incidence of failure.
Conn {Postgrad. Med., 1951, 9, 144) treated 36
cases and concluded that the drug was as effective
(only 11 per cent failures), better tolerated and
more convenient than alternating courses of di-
iodohydroxyquinoline and carbarsone. For colonic
amebiasis without dysentery Sodeman (Med. Ann.
District Columbia, 1951, 20, 409) recommended
administration of 500 mg. three times daily for
8 days. If dysentery is present, he advised use of
1 mg. of emetine per kilo of body weight daily
for 3 or 4 days to control the diarrhea before
treatment with bismuth glycolylarsanilate. If
treatment failed, he recommended giving either
diiodohydroxyquinoline or carbarsone.

A combination of drugs has proved to be more
effective and less toxic for the treatment of sys-
temic amebiasis. Vegas (J. A.M. A., 1953, 151,
1059) reported obtaining best results (clearing of
89 per cent of 102 cases, although some required
a second or even a third course of treatment)
with a combination of 500 mg. of bismuth gly-
colylarsanilate and 150 mg. of chloroquine phos-
phate administered twice daily for 15 days. Re-
sults were equally good, but untoward effects
were more frequent, with a dose of 400 mg. and
100 mg., respectively, given three times daily.
Side effects observed were nausea, vomiting,
pruritus ani, left lower abdominal pain and diar-
rhea. The bismuth component of the drug tends
to diminish diarrhea but it is generally recognized
that the dose should be increased in cases of
active diarrhea because of the more rapid elimi-
nation of the drug. In combination with oxytetra-
cycline (Terramycin), Vegas reported efficacy of
77.3 per cent at six months.

Prophylaxis of amebiasis seems to have become
a practical reality with use of a combination
tablet of 250 mg. of bismuth glycolylarsanilate
with 75 mg. of chloroquine phosphate. Berberian
et al. (J.A.M.A., 1952, 148, 700) observed that
the ingestion of 6 such tablets in a day, once
weekly, reduced the incidence of infestation from
76 per cent in untreated persons to 25 per cent;
daily use of two of the tablets reduced the inci-
dence to 10 per cent. No untoward effects were
noted. Hoekenga (/. Lab. Clin. Med., 1952, 39,
267) studied the effect of 3 of the tablets taken
on two consecutive days each week for 12 weeks.
At the beginning of the study, 36 per cent of 201
cases had positive stool examinations (7 per cent
had trophozoites as well as cysts) ; at the end of
the 3 months, only 3 per cent of 188 patients
showed cysts in their feces, compared with 29 per
cent of 190 untreated persons. Furthermore, 13
cases of amebiasis and 15 cases of malaria were
admitted to the hospital from the untreated group
whereas there were no such cases in the group re-
ceiving prophylactic medication. In this study, a

dose of 2 tablets daily on two consecutive days
each week was given to children 4 to 6 years of
age, 1 tablet to those 1 to 3 years old, and l/z
tablet for babies under 1 year of age.

Dose. — The usual dose of bismuth glycolylar-
sanilate, for the adult, is 500 mg. (approximately
ll/2 grains) three times daily.

Storage. — Preserve "in well-closed, light-re-
sistant containers." N.F.

GLYCOBIARSOL TABLETS.

Bismuth Glycolylarsanilate Tablets

N.F.

"Glycobiarsol Tablets contain not less than 92.5
per cent and not more than 107.5 per cent of the
labeled amount of CsHoAsBiNOe." N.F.

Usual Sizes. — 250 and 500 mg. (approxi-
mately 4 and lYi grains).

GLYCYRRHIZA. U.S.P. (B.P.)

Licorice Root, [Glycyrrhiza]

"Glycyrrhiza is the dried rhizome and roots
of Glycyrrhiza glabra Linne, known in commerce
as Spanish Licorice, or of Glycyrrhiza glabra
Linne var. glandidifera Waldstein et Kitaibel,
known in commerce as Russian Licorice, or of
other varieties of Glycyrrhiza glabra Linne,
yielding a yellow and sweet wood (Fam. Legutni-
nos(B):, U.S.P. The B.P. gives the botanical
source as Glycyrrhiza glabra Linn, and other spe-
cies of Glycyrrhiza; both peeled and unpeeled
root and stolon are recognized.

B.P. Liquorice. Spanish Licorice Root; Liquorice Root;
Sweet Wood, Glycyrrhiz«e Radix; Liquiritiae Radix. Fr.
Reglisse; Racine de reglisse; Bois doux; Racine douce.
Get. Sussholz ; Lakritzenwurzel; Siiszholzwurzel. It.
Liquirizia; Regolizia; Glicirriza. Sp. Raiz de regaliz ;
Rcgaliz.

Glycyrrhiza glabra is a perennial herb, occurring
in several varieties. Its underground portion con-
sists of a slender branching rhizome bearing a
number of rootlets. The stems are herbaceous,
erect, slightly branching, and usually three or four
feet in height. The leaves are alternate, pinnate,
consisting of several pairs of ovate, blunt, petiolate
leaflets, with a single leaflet at the end, of a pale-
green color, and clammy on their under surface.
The flowers are papilionaceous, pale lavender to
violet, and arranged in axillary spikes having long
peduncles. The calyx is tubular and persistent.
The fruit is a compressed, smooth, acute, one-
celled legume, containing from one to six small
kidney-shaped seeds. This plant grows best on
sandy or clay soil in valleys which are subject to
occasional inundation from nearby rivers. It is
indigenous to Spain, southern Italy, Greece, Asia
Minor, Syria, Iraq, Caucasian and Transcaspian
Russia and northern China. All of these sources
lie close to the 40th parallel of north latitude.
Small quantities have from time to time been
produced in other countries but as sources of
supply they are negligible. The experimental plant-
ings in the United States, made from about 1895
to 1918, appear to have virtually died out, but it
is thought that the southwest of this country
would provide favorable conditions, such as a
definite dry season and absence of severe freezing.
A small quantity of licorice root has grown wild
in the Salt River Valley in Arizona. The classifica-

618 Glycyrrhiza

Part I

tion of the licorice plant into species and varieties
has not been well established, but Viehoever
(1936, unpublished communication) considers
that Spanish and Italian licorice are from G.
glabra typica and the Anatolian and Russian from
G. glabra glandulifera; Syrian, in the main, is a
hybrid of Spanish and Iraq (violacea). His con-
clusions are tentative because many specimens
examined were immature. Iraq licorice root, grow-
ing in the valleys of the Tigris and Euphrates, is
usually thicker than that from other countries.

Asiatic licorice, known as Chuntschir, is ob-
tained from G. uralensis Fisch. The plant is found
in Siberia, Turkestan and Mongolia, and is grown
on a large scale in the Fengtien province of China.
During the war of 1914-1918, when transportation
of licorice root through the Mediterranean was
prevented, large quantities of Chinese licorice
root were brought to the United States across the
Pacific Ocean. The yield of extract from Chinese
licorice root is about as high as that from Russian
and Anatolian, but the Chinese extract is markedly
pungent, which is undesirable ; it is said to be used
in soy sauce.

G. echinata L. is grown for its root in the
northern provinces of China. It was formerly
exported to Russia.

G. lepidota (Nutt.) Pursh. grows abundantly
from Missouri westward to northern California.
Although McCullough in 1890 reported the pres-
ence of glycyrrhizin in its rhizome, Fischer and
Lynn (7. A. Ph. A., 1933, 22, 1225) could find no
glycyrrhizin in this species nor in the licorice
fern (Polypodium vulgare, L., var. occidentale) ;
their sweetness was due to sucrose or other sugars.
In the licorice fern they found also a glycoside,
polypodin.

Propagation of licorice root is best done from
runners, though seeds germinate without difficulty.
The root is dug about every third year, and
enough always remains in the ground to renew
itself during the ensuing three years. When the
fresh root is brought from the digging fields to the
buying stations, piles are made which are turned
periodically while the root is "curing." It is usu-
ally fit to be baled about 6 months after digging.
Thoroughly cured root may have a moisture con-
tent of from 8 to 10 per cent; above 12 per cent
moisture exposes the baled root to danger of de-
veloping mold.

During 1952, there were imported into the
United States 39,718,304 pounds of licorice root
and 645,667 pounds of licorice extract. The sup-
plies of licorice root came from Turkey, Iraq,
Italy, Russia, Syria, British East Africa; the
licorice extract was shipped here mostly from
Spain, a very small amount coming from Japan.
A comparatively small portion of the licorice im-
ported into the United States is used by the drug
industry, the greater bulk of the huge supply
being consumed by the tobacco and confectionery
trades and in fire extinguisher compounds. The
root is collected alike from wild and cultivated
plants, cleaned and variously prepared for the
market.

Licorice is often offered for entry that is poorly
dried, moldly, insect infested or partially decayed;
such roots should be rejected.

Description. — "Unground Spanish Glycyr-
rhiza usually occurs in nearly cylindrical pieces
variable in length and from 5 to 20 mm. in thick-
ness. The upper portion is more or less knotty.
Externally it is yellowish brown or dark brown
in color, longitudinally wrinkled, the thinner rhi-
zomes often having prominent alternate buds, the
thicker rhizomes having distinct corky patches;
its fracture is coarsely fibrous. Internally it is
yellow and radiate; its odor is distinctive and its
taste is sweetish and slightly acrid.

"Unground Russian Glycyrrhiza is nearly cylin-
drical, somewhat tapering, sometimes split longi-
tudinally, variable in length and from 1 to 5 cm.
in diameter; when deprived of the outer corky
layer, it is externally pale yellow; its fracture is
coarsely fibrous. Internally it is pale yellow and
shows a radially cleft wood. Its odor is distinc-
tive; its taste, sweetish." U.S.P. For histology
see U.S.P. XV.

"Powdered Glycyrrhiza is brownish yellow (un-
peeled Licorice) or pale yellow (peeled Licorice).
The elements of identification are: numerous,
mostly simple and elliptical, oval, or spheroidal
starch grains, up to 20 \i in diameter; vessels
mostly with bordered pits up to 200 n in diameter;
numerous wood and phloem fibers which are very
long, much attenuated at the ends and about 10 m>
in width; crystal-fibers with monoclinic prisms of
calcium oxalate, the latter up to 30 n in length;
and fragments of reddish brown cork cells which
are practically absent in the powder prepared
from peeled Licorice." U.S.P.

Standard and Test. — Glycyrrhiza yields not
more than 2.5 per cent of acid-insoluble ash.
U.S.P.

The B.P. requires that it shall yield not less
than 20.0 per cent of water-soluble .extractive;
and that the ash shall not be more than 6.0 per
cent of the peeled, nor more than 10.0 per cent
of the unpeeled, drug. The acid-insoluble ash
should not be more than 1.0 per cent of the peeled,
nor more than 2.5 per cent of the unpeeled, drug.

Constituents. — Licorice root contains from
5 to 10 per cent of its characteristic principle
glycyrrhizin; in addition there are present 5 or
10 per cent of sugars, some bitter substances, be-
side resins, cellulose, lignin, etc.

Glycyrrhizin, also known as glycyrrhizic acid,
occurs in the root in the form of calcium and
potassium salts; it is said to be approximately 50
times as sweet as sucrose. It is a glycoside for
which the formula C42H62O16 appears to have
been established; on hydrolysis it yields two mole-
cules of glucuronic acid and one molecule of
glycyrrhetinic acid (also called glycyrrhetic acid).
The latter is a pentacyclic terpene of the formula
C30H46O4 (see Ruzicka et al., Helv. Chim. Acta,
1943, 26, 2143, 2278); its structure bears some
resemblance to that common to the steroids,
which may have some connection with the fact
that glycyrrhizin appears to possess in some de-
gree the physiological action of the steroid desoxy-
corticosterone. Glycyrrhiza appears also to con-
tain a spasmolytic principle, and an estrogenic
substance. For the evidence in support of this
see under Uses. Houseman (loc. cit.) reported a

Part I

Glycyrrhiza Extract 619

hemolytically active saponin in the inner bark of
licorice root.

For the quantitative determination of glycyr-
rhizin in licorice root the method of Houseman,
referred to under Glycyrrhiza Extract, may be
used, but when applied to root, a preliminary ex-
traction with ether is desirable in order to remove
ether-soluble resins which are present in the root
but not in the extract.

Under the name of Glycyrrhizinum Ammoni-
atum (Ammoniated Glycyrrhizin) , the U.S. P. IX
recognized a material prepared by precipitating
crude glycyrrhizic acid from a solution of licorice
extract by means of dilute sulfuric or hydro-
chloric acid, dissolving the well-washed precipi-
tate in ammonia water and drying the solution on
glass or other suitable surface. Lustrous black
flakes are formed as the solution dries.

Uses. — By far the largest part of the licorice
root entering this country is extracted for use in
the tobacco industries as a flavoring and condi-
tioning agent. Considerable is used by the con-
fectionery industry. The residual material of the
root after extracting licorice is used as a fertilizer
for mushrooms and as a stabilizer in the manufac-
ture of foam fire-extinguishers.

Powdered licorice root is used for various phar-
maceutical purposes as in the preparation of pills,
either to give them proper consistence or to cover
their surface and prevent them from cohering, as
a diluent of powdered extracts, etc. As a remedial
agent it has been almost entirely replaced by the
extract.

In the form of the extract, glycyrrhiza is fre-
quently incorporated in cough medicaments by
virtue of its demulcent and expectorant prop-
erties.

In recent years licorice extract has come into
prominence as an agent of potentially great thera-
peutic utility. In Denmark, it has been observed
to be effective in the treatment of gastric and
duodenal ulcer, especially the former; a paste is
prepared by mixing 100 Gm. of glycyrrhiza ex-
tract, in powder form, with 50 ml. of water, of
which one teaspoonful is taken by the patient
three times daily, about an hour before breakfast
and lunch, and again on retiring. In 27 of 48 pa-
tients treated in this manner the symptoms sub-
sided between the first and fourth days; in 10
others between the fourth and eighth days, and
in 6 others somewhat later. Five patients received
no benefit from the treatment (Revers, Neder-
landsch Tijdscrift v. Geneeskunde, 1948, 92,
2968). This effect may be attributable to the pres-
ence of an unidentified spasmolytic principle in
glycyrrhiza, but not to glycyrrhizin. About 20 per
cent of the patients, however, developed edema
and hypertension or cardiac asthma.

Seeking to find an explanation for the untoward
effects observed by Revers, Borst and his col-
leagues (Lancet, 1950, 259, 381; 1953, 1, 657)
found that glycyrrhiza extract, administered by
mouth, causes sodium retention and potassium
loss, which leads to an increase in extracellular
fluid and plasma volume and through this to an
increased venous pressure with increase in sys-
tolic arterial pressure and in pulse pressure. These
effects they attributed to the presence in glycyr-

rhiza of a substance with desoxycorticosterone-
like action. In later experiments, Groen et al.
(New Eng. J. Med., 1951, 244, 471) not only
confirmed the findings of Borst and his associates
but reported a case of Addison's disease which
after preliminary treatment with desoxycorti-
costerone acetate maintained mineral equilibrium
with administration of 15 Gm. of glycyrrhiza
extract daily; withdrawal of the extract was fol-
lowed by reappearance of characteristics of the
disease. Another patient, previously maintained
on 2.5 mg. of desoxycorticosterone acetate daily,
was kept in mineral equilibrium with 3.3 Gm. of
ammonium glycyrrhizinate daily. Card et al.
(Lancet, 1953, 1, 663) found that glycyrrhetinic
acid, when given to a patient with Addison's dis-
ease, had effects on weight and electrolytes simi-
lar to those found after administration of desoxy-
corticosterone and cortisone; the acid did not,
however, prolong the survival of rats whose
adrenals had been removed.

Investigation of the basis for the empirical use
of glycyrrhiza in a proprietary formula having
estrogenic action, by Costello and Lynn (/. A.
Ph. A., 1950, 39, 177) led to the finding that sig-
nificant, though small, amounts of estrogenic ma-
terial are present in glycyrrhiza.

Off. Prep.— Glycyrrhiza Fluidextract, U.S.P.,
B.P.; Pure Glycyrrhiza Extract; Glycyrrhiza
Syrup, U.S. P.; Glycyrrhiza Extract; Aloin, Bella-
donna, Cascara and Podophyllum Pills, N.F.;
Compound Senna Powder, N.F., B.P.; Elixir of
Cascara Sagrada, B.P.

GLYCYRRHIZA ELIXIR. N.F.

Licorice Elixir, [Elixir Glycyrrhiza]
Adjuvant Elixir. Elixir Adjuvans.

Mix 125 ml. of glycyrrhiza fluidextract with
875 ml. of aromatic elixir and filter the liquid.

Alcohol Content. — From 21 to 23 per cent,
by volume, of C2H5OH. N.F.

This elixir is used as a vehicle for various
medicinals; the glycyrrhiza aids in disguising or
obtunding the taste of bitter substances and also
imparts a deep brown color which is sometimes
desirable. Acids, by precipitating glycyrrhizic acid,
render it less effective as a masking vehicle.

Storage. — Preserve "in tight containers." N.F.

GLYCYRRHIZA EXTRACT. N.F.

Licorice Root Extract, Licorice, [Extractum
Glycyrrhizae]

"An extract prepared from the rhizome and
roots of species of Glycyrrhiza Tournefort ex
Linne (Fam. Le gummosa) ." N.F.

Succus Liquiritiae. Fr. Sue de reglisse. Ger. Siiszholz-
saft; Lakrits; Lakritzensaft. It. Legorizia. Sp. Extracto
de Regaliz.

Commercial glycyrrhiza extract is prepared in
a manner similar to that used for making the
pure extract (q.v.) except that for the former
a more drastic extraction is employed and con-
sequently a higher yield of extractive obtained.
No filler is added to the commercial extract as
is sometimes supposed, the only difference be-

620 Glycyrrhiza Extract

Part I

tween the two extracts being one of quality; the
pure extract is so designated by virtue of its being
obtained through milder extraction.

The largest proportion of commercial extract
of licorice is made in the United States, with some
prepared in Asia Minor, and a relatively small
amount made in Spain and Italy. The only official
British extract of licorice is nearly the same as
the "pure extract" of the U.S. P.

The most important constituent of licorice
extract is the sweet principle, glycyrrhizin (see
under Glycyrrhiza). Of the several methods which
have been proposed for the determination of this
constituent that of Houseman (J.A.O.A.C., 1922,
6, 191 ) is the simplest and best adapted to com-
mercial use. It is based upon weighing the glycyr-
rhizin precipitated upon acidification of an aque-
ous solution of licorice extract from which starch
and gums have previously been precipitated with
alcohol.

Description. — "Glycyrrhiza Extract occurs as
a brown powder, in flattened, cylindrical rolls, or
in masses. The rolls or masses have a glossy black
color externally, and a brittle, sharp, smooth,
conchoidal fracture. The Extract has a charac-
teristic and sweet taste which is not more than
very slightly acrid." N.F.

Standards and Tests. — Insoluble matter. —
Not over 25 per cent is insoluble in cold water.
Foreign starch. — The sediment from a 5 per cent
mixture of the extract with cold water shows no
foreign starch when mounted and examined under
a microscope. Ash. — Not more than 8 per cent in
the anhydrous extract. N.F.

It should be noted that the state of having "a
brittle, sharp, smooth, conchoidal fracture" is
dependent on having the proper relationship of
moisture content and starch content. Licorice ex-
tract formerly appeared in brittle, cylindrical rolls
about 6 inches long and up to an inch in diameter;
this form, however, is now seldom seen in Amer-
ica. The commercial licorice extract made in this
country (Licorice Paste, Licorice Mass) is in
blocks weighing 26 pounds. 52 pounds and 260
pounds. It is of a hard tough consistence, the mass
having been run into a mold while hot and then
allowed to cool. This commercial extract usually
contains from 18 to 24 per cent moisture, accord-
ing to various trade requirements and blends of
root used. The composition of the root, specifically
its starch content, influences the amount of mois-
ture which the licorice mass retains for a given
degree of hardness, as well as the percentage of
material which is insoluble in cold water. Winter-
dug root usually yields a more starchy extract
than spring-dug root. The "matter insoluble in
cold water" in licorice mass frequently increases
with the age of the mass; thus a freshly prepared
extract which shows 5 per cent insoluble in cold
water may show over twice that amount a month
or two later, due to progressive deposition of in-
soluble starch.

Spanish licorice mass contains about 10 per
cent glycyrrhizin; Italian and Greek somewhat
more; the highest glycyrrhizin content — about 20
per cent — is shown by extracts from Anatolian.
Russian, Syrian and Iraq roots. The Anatolian

and Russian roots also give the highest yields of
extract. Extract from Spanish root is, however,
notably lower in bitter substances, and commands
the highest price, in spite of its lower percentage
of glycyrrhizin. Preparations of licorice are in-
compatible with acids, which cause partial or com-
plete precipitation of glycyrrhizin according to
their kind and concentration.

The taste of licorice extract is quite character-
istic; strongly sweet, with some bitterness, and
"bite." From the common use of anise oil as an
added flavor in licorice confectionery there has
arisen the widespread confusion of anise and
licorice flavors, which actually are not related.

Uses. — In addition to the very large amount
of licorice extract used in tobacco products, and
the much smaller quantity used in confectionery,
licorice is a popular addition to cough prepara-
tions because of its demulcent and expectorant
properties. The pure extract is preferred for some
of the medicinal uses. For the uses of glycyrrhiza
extract in the treatment of gastric ulcers, and as
a preparation having desoxycorticosterone-like
action, see under the uses of Glycyrrhiza.

Storage. — Preserve "in well-closed contain-
ers." N.F.

PURE GLYCYRRHIZA EXTRACT.

U.S.P.

Pure Licorice Root Extract, [Extractum
Glycyrrhiza; Purum]

Moisten 1000 Gm. of glycyrrhiza. in granular
powder, with boiling water, transfer to a perco-
lator, and percolate with boiling water until the
glycyrrhiza is exhausted. Add sufficient ammonia
solution to the percolate to make it distinctly
ammoniacal in odor, then boil the liquid until it
is reduced to a volume of about 1500 ml. Filter
the liquid, and immediately evaporate it to a
residue of pilular consistence. U.S.P.

Succus Liquiritiae Depuratus. Fr. Extrait de reglisse.
Ger. Gereinigter Siiszholzsaft. It. Estratto di liquirizia.
Sp. Extracto de Reyali: Puro.

The color of glycyrrhiza extract, as well as of
the fluidextract. is somewhat variable. At least
two factors are involved: the greater the alka-
linity the more intense the color, and the higher
the concentration of iron in the extract the deeper
its color (Collett, Mfg. Chemist, 1950. 21, 421).
It appears also that higher temperatures of
evaporation of solution favor intensification of
color.

Description. — "Pure Glycyrrhiza Extract is
a black, pilular mass having a characteristic, sweet
taste." U.S.P.

Pure glycyrrhiza extract is employed principally
as a flavoring agent, as in the aromatic cascara
sagrada fluidextract. Formerly it was sometimes
employed as an excipient in the extemporaneous
preparation of pills. For other uses see under
Glycyrrhiza.

Storage. — Preserve ''in well-closed contain-
ers." U.S.P.

Off. Prep. — Aromatic Cascara Sagrada Fluid-
extract, U.S.P.

Part I

Gold Sodium Thiomalate

621

GLYCYRRHIZA FLUIDEXTRACT.
U.S.P. (B.P.)

Licorice Root Fluidextract, [Fluidextractum
Glycyrrhizae]

B.P. Liquid Extract of Liquorice; Extractum Glycyr-
rhizae Liquidum. Fluidextract of Licorice; Fluidextract of
Licorice Root. Extractum Liquiritiae Fluidum. Fr. Extrait
fluide de reglisse. Ger. Siiszholzfluidextrakt. It. Estratto
fluido di liquirizia. Sp. Extracto Fh'iido de Regaliz.

To 1000 Gm. of coarsely ground glycyrrhiza
add about 3000 ml. of boiling water, mix well,
and allow to macerate in a suitable, covered me-
tallic percolator for 2 hours. Then allow percola-
tion to proceed at a rate of 1 to 3 ml. per
minute, gradually adding boiling water until the
glycyrrhiza is exhausted. Add sufficient diluted
ammonia solution to the percolate to make it dis-
tinctly ammoniacal in odor, then boil the liquid
until it is reduced to a volume of about 1500 ml.
Filter the liquid and evaporate it on a water bath
to 750 ml., cool, and gradually add 250 ml. of
alcohol and sufficient water to make 1000 ml. of
the product. Mix it thoroughly. U.S.P.

The B.P. Liquid Extract of Liquorice is made
from unpeeled licorice root, in coarse powder, by
percolation with chloroform water. The percolate
is boiled for a short rime and set aside to permit
sedimentation. The supernatant liquid is then
decanted, the residue filtered and the combined
liquids concentrated until the product has a weight
per ml., at 20°, of 1.198 Gm. To this liquid one-
fourth of its volume of 90 per cent alcohol is
added. After the liquid extract is allowed to stand
it is filtered. The alcohol content is approximately
18 per cent by volume. The reason for the use of
chloroform water in the B.P. process is to avoid
fermentation during the extracting process.

Alcohol Content. — From 20 to 24 per cent,
by volume, of C2H5OH. U.S.P.

Glycyrrhiza fluidextract is of a dark brown
color, the intensity of which increases with pH
and with the concentration of iron in the fluid-
extract (Collett. Mfg. Chemist, 1950, 21, 421).
It has the sweet taste of licorice. When shaken
with water it foams considerably, a property
which has a practical application in stabilizing the
foam of certain types of fire extinguishing com-
positions.

The fluidextract is employed as a flavoring
agent, especially for masking bitter or salty tastes.
Its usefulness is attributable partly to its sweet-
ness and partly to its viscid consistency. Acids
reduce its effectiveness through precipitation of
glycyrrhizic acid.

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." U.S.P.

Off. Prep.— Glycyrrhiza Syrup, U.S.P.; Glyc-
yrrhiza Elixir; Compound Opium and Glycyr-
rhiza Mixture; Compound Sarsaparilla Syrup,
N.F.

GLYCYRRHIZA SYRUP. U.S.P.

Licorice Syrup, [Syrupus Glycyrrhizae]

Sirupus Liquiritiae. Ger. Siiszholzsirup. Sp. Jarabe de
Regalie.

Mix 0.05 ml. of fennel oil and 0.5 ml. of anise

oil with 250 ml. of glycyrrhiza fluidextract and
add enough syrup to make 1000 ml. Mix the
product well.

Alcohol Content. — From 5 to 6 per cent, by
volume, of C2H5OH. U.S.P.

This syrup may be useful as a vehicle for bitter
and salty medicaments, though many do not con-
sider it very efficient. In acid media, especially,
it is likely to be ineffective in masking unpleasant
tastes.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 25°." U.S.P.

Off. Prep.— Five Bromides Elixir, N.F.

GOLD SODIUM THIOMALATE.
N.F. (B.P.)

Auri Sodii Thiomalas

CH2COONa

.H2O
AuSCHOONa
"Gold Sodium Thiomalate yields not less than
93.3 per cent and not more than 101.5 per cent of
C4H3AuNa204S.H20." N.F.

The B.P. requires Sodium Aurothiomalate to
contain not less than 44.5 per cent and not more
than 46.0 per cent of Au, and not less than 10.8
per cent and not more than 11.3 per cent of Na,
both calculated with reference to the substance
dried over phosphorus pentoxide at a pressure not
exceeding 5 mm. of mercury for 24 hours.

B.P. Sodium Aurothiomalate; Sodii Aurothiomalas.
Disodium Aurothiomalate; Sodium Aurothiomalate. Myo-
chrysine (Sharp &■ Dohtne).

Gold sodium thiomalate may be prepared by
the interaction of sodium thiomalate and a gold
halide; for details see U. S. Patent 1,994,213
(1935). The salt contains approximately 50 per
cent of elemental gold.

Description. — "Gold Sodium Thiomalate oc-
curs as a white to yellowish white, odorless, fine
powder. It is affected by light. Gold Sodium Thio-
malate is very soluble in water; it is insoluble in
alcohol, in ether, and in most organic solvents."
N.F.

Standards and Tests. — Identification. — (1)
A white precipitate, soluble in diluted nitric acid
but reprecipitated upon addition of ammonium
acetate T.S., is produced on adding a solution of
calcium nitrate to a solution of gold sodium thio-
malate. (2) No precipitate forms on adding silver
nitrate T.S. to the supernatant liquid separated
from the precipitate in a mixture of gold sodium
thiomalate and calcium nitrate. (3) A yellowish
precipitate, soluble in an excess of ammonia T.S..
is produced on adding silver nitrate T.S. to a
solution of gold sodium thiomalate. (4) Follow-
ing treatment of a solution of gold sodium thio-
malate with ammonia T.S. and hydrogen peroxide
(30 per cent), then evaporating the solution and
igniting the residue, particles of gold separate and
the filtrate responds to tests for sodium and sul-
fate. pH. — The pH of a 1 in 10 solution is be-
tween 5.8 and 6.5. N.F.

Assay. — About 500 mg. of gold sodium thio-
malate is heated with a mixture of nitric acid,
sulfuric acid and water until fumes of sulfur

622

Gold Sodium Thiomalate

Part I

trioxide are evolved. The mixture is diluted with
water and the precipitated elemental gold is
filtered into a tared Gooch crucible, dried at 105°,
and weighed. The weight of gold, multiplied by
2.072, represents the weight of C4H.3AuNa2S.H2O.
N.F.

Uses. — In one form or another gold has been
used empirically, and more or less enthusiastically,
by physicians since the time of Paracelsus. It has
been employed in many chronic diseases, usually
with indifferent and controversial results. At the
present time gold salts enjoy the confidence of
the therapist in active rheumatoid arthritis and
certain skin diseases, notably chronic discoid lupus
erythematosus. Gold salts have been used in mod-
ern times in the treatment of tuberculosis and
malignant disease but, because of unrewarding
results in these conditions, such uses have been
abandoned. The use of gold salts in tuberculosis
led, however, to its use in rheumatoid arthritis,
by Forestier (Bull. soc. med., 1929, 53, 323), and
in chronic discoid lupus erythematosus by Scham-
berg (Arch. Dermat. Syph., 1927, 15, 119).
Radioactive gold (Au-198) is at present being
tried as palliative therapy in certain types of ma-
lignant disease (see in Part II).

Action. — The mechanism of action of gold
salts is unknown. Studies of gold metabolism
(Freyberg et al., J. Clin. Inv., 1941, 20, 401)
have been helpful in clarifying the manner in
which the body handles gold salts. The salts are
poorly absorbed from the gastrointestinal tract
following oral administration. Most of an oral
dose can be recovered in the feces unless gastric
irritation, which is common, results in partial loss
by vomiting. The usual route of administration
is by intramuscular injection. From the injection
site, the gold is slowly absorbed into the blood
stream, where it is bound to protein complexes.
The amount found in red blood cells is negligible.
The chief route of excretion is through the urine,
with small and variable amounts excreted in the
feces. Absorbed gold is concentrated mostly in
the kidney, liver, spleen and skin.

Since gold salts are commonly injected weekly
over long periods of time, it is of interest to out-
line the results of long-term metabolic studies in
patients under actual therapy. Following weekly
injections of 25 to 50 mg. of a gold salt there is
an initial stepwise increase in the plasma concen-
tration of gold, leveling off at a fairly constant
concentration of 0.4 to 0.8 mg. per 100 ml. Thus
there appears to be no accumulation in the blood
after a certain level is reached, the level being
determined by the size of the weekly dose. In the
24-hour period following an injection there is a
marked increase in urinary excretion of gold,
amounting to 2.5 to 3.5 mg. as compared to 0.8
to 1.2 mg. for 24 hours on days between injec-
tions. This suggests that as gold is absorbed from
its intramuscular depot it initially circulates in a
freely excretable form, which rapidly passes out
of the plasma into tissues as well as urine. The
total excretion of gold, measured between two
weekly doses after the patient is on a regular
dosage schedule, is such as to indicate that 75 to
80 per cent of the injected gold is retained in the
body after each injection; this cumulative reten-

tion can also be demonstrated by measuring blood
levels and excretion after discontinuance of ther-
apy. Depending on the size of the weekly dose
and the duration of treatment, significant blood
levels and excretion of gold will continue for 4
to 15 months after cessation of injections.

Certain other generalizations concerning the
metabolism and action of gold salts may be made.
Since the effective component of a gold com-
pound is gold, and since various compounds differ
in their content of this element, interchange of
such compounds during therapy should not be
made without adjustment of dose to maintain
equivalent amounts of gold per injection (auro-
thioglucose and gold sodium thiomalate each con-
tain 50 per cent of gold, while gold sodium thio-
sulfate contains 37 per cent). In general, water-
soluble salts of gold administered in an oil sus-
pension give more prolonged, but irregular, ab-
sorption and excretion values of gold.

The mode of antirheumatic action of gold is
unknown, but many theories have been postulated.
The effectiveness in rheumatoid arthritis has been
attributed to a liver damage, since gold tends to
accumulate in liver cells, and since hepatitis and
jaundice are among the situations which accom-
pany remissions of rheumatoid arthritis (Hench,
Proc. Mayo, 1938, 13, 161). A bacteriostatic
mechanism has been advanced on the basis of
the effectiveness of gold in preventing and curing
the experimental polyarthritis in rats caused by
pleuropneumonia organisms (Sabin and Warren,
J. Bad., 1940, 40, 823), and also because gold
prevented the experimental arthritis due to the
hemolytic streptococcus organism (Rothbard, et
al., J. Pharmacol., 1941, 72, 164). However in-
teresting these facts may be, there is no demon-
strated bacterial etiology in human rheumatoid
arthritis. The most widely accepted, though in-
definite, theory is that gold combines with sulf-
hydryl groups on cellular proteins and thereby
exerts its influence by some unknown mechanism
involving actions of cellular enzyme systems
(Livenson, Exp. Med. Surg., 1945, 3, 146).

Therapeutic Use. — The sole indication for
gold therapy in arthritis is active rheumatoid
arthritis. The fact that it does not exert a wide-
spread antirheumatic effect that might be helpful
in other forms of arthritis restricts its usefulness
and imposes a rigid limitation on the physician.
This limitation is frequently a source of difficulty
in diagnosing atypical cases of rheumatoid arthri-
tis. Only rarely is a therapeutic trial of gold in
confusing cases of arthritis justified. The drug is
not especially beneficial in old burned-out or
arrested cases of rheumatoid arthritis which are
characterized by minimal or questionable activity,
marked joint destruction and crippling. Gold
therapists are agreed that the most favorable
results are likely to be obtained in early cases of
disease (Batterman, J.A.M.A., 1953, 152, 1013).

The results of gold therapy have been difficult
to evaluate because of conflicting reports. Many
studies of gold therapy were performed at a time
when confusion as to the type of compound, its
dosage, and duration of treatment was prevalent.
In addition to these handicaps there is lack of
general agreement among workers in the field as

Part I

Gold Sodium Thiosulfate

623

to diagnosis and classification of severity of the
disease. Most reliable and enthusiastic workers
feel that in properly selected cases about 70 per
cent can expect to go into remission (Adams and
Cecil, Ann. Int. Med., 1950, 33, 163); the spon-
taneous tendency of the disease to go into remis-
sion, regardless of therapy, in from 15 to 25 per
cent of cases. In addition to the usual and com-
mon form of rheumatoid arthritis, gold has been
beneficial in Still's disease or juvenile rheumatoid
arthritis. It has not been of help in rheumatoid
spondylitis.

Toxicology. — Gold salts have considerable
potential toxicity. This is true of practically all
drugs that are of some benefit in rheumatoid
arthritis. The chief toxic manifestations of gold
salts are various types of dermatitis, usually
pruritic in character; somatitis; nausea, vomiting
and diarrhea; nephritis; various hematologic ab-
normalities such as leukopenia and thrombocyto-
penia. These toxic symptoms have been reported
to occur in from 4 to 40 per cent of gold-treated
patients. By careful attention to these potential
dangers, physicians can reduce their occurrence
to a minimum and practically eliminate serious
reactions. The following routine procedure should
be observed when gold therapy is employed. The
patient should be informed about toxic symptoms
and told to report to the physician any question-
able symptom. The physician should question the
patient, prior to each injection, concerning any
toxic manifestation. Before commencing therapy,
and also at least monthly after instituting therapy,
a white blood cell count, a differential cell count,
and a urinalysis must be performed. If any symp-
tom which might be due to gold is suspected,
therapy should be temporarily interrupted until
the situation is clarified. After the symptom
clears, or is otherwise explained, gold therapy may
be cautiously resumed. Patients should be warned
against the dangers of photosensitization which
may follow exposure to sunlight.

Gold therapy should not be instituted in pa-
tients with nephritis, hepatic disease, anemia,
hemorrhagic tendency or other blood dyscrasia,
tuberculosis or in acute disseminated lupus
erythematosus.

Most manifestations of gold toxicity will re-
spond favorably to discontinuance of use of the
drug if the danger is recognized early. Recovery
may be facilitated by judicious use, orally or
intramuscularly, of cortisone or by use of dimer-
caprol, either locally as in ointment form or intra-
muscularly in the same manner as recommended
for poisoning by other heavy metals (Strauss et
al., Ann. Int. Med., 1953, 37, 323).

Dose. — The usual schedule of treatment calls
for initial administration of small doses of gold
salts, gradually increased weekly to a maintenance
level. One can start with an initial dose of 10 mg.
of a gold salt and increase the amount, at weekly
intervals, to a dose of 50 mg., and even up to 75
mg., weekly. Lansbury (Pennsylvania M. J., 1943,
47, 216) advocated beginning doses of 1, 3, 6,
and 15 mg. on successive days, followed by 25
mg. administered once or twice weekly. Courses
of gold therapy have usually consisted of a total
dosage of 500 to 1500 mg. of gold salt; sometimes

the total dose has been as much as 2000 mg. At
the termination of a course of injections of gold,
some physicians have administered a monthly
dose, rather indefinitely, to reduce tendency to
relapse.

Storage. — Preserve "Gold Sodium Thiomalate
in tight, fight-resistant containers." N.F.

GOLD SODIUM THIOMALATE
INJECTION. N.F. (B.P.)

Injectio Auri Sodii Thiomalatis

"Gold Sodium Thiomalate Injection is a sterile
solution of gold sodium thiomalate in water for
injection. It contains not less than 95 per cent
and not more than 105 per cent of the labeled
amount of C4H.3AuNa2O4S.H2O." N.F.

The B.P. Injection of Sodium Aurothiomalate,
prepared with water for injection, contains Au
equivalent to not less than 42.3 per cent and not
more than 48.3 per cent of the labeled content of
sodium aurothiomalate.

B.P. Injection of Sodium Aurothiomalate.

Storage. — Preserve "in single-dose or multi-
ple-dose containers, preferably of Type I glass."
N.F.

Usual Sizes.— 10, 25, 50, and 100 mg. (ap-
proximately y&, Y%, yi, and \Yi grains) in 1 ml.
ampuls.

GOLD SODIUM THIOSULFATE. N.F.

Auri Sodii Thiosulfas

Na3Au(S203)2.2H20

"Gold Sodium Thiosulfate contains not less
than 36.7 per cent and not more than 37.7 per
cent of Au." N.F.

Sodium Gold Thiosulfate; Sodium Aurothiosulfate.

This double salt is formed by combination of
one molecule of aurous thiosulfate and three mole-
cules of sodium thiosulfate.

Description. — "Gold Sodium Thiosulfate oc-
curs as white, needle-like or prismatic, small,
glistening crystals. It slowly darkens on exposure
to fight. Its solution (1 in 20) is neutral or alka-
line to litmus. One Gm. of Gold Sodium Thio-
sulfate dissolves in 2 ml. of water; it is insoluble
in alcohol and in most other organic solvents."
N.F.

Test. — Identification. — The odor of sulfur di-
oxide is apparent and a brown precipitate of gold
sulfide results when 1 ml. of diluted hydrochloric
acid is added to a solution of 50 mg. of gold
sodium thiosulfate in 1 ml. of water and the mix-
ture heated on a water bath. After washing the
precipitate with hot water by decantation, it is
transferred to a porcelain crucible, mixed with
3 ml. of hydrochloric acid and 1 ml. of nitric acid
and the mixture evaporated almost to dryness on
a water bath. The residue is treated with 10 ml.
of distilled water and filtered if necessary. To
2 ml. of the filtrate, diluted with 5 ml. of distilled
water, 2 ml. of sodium hydroxide T.S. and 1 ml.
of hydrogen peroxide T.S. are added and the mix-
ture heated on a water bath. A purple-red to
brown precipitate is produced. To a 2-ml. portion
of the filtrate, diluted with 5 ml. of distilled

624

Gold Sodium Thiosulfate

Part I

water, a few drops of stannous chloride T.S. are
added: a purple color, due ta colloidal gold, is
produced.

Assay. — About 500 mg. of the salt is dissolved
in distilled water, boiled with nitric acid, diluted
with water, and the precipitate of metallic gold
produced by the reducing action of sulfur dioxide
filtered off, washed, dried and ignited to constant
weight. N.F.

Uses. — Gold sodium thiosulfate was introduced
as a remedy for pulmonary tuberculosis and seems
to exert, in some cases, a favorable influence.
Such use, however, is not free from danger (see
J.A.M.A., 1925, 84, 287); streptomycin, />-amino-
salicylic acid, isonicotinic hydrazide and other
drugs are more effective and gold salts are seldom
used for this purpose. It is strongly antiseptic
toward M. tuberculosis but much less so against
other species of bacteria. Its value in lupus
erythematosus seems to be established (Scham-
berg. Arch. Dermat. Syph., 1927, 15, 119) but it
is contraindicated in the acute disseminated form
of the disease. Schlossberger (Derm. Ztschr.,
1930, 59, 133) claimed that it was therapeutically
useful in syphilis and trypanosomiasis. It has also
been used for psoriasis. At present it finds its
largest use in the management of rheumatoid
arthritis (Comroe, J. A.M. A., 1945, 128, 848), an
outgrowth of the observations of Forestier {Bull,
soc. med., 1929, 53, 323). The pleuropneumonia-
like bacteria, which produce chronic proliferative
arthritis in mice, grow readily in vitro in the pres-
ence of gold (Sabin and Warren, /. Bad., 1940,
40, 823) although gold therapy is beneficial in
this condition. It has been employed in those
cases of leprosy in which there is an inadequate
tissue response to the disease (Cochrane, Med.
Press, May 9, 1945, p. 295).

Action. — Gold salts are poorly absorbed after
oral administration, passing out in the feces. After
parenteral administration, gold enters the blood
stream and is stored in the tissues, chiefly in the
liver, spleen, kidneys and skin, and gradually
excreted, for the most part, in the urine. After
intramuscular injection, Block et at. (J. Pharma-
col., 1944, 82, 391) found that absorption at the
site of injection was incomplete and that gold
remained in the blood, fiver and other tissues 85
days later in rats (for observations on humans
see under Gold Sodium Thiomalate). This pro-
longed retention of gold explains the seriousness
of toxic reactions when they occur. Libenson
(Exp. Med. & Surg., 1945, 3, 146) suggested that
gold acted by blocking the sulfhydryl groups of
glutathione, etc. and thereby altered oxidation-
reduction processes within tissue cells.

Therapeutic Use. — Gold salts have been com-
monly administered in doses corresponding to
50 mg. of gold weekly, given for a period of 10
to 15 weeks. Freyberg (Ohio State M. J., 1942,
38, 813) reported an incidence of toxic reactions
of 41 per cent with this dosage; similar thera-
peutic effects and a toxicity of 30 per cent were
obtained when half this dose was given. Using a
quarter of the dose, the toxicity was only 18 per
cent but therapeutic benefit was less certain.

Gold therapy is beneficial in some cases of
rheumatoid arthritis but is not indicated in other

forms of arthritis. Often there is little or no im-
provement in the arthritic manifestations for 1
to 3 months of the treatment. Relapse occurs in
some instances after treatment has been stopped.

Precautions. — Gold salts should not be ad-
ministered to patients with a history of any dis-
ease having symptoms similar to the toxic reac-
tions of gold, such diseases including purpura,
agranulocytosis, severe anemia, etc., nor should
they be used in patients with severe renal or
hepatic disease, or in pregnancy, or in the pres-
ence of diabetes mellitus, eczema, chronic derma-
titis or severe asthma. The most careful attention
of the physician is required; indeed, other meth-
ods of treatment should be tried before resorting
to gold. The risk should be explained to the pa-
tient, and his consent to undergo such therapy
obtained before instituting treatment. During
treatment the patient should be questioned con-
cerning toxic symptoms that may develop and
examined for signs of toxicity before administer-
ing each dose; urinalysis and blood examination
should be performed every 2 to 4 weeks. At the
slightest suggestion of toxicity injections should
be discontinued, at least temporarily. Exposure
to sunlight should be avoided to avoid photo-
sensitization. Adequate nutrition, supplying par-
ticularly sufficient protein, carbohydrate, thiamine
and ascorbic acid, and including parenteral use of
liver extract, is important in preventing toxic re-
actions (see Hughes. Brit. M. J., 1950. 1, 634).

Toxicology. — The toxic reactions of gold are
almost legion, resembling those of the arsenicals;
they are discussed under Gold Sodium Thio-
malate. Decreased dosage lessens, but does not
eliminate, toxic reactions.

Dose. — The usual dose, according to the N.F.,
is to be determined by the prescriber. Weekly
doses ranging from 5 to 75 mg. (about %a to \yi
grains) have been given; in a course of therapy
a total dose of 0.5 to 1 Gm. is usually uesd but
more is sometimes given. A small test dose should
be used before full dosage is commenced. The salt
is usually given intramuscularly, rarely intra-
venously, in 1 to 10 per cent solution in water
for injection.

Storage. — Preserve "in well-closed, light-re-
sistant containers." N.F.

STERILE GOLD SODIUM
THIOSULFATE. N.F.

Auri Sodii Thiosulfas Sterile

"Sterile Gold Sodium Thiosulfate contains not
less than 36.7 per cent and not more than 37.7
per cent of Au." N.F.

This monograph provides specifications for the
sterile form of gold sodium thiosulfate employed
to prepare solutions for parenteral administration.
It is required to meet all specifications for Gold
Sodium Thiosulfate and, in addition, must be
sterile.

Storage and Labeling. — Preserve "in tight
containers, so closed that the sterility of the prod-
uct is maintained until the package is opened for
use. The quantity of Sterile Gold Sodium Thio-
sulfate and the lot number must be stated on the
label of each package." NJ?.

Part I

Gonadotropin, Chorionic 625

Usual Sizes.— 10, 25, SO, 75 and 100 mg. (ap-
proximately V%, Y%, $4, \lA, and 1^ grains).

CHORIONIC GONADOTROPHIN.
B.P., I.P.

Gonadotrophinum Chorionicum

The B.P. defines this substance as a dry, sterile
preparation of the gonad-stimulating substance
obtained from the urine of pregnant women ; it is
required to contain not less than 400 units per mg.
The LP. definition is the same.

Chorionic Gonadotropin (N.N.R.). Entromone (Endo);
Follutein {Squibb).

The B.P. describes the following method of
preparing chorionic gonadotrop(h)in: The urine
is adjusted to pH 6, sufficient alcohol is added to
provide a concentration of 50 per cent v/v, and
the precipitate of inert matter is filtered off. De-
hydrated alcohol is added to the filtrate to a con-
centration of alcohol between 80 and 90 per cent
v/v, the pH is adjusted to 5, and the resulting
precipitate is separated by centrifuging; after
washing, successively, with 90 per cent alcohol,
dehydrated alcohol, and ether, this precipitate is
dried in vacuo and powdered. The product is
assayed biologically.

Description. — Chorionic gonadotrop(h)in oc-
curs as a white or fawn powder, which is soluble
in water.

Assay. — The assay is based on the principle
that the weight of the ovaries of immature female
rats can be increased by the action of chorionic
gonadotrop(h)in from an unstimulated level of
about 10 mg. to a maximum of about 40 mg. or
more if very large doses are given; the increase
in weight, compared with that produced by the
standard preparation, is used to calculate the re-
sults. The characteristic luteinizing action of the
gonadotrop(h)in is verified by microscopic ex-
amination of sections of the ovaries.

The unit employed by the B.P. in evaluating
the potency of this product represents the activity
of 0.1 mg. of a standardized preparation of the
hormone used for comparison in the biological
assay.

Uses. — A general discussion of gonadotropic
hormones is provided in the article on Pituitary,
in Part II. This anterior pituitary-like (APL)
gonadotropin is formed by the cytotrophoblast
of the placenta; it is found in the urine of pri-
mates (Selye et al., Proc. S. Exp. Biol. Med.,
1933, 30, 589). It has luteotropic, Leydig-cell,
and adrenocortical-stimulating actions (Brown
and Bradbury, Am. J. Obst. Gyn., 1947, 53, 749;
Bartter et al., J. Clin. Endocrinol., 1952, 12,
1532; Opsahl et al., Yale J. Biol. Med., 1951, 23,
399). It is recommended in the treatment of
cryptorchidism at the age of about 11 years; a
dose of 250 to 1000 units subcutaneously 3 times
weekly (for as long as 2 months) is given until
the testes descend into the scrotum or puberty
develops (Thompson and Heckel, J. A.M. A., 1939,
112, 397). If descent is not accomplished, surgery
should be considered. If assays of urine in such
cases show a high concentration of gonadotropin,
the testes are nonfunctional and therapy with
chorionic gonadotropin is probably useless. In

hypoleydigism (eunuchoidism), a therapeutic trial
with chorionic gonadotropin will demonstrate the
functional ability of the testes. A dose of 5000
units intramuscularly twice weekly has been used;
appearance in 4 to 6 weeks of secondary sexual
characteristics and an increase in the urinary ex-
cretion of 1 7-ketosteroids demonstrate testicular
function and suggests the presence of hypopitui-
tarism. Most cases relapse when chorionic gona-
dotropin is discontinued (Bartter et al., loc. cit.).
These authors reported that one weekly injection,
in an oil and wax vehicle, has the same effect as
daily injections of aqueous solution.

Glass and Johnson (J. Clin. Endocrinol., 1944,
4, 540) tried chorionic gonadotropin in cases of
male homosexuality with inconclusive results.
Some obese adolescents have delayed gonadal de-
velopment; chorionic gonadotropin therapy will
correct the androgen deficiency but does not bene-
fit the obesity. In men with cirrhosis of the liver,
Klatskin and Munson (Yale J. Biol. Med., 1952,
24, 474) reported gynecomastia, after injections
of chorionic gonadotropin, which they ascribed to
increased formation of estrogen by adrenal glands;
urinary 1 7-ketosteroids did not increase.

Stimulation of androgen formation by the ad-
renal cortex was described by Plate (Nederland.
Tijdschr. verlosk. en gynae., 1953, 53, 389), but
androgens may also be derived from ovaries in
women. Sternberg et al. (J. Clin. Endocrinol.,
1953, 13, 139) observed stimulation histologically
of Leydig-like cells located in the hilus of the
human ovary after chorionic gonadotropin injec-
tions daily for 1 to 3 weeks. Tumors of this cell
type in the ovary have been correlated with
virilism and increased excretion of 1 7-ketosteroids
(Taliaferro et al., Arch. Int. Med., 1953, 91, 675).
Bioassay of the placenta showed high concentra-
tions of chorionic gonadotropin in some cases of
preeclampsia and in diabetes (Loraine and Doug-
las, J. Obst. Gyn. Br. Emp., 1953, 60, 640).
Studies of pregnancy urine by paper electro-
phoresis disclosed that chorionic gonadotropin
migrated to the cathode at a characteristic rate
which differed from the rate of migration of pitui-
tary gonadotropin (Stran and Jones, Bull. Johns
Hopkins Hosp., 1953, 93, 51). In cases of anovu-
latory menstruation (functional uterine bleeding,
hyperestrogenic polycystic glandular hyperplasia
of the endometrium), chorionic gonadotropin
therapy caused ovulation, corpus luteum forma-
tion and correction of the menorrhagia (Wahlen,
Acta endocrtnol., 1952, 9, 69; 11, 67) but pro-
gesterone is equally effective and may be adminis-
tered by mouth (de Alvarez, J.A.M.A., 1954,
156, 528).

Leathern and Bradbury (West. J. Surg. Obst.
Gyn., 1949, 57, 173) described antibody in the
blood of a patient after prolonged use of chorionic
gonadotropin.

The only established use of chorionic gonado-
tropin is in the treatment of cryptorchidism.

The B.P. gives the dose as 500 to 1000 units,
by intramuscular injection, twice weekly.

Storage. — Preserve in a well-closed container,
sealed to exclude microorganisms, at a tempera-
ture not exceeding 20°. Under these conditions
potency is retained for 2 years.

626 Gonadotrophs, Injection of Chorionic

Part I

INJECTION OF CHORIONIC
GONADOTROPHIN. B.P.

Injectio Gonadotrophini Chorionic!

This injection is a sterile solution of chorionic
gonadotrophin in water for injection containing
0.5 per cent w, v of phenol; it is prepared by
dissolving the contents of a sealed container of
the gonadotrophin in the proper amount of water
for injection, to which has been added the phenol,
immediately before use. The content of chorionic
gonadotrophin in the sealed container is not less
than 90.0 per cent and not more than 110.0 per
cent of the labeled content. The sealed container
may also contain a suitable quantity of sterile
powdered lactose or sterile powdered sodium
chloride. B.P.

SERUM GONADOTROPHIN. B.P., LP.

Gonadotrophinum Sericum

The B.P. defines this gonadotrop(h)in as a dry
sterile preparation of the foUicle-stimulating sub-
stance obtained from the serum of pregnant
mares; it is required to contain not less than 100
units per mg. The LP. definition is the same.

Serum Gonadotropin.

The following method of preparation is de-
scribed by the B.P. : Oxalated blood from preg-
nant mares in the 60th to 75th day of pregnancy
is allowed to stand overnight, the plasma is sepa-
rated, adjusted to pH 9 with a sodium hydroxide
solution and an equal volume of alcohol added:
the precipitate of inert protein is filtered off.
Dehydrated alcohol is added to the filtrate to in-
crease the concentration of alcohol to 70 per cent
v v. the pH is adjusted to 5, and the resulting
precipitate is collected and suspended in water.
The pH is adjusted to 9. an equal volume of alco-
hol is added, and the precipitate of inert matter
is filtered off. To the filtrate dehydrated alcohol
is again added to obtain a concentration of 70
per cent, the pH is adjusted to 5, and the pre-
cipitate is collected, dried in vacuo, and powdered,
and assayed biologically.

Description. — Serum gonadotrop(h)in is a
white powder, soluble in water.

Assay. — The assay is based on the principle
that the weight of the ovaries of immature female
rats can be increased by the action of serum
gonadotrop(h)in from an unstimulated level of
about 10 mg. to a maximum of about 220 mg.;
the increase in weight, compared with that pro-
duced by the standard preparation, is the basis
for calculation of results. The characteristic fol-
licular growth stimulation produced by the
gonadotrop(h)in is verified by microscopic ex-
amination of sections of the ovaries.

The unit employed in evaluating the potency
of this preparation represents the activity of 0.25
mg. of a standardized preparation of the hormone
used for comparison in the biological assay.

For uses of this hormonal substance see the
article on Chorionic Gonadotrophin, and also the
discussion of Gonadotropic Hormones, under Pi-
tuitary, in Part H.

The B.P. gives the dose as 200 to 1000 units,
by intramuscular injection, twice weekly.

Storage. — Preserve in a well-closed container,
sealed to exclude microorganisms, at a tempera-
ture not exceeding 20\ Under these conditions
potency is retained for 2 years.

INJECTION OF SERUM
GONADOTROPHIN. B.P.

Injectio Gonadotrophini Serici

This injection is a sterile solution of serum
gonadotrophin in water for injection containing
0.5 per cent w v of phenol: it is prepared by dis-
solving the contents of a sealed container of the
gonadotrophin in the proper amount of water for
injection, to which has been added the phenol,
immediately before use. The content of serum
gonadotrophin in the sealed container is not less
than 90.0 per cent and not more than 110.0 per
cent of the labeled content. The sealed container
may also contain a suitable quantity of sterile
powdered lactose or sterile powdered sodium
chloride. B.P.

GRINDELIA. N.F.

Grindelia Robusta. Gum Plant, [Grindelia]

"Grindelia consists of the dried leaf and flow-
ering top of Grindelia camporum Greene, of
Grindelia humilus Hooker et Amott. or of
Grindelia sguarrosa (Pursh) Dunal (Fam. Com-
positeur NJ.

Gum Plant; Gumweed: Tar Weed. Herba Grindeliz.
Ft. Grindelia. Ger. Grindeliakraut. Sp. Grindelia.

The genus Grindelia includes some twenty-five
species, six or eight of which are found in South
America and the remainder occurring in the
United States, mostly west of the Mississippi.
They are coarse perennial or biennial herbs, being
occasionally shrub-like. Most, if not all. of the
species produce a sticky resinous exudation on
the stem and leaves and especially on the flower-
heads, whence they are called '"gum plar
The leaves are alternate, sessile or clasping and
spinulose-dentate. The flowers occur in heads
which are either solitary on the ends of branches,
or in cymes or panicles. Both the outer ray florets
and the central tubular florets are yellow in color.
The ray flowers are pistillate and the involucre is
bell-shaped or hemispherical, the bracts being
imbricated, in several series, being usually sub-
dulate- tipped.

The drug of the market appears to be derived
in part from G. camporum Greene, or Field Gum-
.:, of California. This occurs abundantly in the
inner coast ranges and in the foothills of the Sierra
Nevada. The leaves are oblong or spatulate. sessile
or clasping, coarsely serrate and of a pale-green
color. The flower-heads are yellow and the in-
volucre consists of several rows of lanceolate,
acuminate, recurved bracts. The achenes are dis-
tinctive in this species and are usually biauriculate
or more rarely unidentate at the summit. Perredes
(Pharm. J., 1909, 29, 596 and 604) reported re-
sults of some experiments in the cultivation of
this species.

Part I

Grindelia

627

G. humilis, known popularly as marsh gum-
weed, closely resembles the previous species. It
differs in being a marsh plant and less glutinous
and in the fact that its leaves are cuneiform in
shape, darker green and not as thick as in G.
camporum.

G. squarrosa, the curly-cup gumweed, is a com-
mon herb on the prairies and dry banks of the
West. It is occasionally found in the East where
it is hardy. It has been reported as occurring
from Manitoba and Saskatchewan to California
and Mexico. It is a glabrous, erect, branching herb
having linear-oblong or spatulate leaves, which are
more or less clasping at the base and sharply
spinulose-dentate. It is especially characterized by
the bracts of the involucre being linear-lanceolate,
subulate tipped and spreading or squarrose at the
summit, giving the species its name. The achenes
are truncate, those of the outer flowers being
usually thicker. The pappus consists of two or
three awns. For a pharmacognostic study of this
species see Wohn {Merck Rep., 1910, p. 310).

It was formerly supposed that the drug of com-
merce was derived from G. robusta. The studies
of Perredes (Proc. A. Ph. A., 1906, 370) showed
this not to be the case. It is apparently not a very
common plant and is distinguished by having
cordate-oblong, amplexicaul, coarsely serrate
leaves and the involucre being squarrose and leafy
at the base.

The leafy tops of Grindelia species are gathered
in July and dried in the sun. Most of the com-
mercial supplies come from California and other
western states.

Description. — "Unground Grindelia occurs as
cylindrical stems and branches, moderate brown
to moderate yellow with occasional reddish brown
blotches, with alternate leaf-scars, occasionally
with basal portions of leaves, sometimes irregu-
larly flexuous and coated with resin, and termi-
nating in resinous flower heads. The leaves are
usually separate from the stem and broken, oblong
to oblong-spatulate, up to 9 cm. in length, mostly
sessile or amplexicaul, dentate-serrate to spinosely
toothed, weak yellowish orange to weak yellow-
green, resinous, somewhat coriaceous and brittle.
Bracts of flowering branches are almost entire
and usually more or less spreading. The flower
heads are from 5 to 20 mm. in diameter, urn-
shaped or conical when unexpanded, but flattened
or depressed when partly open, and usually very
resinous; involucre bracts are numerous, imbri-
cated, with recurved tips; ray florets are yellow-
ish, ligulate, and pistillate ; disk florets are brown-
ish, tubular, and perfect. The pappus consists of
2 or 3, mostly unequal, linear awns about the
length of the disk florets; the disk achenes are
ovoid or oblong, compressed, quadrangular, or
triquetrous, and with a diauriculate, broadly
unidenate or broadly truncate, corky, thickened
summit. Grindelia has a balsamic odor, and an
aromatic, bitter and resinous taste.

"Powdered Grindelia is light yellowish brown
to yellow. It shows numerous fibrous fragments
bearing tracheae with annular and spiral thicken-
ings or marked with simple or bordered pores,
associated with numerous, narrow, strongly ligni-

fied wood fibers; pith cells more or less tabular
and containing a layer of protoplasm in which are
imbedded numerous spheroidal granules; frag-
ments of leaf epidermis showing more or less
polygonal areas containing chloroplastids and
basal cells of the glandular hairs; the latter with
compound heads up to 100 n in diameter, each
cell of which contains a rosette of crystals from
5 to 8 n in diameter. The pollen grains are
spherical, about 35 h- in diameter, spinose, and in
section show 3 pores." N.F.

Standards and Tests. — Stems. — Not over
30 per cent of its stems are over 2 mm. in diam-
eter. Foreign organic matter. — Not over 2 per
cent, other than stems. Acid-insoluble ash. — Not
over 2 per cent. N.F.

Constituents. — The activity of the drug prob-
ably resides in the resinous component. Clark and
Fischer (Am. J. Pharm., 1888) reported the pres-
ence of an alkaloid, grindeline, and Schneegans
(Am. J. Pharm., 1892) the presence of a saponin.
Power and Tutin (Proc. A. Ph. A., 1905 and
1907) were unable to confirm these findings and
attributed the value of the drug to the amorphous
resins which compose over 21 per cent of the
drug. The greater portion of this resinous matter
is a complex mixture of liquid acids which are
chiefly unsaturated cyclic compounds and which
are optically active. They found also traces of a
bright yellow volatile oil having the characteristic
odor of the drug. Power and Salway (/. Chem. S.,
1913, 103, 399) found also grindelol, a poly-
hydric alcohol derived from "phytosterol."

Bandoni [Semana med. (Buenos Aires), 1931,
1, 1686] found in G. discoidea a small amount of
saponin; the chief constituent is a balsamic resin,
representing about 16 per cent of the dried drug.
Glycosides and alkaloids were absent.

Uses. — Grindelia possesses only feeble physio-
logic powers. According to Buffington, when given
to lower animals in very large doses it produces
narcosis, with dilated pupils, slowing of the action
of the heart from stimulation of the inhibitory
nerves, and elevation of the blood pressure from
stimulation of the vasomotor center. Dobroklow-
sky found it to have a primary stimulating, and
later depressant, effect on the isolated frog's
heart. He found further that it acts chiefly upon
the motor nerves and muscles, but Buffington
believed that it paralyzes first the sensory nerve-
trunks, then the sensory side of the spinal cord,
afterwards involving the motor nerve-trunk and
cord. It is possible that some of these effects may
be due to the fact that the grindelias are capable
of absorbing selenium from the soil.

Grindelia has been used in the treatment of
acute bronchitis, especially when there is a tend-
ency to asthma. Its action is probably simply that
of a stimulating expectorant, but some believe it
exerts also an antispasmodic effect. It has been
frequently used in conjunction with stramonium
leaves in the preparation of "asthma powders" or
cigarettes. Its active principles appear to be ex-
creted from the kidneys; hence, after large doses,
there are sometimes evidences of renal irritation.
In chronic catarrh of the bladder it was used for
its stimulant influence upon the mucous mem-

628

Grindelia

Part I

brane. As a local application, grindelia has been
employed in burns, vaginitis, etc., applied either
in the form of a poultice or in solution. Especially
in the form of the aqueous (unofficial) fluid-
extract it is used as a local application in the
treatment of rhus poisoning.

The N.F. gives the usual dose as 2 Gm. (ap-
proximately 30 grains).

GRINDELIA FLUIDEXTRACT. N.F.

[Fluidextractum Grindeliae]

Extractum Grindeliae Fluidum. Fr. Extrait Fluide de
grindelia. Ger. Grindeliafluidextrakt.

Prepare the fluidextract from grindelia, in mod-
erately coarse powder, by Process A (see under
Fluidextracts) , using a menstruum of 3 volumes
of alcohol and 1 volume of water. Macerate the
drug during 48 hours, and percolate at a moderate
rate. N.F.

Alcohol Content. — From 57 to 63 per cent,
by volume, of C2IJ5OH. N.F.

Grindelia fluidextract is sometimes used as a
local application for ivy poisoning, for which pur-
pose it is usually diluted with an equal volume of
water. It is also occasionally used as an expec-
torant in certain types of bronchitis.

The aqueous "fluidextract" of grindelia which
is commercially available is not equivalent to the
official fluidextract and should be dispensed only
when it is specially requested.

Dose, 2 ml. (approximately 30 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

GUAIAC. N.F.

Guaiac Resin, [Guaiacum]

"Guaiac is the resin of the wood of Guajacum
officinale Linne, or of Guajacum sanctum Linne
(Fam. Zygophyllacea)." N.F.

Gum Guaiac. Guaiaci Resina: Resina Guajaci. Fr. Resine
de gai'ac ; Resine de gayac. Ger. Guajakharz. It. Resina
di guajaco.

Guajacum officinale is a middle-sized or low
evergreen tree indigenous to the West Indies and
northern part of South America. The branches
are knotted, and covered with an ash-colored
striated bark. That of the stem is of a dark-gray
color, variegated with greenish or purplish spots.
The leaves are opposite, leathery, and abruptly
pinnate, consisting of 2, 3 or 4 pairs of leaflets,
which are obovate, smooth, shining, dark green,
up to 1^2 in. long, and almost sessile. The flowers
are of a rich blue color, long peduncled, and occur
in the axils of the upper leaves. The seeds are
solitary, hard, and oblong.

G. sanctum, L., is distinguished from G. offi-
cinale by its five-celled fruit and its oblong or
obliquely obovate or sometimes rhomboid-ovate
leaflets, six to eight to each leaf. It grows in Cuba,
Haiti, the Bahama Islands and Florida. Its wood
is smaller than that of G. officinale, and is said by
Fee to be paler and less dense.

Under the title Guaiaci Lignum {Guaiacum
Wood) the B.P. 1914 recognized the heart-wood
of these trees. This wood, which is commonly
known as lignum vitas, or lignum sancti, is remark-

able for its hardness and density. The color of
the sap-wood is yellow, that of the older and cen-
tral layers greenish-brown, that of the shavings a
mixture of the two.

Guaiac resin exists in the tree as a physio-
logical product filling up tissues of the wood. It is
obtained in several different ways. The most
simple is by spontaneous exudation. Another
method is by sawing the wood into billets about
three feet long, boring them longitudinally with
an auger, then placing one end of the billet on the
fire, and receiving in a calabash the melted guaiac,
which flows out through the hole at the opposite
extremity. But the method probably most fre-
quently used is to boil the wood, in the form of
chips or sawdust, in a solution of common salt or
in sea water and skim off the substance which
rises to the surface. Guaiac resin is chiefly pro-
duced in the eastern portion of the Island of
Haiti, being exported from Azua and Gonai'ves in
bags within cases. Importations during the recent
war period possessed an objectional smoky odor.

Description. — "Guaiac occurs in irregular
masses enclosing fragments of vegetable tissues,
or in large, nearly homogeneous masses, and
occasionally in more or less rounded or ovoid
tears; externally brownish black to dusky brown,
acquiring a greenish color on long exposure, the
fractured surface having a glassy luster, the thin
pieces being translucent and varying in color from
brown to yellowish orange. The powder is moder-
ate yellowish brown, becoming olive-brown on ex-
posure to the air. It has a balsamic odor and a
slightly acrid taste. Guaiac dissolves readily but
incompletely in alcohol, in ether, in chloroform,
in creosote, in solutions of the alkalies, and in
chloral hydrate T.S. It is slightly soluble in car-
bon disulfide or benzene. Guaiac melts between
85° and 90°." N.F.

Standards and Tests. — Identification. — (1)
A blue color, gradually changing to green and
finally to greenish yellow, forms when 1 drop of
ferric chloride T.S. is added to 5 ml. of a 1 in 100
alcoholic solution of guaiac. (2) A mixture of 5
ml. of a 1 in 100 alcoholic solution of guaiac with
5 ml. of distilled water becomes blue on shaking
with 20 mg. of lead peroxide. On filtering, and
boiling a portion of the filtrate, the color dis-
appears but may be restored by further addition
of lead peroxide and agitation. Addition of a few
drops of diluted hydrochloric acid to a second por-
tion of filtrate discharges the color immediately.
Rosin. — A 1 in 10 solution of guaiac in petroleum
benzin is colorless and when this is shaken with
an equal volume of a fresh aqueous solution ( 1 in
200) of cupric acetate the former solution has no
more of a green color than a similar mixture of
cupric acetate solution and benzin. Acid-insoluble
ash. — Not over 2 per cent. Alcohol-insoluble
residue. — Not over 15 per cent. N.F.

Constituents. — Guaiac resin is composed
chiefly of resin acids (Liicker, Proc. A. Ph. A.,
1894). Of these guaiaconic acid (or guaiaconresi-
nol) , which composes some 70 per cent of the resin,
occurs in two forms known as alpha- and beta-
guaiaconic acid. Alpha-guaiaconic acid, present
in larger proportion, has the formula C22H26O6,
melts at about 73°, and is amorphous. The beta

Part I

Guaiacol

629

acid is crystalline, has the formula C21H26O5
and melts at 127°. Guaiaretic acid, C2oH2404,
present to the extent of about 10 per cent, is an
unsaturated acid. Other constituents include va-
nillin, a saponin (see Winterstein, Ztschr. physiol.
Chem., 1931, 199, 64) and a coloring matter
known as guaiac yellow.

On dry distillation guaiac resin yields gaaiacene,
CsHsO, guaiacol, cresol (see Creosote), guaiem
and finally pyroguaiacin, which is 6-hydroxy-7-
methoxy-2,3-dimethylnaphthalene. Guaiacene is
the aldehyde of tiglic acid, C5H8O2, while guaiene
is a sesquiterpene related to azulene (see under
Volatile Oils).

According to the experiments of W. Frieboes
(Inaugural Dissertation, Rostock, 1903), the
guaiac saponin (1 to 1000) forms a frothing solu-
tion which is persistent, is an excellent emulsifier,
has the power to disperse large proportions of
sparingly soluble substances and is innocuous and
non-irritant.

Incompatibilities. — The incompatibilities of
guaiac include the mineral acids, oxidizing agents,
ethyl nitrite spirit, and acacia. Water added to an
alcoholic solution causes precipitation.

Adulterations. — Guaiac resin has been some-
times adulterated with the rosin of the pine. The
fraud may be detected by the terebinthinate odor
evolved when the adulterated guaiac is ignited, as
well as by its partial solubility in hot turpentine
oil. This liquid dissolves rosin, but not pure guaiac.

Uses. — Formerly guaiac was included in that
mysterious group of drugs known as alteratives,
which were used in all sorts of chronic diseases
for which there was no satisfactory treatment,
such as scrofula, syphilis, chronic rheumatism,
et cetera. Because of its local irritant action upon
the stomach, in full dose it may cause some nausea
which will increase a tendency to sweat, but it is
doubtful whether it has any therapeutic virtue
beyond that of other nauseants. It has been aban-
doned in the treatment of skin diseases, as has its
use in rheumatic affections. A once-popular dosage
form was the ammoniated guaiac tincture, repre-
senting 20 per cent w/v of guaiac macerated with
aromatic ammonia spirit.

Guaiac is used as a reagent for the detection of
occult blood; blue color is produced by it, when
in contact with blood, and in the presence of
hydrogen peroxide. This reaction, however, is not
limited to blood. It is a test rather for the pres-
ence of an oxidizing enzyme. The oxidase of acacia
and of certain plant extracts, for example, also
gives the same test with guaiac. It is also used as a
test for the presence of cyanogenetic glycosides.

Guaiac was given in doses of 0.6 to 2 Gm. (ap-
proximately 10 to 30 grains).

GUAIACOL. N.F.

[Guaiacol]

"Guaiacol is a liquid consisting principally of
C6H4(OH)(OCH3) 1:2, usually obtained from
wood creosote, or a solid, consisting almost en-
tirely of C6H4(OH)(OCH3) 1:2, usually pre-
pared synthetically." N.F.

Gaiacolum; Guajacolum. Fr. Gaiacol. Ger. Guajacol.
It. Guajacolo. Sp. Guayacol.

Guaiacol, the monomethyl ether of o-dihydroxy-
benzene or catechol, may be prepared from the
latter by methylation. Another synthesis utilizes
o-anisidine, which is o-methoxyaniline; on diazo-
tization followed by treatment of the resulting
derivative with copper sulfate solution a hydroxyl
group is introduced in place of the amino group
in the o-anisidine.

Since guaiacol is the principal constituent of
beechwood creosote it is also obtained from this
source by fractional distillation. Guaiacol derives
its name from the fact that it was first isolated
from guaiac resin.

Description. — "Liquid Guaiacol is colorless
or yellowish. Solid Guaiacol is crystalline and is
colorless or yellowish. Guaiacol becomes darker
on exposure to light. The liquid obtained by melt-
ing solid Guaiacol does not readily crystallize even
upon chilling. Guaiacol has an agreeable, aromatic
odor. One Gm. of Guaiacol is soluble in from 60
to 70 ml. of water and in about 1 ml. of glycerin,
but it separates from the glycerin solution when
water is added. It is miscible with alcohol, with
chloroform, with ether, and with glacial acetic
acid. The specific gravity of Hquid Guaiacol is
not less than 1.112, and the specific gravity of
melted solid Guaiacol is about 1.132. Solid Guaia-
col melts at about 28°." N.F.

Standards and Tests. — Distillation range. —
Not less than 85 per cent of liquid guaiacol distils
between 200° and 210°, when determined by
Method II. Solid guaiacol distils between 204°
and 206°. Identification. — A blue color, chang-
ing to green and finally to a yellow, is pro-
duced on adding 1 drop of ferric chloride T.S. to
10 ml. of a 1 in 100 alcohol solution of guaiacol.
Impurities. — After shaking 2 ml. of liquefied solid
guaiacol with 4 ml. of petroleum benzin the mix-
ture separates into 2 distinct, clear layers. A per-
manent turbidity, or failure to separate into lay-
ers, indicates presence of impurities. Residue on
ignition. — Not over 0.1 per cent. Hydrocarbons.
— 1 ml. of liquid guaiacol or of melted solid
guaiacol dissolves in 2 ml. of potassium hydroxide
solution (15 in 100) after heating for 1 minute
in boiling water; on cooling, the solution con-
geals. Failure to congeal indicates presence of
impurities. The mass thus obtained forms a clear
solution with 25 ml. of distilled water. N.F.

Uses. — Guaiacol is locally irritant and some-
what anesthetic; its characteristic odor masks
many unpleasant ones. The studies of Gershenfeld
and Wood (/. A. Ph. A., 1933, 22, 198) indicate
it to be a less active germicide than creosote, in
this respect being about equal to phenol. It is
absorbed readily, not only from the alimentary
canal, but also through the skin; it is eliminated
chiefly through the kidneys conjugated with sul-
furic and glucuronic acids. Its general physio-
logical action seems to resemble that of phenol,
although it is less poisonous. In toxic amounts
it produces cardiovascular collapse.

Guaiacol is used internally chiefly as a stimu-
lating expectorant. When given orally it increases
respiratory tract fluid by means of a gastric reflex,
according to Stevens (Can. Med. Assoc. J., 1943,
48, 124). A proprietary cough syrup (Robitussin,
Robins), containing 100 mg. of glyceryl guaia-

630

Guaiacol

Part I

colate and 1 mg. of methamphetamine hydrochlo-
ride per 5 ml. was reported to be an effective
expectorant by Cass and Frederick (Am. Pract.
Dig. Treatment, 1951, 2, 844). The similar use
of guaiacol carbonate and potassium guaiacol-
sulfonate is also noted, though the mechanism of
action may not necessarily be the same. Guaiacol
was once widely used in the treatment of pulmo-
nary tuberculosis but it has no specific effect on
the tubercle bacillus. Given intravenously, guaia-
col is excreted by the lungs ; it was formerly used
for the treatment of lung abscesses.

Locally, guaiacol is employed for its anes-
thetic effect in various skin diseaess and even in
minor nose, throat and dental operations; 12 ml.
of it. diluted to 30 ml. with ohve oil, has been
thus used. Although it has been recommended as
a mild antiseptic in treating chronic ulcers it is
probably never used thus today. S

Dose, orally, 0.3 to 0.6 ml. (approximately 5 to
10 minims) ; intravenously, 0.3 to 0.6 ml. dis-
solved in 2 ml. of ethyl alcohol and diluted to
18 ml. with a 1 per cent solution of potassium
iodide (Nammach and Tiber. J.A.M.A., 1937,
109, 330), administered slowly every 3 or 4 days;
percutaneously, 10 to 20 drops gently rubbed on
the skin over the abdomen and covered with oiled
silk (but large areas should not be covered).

Storage. — Preserve "in tight, light-resistant
containers." N.F.

HALAZONE. N.F.

[Halazonum]

H00C-/ \-S02NCI2

"Halazone contains not less than 91.5 per cent
and not more than 100.5 per cent of C7H5O2-
NOiS." N.F.

p-Sulfonedichloramidobenzoic Acid; />-Sulfobenzoic Acid
Dichloramide.

This compound may be considered to be de-
rived from dichloramine-T by oxidation of the
methyl group to carboxyl. In the synthesis of
halazone ^-toluenesulfonamide is oxidized so as to
convert the methyl group to carboxyl. and the
resulting compound treated with hypochlorite to
form £-sulfonedichloramidobenzoic acid or hala-
zone (see also the method of synthesizing dichlora-
mine-T) .

Description. — "Halazone occurs as a white,
crystalline powder having a characteristic chlo-
rine-like odor. It is affected by light. Halazone
dissolves in glacial acetic acid and in solutions of
alkali hydroxides and of alkali carbonates with
the formation of a salt. It is slightly soluble in
water and in chloroform." N.F.

Standards and Tests. — Identification. — (1)
Bromine is liberated when 100 mg. of halazone is
added to 5 ml. of a 1 in 10 aqueous solution of
sodium bromide. (2) Iodine is liberated when 100
mg. of halazone is added to 5 ml. of potassium
iodide T.S. Loss on drying. — Not over 0.5 per
cent when dried over sulfuric acid for 4 hours.
Readily carbonizable substances. — No blackening

occurs although some effervescence may be ob-
served when 100 mg. is dissolved in 0.5 ml. of
sulfuric acid. N.F.

Assay. — About 150 mg. of halazone is mixed
with water and dissolved with the aid of sodium
hydroxide. Potassium iodide and acetic acid are
added, whereupon elemental iodine is liberated
as a result of the reduction of the +1 valence of
chlorine in halazone to the — 1 valence of chloride
ion; each atom of chlorine in halazone liberates
one molecule of iodine. The iodine is titrated with
0.1 N sodium thiosulfate. Each ml. of 0.1 N so-
dium thiosulfate represents 6.753 mg. of C7H5-
CI2NO4S. A blank titration is performed on the
reagents. N.F.

Uses. — Halazone, first prepared by Dakin and
Dunham (Brit. M. J., 1917, 1, 682), is a disin-
fectant used for the sterilization of drinking water.
Dakin and Dunham reported that, in the presence
of some alkali, as supplied by a carbonate, borate
or phosphate, halazone sterilizes water contami-
nated with such organisms as Bacterium coli,
Bacterium typhosum, Bacterium paratyphosum
A and B, Vibrio cholera, and Bacterium dys-
enteric, in a period of 30 to 60 minutes when
used in concentrations as low as 1 in 200,000 to
1 in 500,000. Halazone tablets were supplied to
American troops in World War II for sterilization
of polluted water.

The antibacterial action of halazone and re-
lated compounds such as succinchlorimide (q.v.),
while commonly associated with the content of
"active chlorine" (not to be confused with "avail-
able chlorine") in the compounds, actually prob-
ably involves intermediate formation of hypo-
chlorite from which oxygen is subsequently re-
leased. Thus, the — NCI2 group of halazone could
react with water to produce HCIO, according to
the equation:

-NCI2 + 2H2O -» — NH2 + 2HC10

The HCIO may then react, in the presence of
oxidizable matter, as follows:

HCIO -> HC1 + [O]

The nascent oxygen, designated [O], thus pro-
duced is then the effective antibacterial agent.

For sterilization of water 4 to 8 mg. (approxi-
mately Me to x/z grain) of halazone, in the form
of tablets containing sodium chloride with either
sodium carbonate or sodium borate, is employed
for each liter (approximately 1 quart) of water;
the mixture should be allowed to stand 30 minutes
before drinking.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

HALAZONE TABLETS.

[Tabellae Halazoni]

N.F.

''Halazone Tablets contain not less than 90 per
cent and not more than 135 per cent of the labeled
amount of C7H5CI2NO4S." N.F.

Among other tests it is required that halazone
tablets dissolve in water and that the pH of a
solution containing one 4-mg. tablet in 200 ml. of
distilled water be not less than 7.0.

Halazone tablets usually contain 4 mg. (ap-

Part I

Hamamelis

631

proximately M.6 grain) of halazone, with sodium
chloride as the tablet base, and a small amount
of either sodium carbonate or sodium borate to
provide a solution having a slightly alkaline reac-
tion (see under Halazone).

HALIBUT LIVER OIL.
(B.P., LP.)

Oleum Hippoglossi

U.S.P.,

"Halibut Liver Oil is the fixed oil obtained
from the fresh or suitably preserved livers of
Hippoglossus hippoglossus Linne (Fam. Pleuro-
nectidae). Halibut Liver Oil contains, in each
Gm., not less than 18 milligrams (60,000 U.S.P.
Units) of vitamin A and not less than 15 micro-
grams (600 U.S.P. Units) of vitamin D. Halibut
Liver Oil may be flavored by the addition of not
more than 1 per cent of a suitable flavoring sub-
stance or a mixture of such substances." U.S.P.
The B.P. requires a minimum of only 30,000
Units of vitamin A activity per Gm.; no rubric
is provided for vitamin D, though it is stated that
the vitamin D activity of the oil is usually be-
tween 2500 and 3500 Units per Gm. The I.P.
rubrics are not less than 30,000 International
Units of vitamin A, and not less than 600 Inter-
national Units of vitamin D, per Gm.

B.P., I.P. Halibut-Liver Oil. I.P. Oleum Jecoris Hippo-
glossi.

The halibut (Hippoglossus hippoglossus) is one
of the largest of the true fishes, the female often
reaching a weight of 400 pounds. Like others of
the flounder family it has acquired the habit of
swimming on the side, the left side of body be-
coming the lower side, the left eye migrating, as
the fish matures, to the upper, or right side. It
is found in the deeper coastal waters of both
the Atlantic and Pacific Oceans. The liver is rela-
tively small, compared to the size of the fish,
and is not so rich in oil as the cod liver. On the
other hand the oil from the halibut liver has a
much higher content of both vitamin A and vita-
min D than cod liver oil.

Description. — "Halibut Liver Oil is a yellow
to brownish yellow, oily liquid, and has a char-
acteristic, slightly fishy, but not a rancid, odor,
and a fishy taste. Halibut Liver Oil is insoluble
in water. It is slightly soluble in alcohol, but is
freely soluble in ether, in chloroform, in carbon
disulfide, and in ethyl actate. The specific grav-
ity of Halibut Liver Oil is between 0.920 and
0.930." U.S.P.

Standards and Tests. — Identification for
vitamin A. — The oil responds to the test for vita-
min A. Acid value. — A solution of 2 Gm. of oil
in 20 ml. of a mixture of equal volumes of alcohol
and ether, previously neutralized with 0.1 N
sodium hydroxide, requires not more than 1 ml.
of 0.1 N sodium hydroxide for neutralization,
using phenolphthalein T.S. as indicator. Unsapon-
ifiable matter. — Not less than 7 per cent and not
more than 22.5 per cent. Iodine value. — Not less
than 125 and not more than 155. Saponification
value. — Not less than 160 and not more than 180.
U.S.P.

As a test for absence of whale-liver oil the
B.P. requires that the absorbancy of a cyclo-

hexane solution of the oil, at 300 m\i, is not
greater than 75 per cent of that at 328 mn.

Assay. — Proceed as directed under Vitamins
A and D Assays (see under Oleovitamin A and
Synthetic Oleovitamin D). U.S.P.

Many studies have been made on the vitamin
potencies of halibut liver oil; these are reviewed
by Holmes, Tripp and Satterfield (Ind. Eng. Chem.,
1941, 33, 944) in connection with their own in-
vestigation of the vitamin potencies and physical
and chemical constants of 7 samples of halibut
liver oil prepared from fish caught off the New
England and Nova Scotia coasts during the sum-
mer and fall. The oils were found to contain from
4440 to 135,000 U.S.P. Vitamin A Units and
from 550 to 20,000 U.S.P. Vitamin D Units per
gram. No consistent relation was found between
the unsaponifiable matter and the content of vita-
mins, although the oil containing the smallest
amount of the former was the least potent in
vitamin content.

Uses. — Halibut liver oil has been used in the
treatment of vitamin deficiencies in place of cod
fiver oil, over which it has the advantage of
much smaller dosage. The vitamin D content
varies and must be ascertained from the label.

The usual dose is 0.1 ml., representing 1.5 mg.
or 5000 U.S.P. Units of vitamin A, daily, with a
range of 0.1 to 0.5 ml. (approximately XYz to 8
minims). A maximum dose of 0.5 ml. per 24 hours
is not usually exceeded. Oils of higher potency
than the U.S.P. minimum requirements should be
given in proportionally smaller dose.

Storage. — "Preserve Halibut Liver Oil in
tight, fight-resistant containers. Halibut Liver Oil
may be bottled or packaged in containers from
which the air has been expelled by the production
of a vacuum or by an inert gas." U.S.P.

HALIBUT LIVER OIL CAPSULES.

U.S.P. (B.P.)

Capsular Olei Hippoglossi

"Halibut Liver Oil Capsules contain not less
than 95 per cent and not more than 105 per cent
of the labeled amount of halibut fiver oil, and the
oil from the Capsules contains, in each Gm., not
less than 18 milligrams (60,000 U.S.P. Units) of
Vitamin A. Halibut Liver Oil Capsules contain
either \y2 milligrams or 7^ milligrams (5000 or
25,000 U.S.P. Units) of Vitamin A per capsule."
U.S.P.

B.P. Capsules of Halibut-liver Oil. Sp. Cdpsulas de
Aceite de Hipogloso.

Storage. — Preserve "in well-closed containers
and protect the oil in the Capsules from light."
U.S.P.

HAMAMELIS. B.P.

Witch Hazel Leaves, Hamamelidis Folium

The B.P. recognizes Hamamelis as the dried
leaves of Hamamelis virginiana L. The N.F. IX
name for the same drug was Hamamelis Leaf, of
the Family Hamamelidacece.

Striped Alder Leaves; Winter Bloom Leaves. Fr. Hama-
melis de Virginie; Feuilles d'hamameUis. Cer. Hamamelis-
blatter; Zauberhaselblatter. It. Amamelide. Sp. Hoja de
hamamelis.

632

Hamamelis

Part I

Witch-hazel is an indigenous shrub or a small
tree, from 5 to 25 feet, rarely to 35 feet in height,
growing in almost all sections of the Eastern and
Central United States, usually on hills or in stony
places, and often on the banks of streams. It is
the only species of the genus native to Eastern
North America, occurring from New Brunswick
and Nova Scotia to Minnesota and southward to
Florida and Texas. It is specifically characterized
by its leaves being obovate or oval, wavy-toothed,
and somewhat downy when young. The seeds are
black and shining externally, white, oily, and
farinaceous within, and edible like the hazelnut.
It is remarkable for the late appearance of its
yellow flowers, which expand in its northern range
from October to early December and continue
until the weather becomes very cold in winter.
The fruit is a 2-beaked, 2-celled woody capsule,
each cell containing a single black seed. It ripens
in October and November and, in the South, as
late as March at the same time the blossoms
appear and is in each instance the product of a
blossom of the previous year.

Description. — "Unground Hamamelis Leaf
has a petiole from 1 to 1.5 cm. long; the lamina,
when entire, is broadly elliptical or rhomboid-
ovate, usually inequilateral, from 8 to 12 cm.
long; has an apex usually acute, sometimes
rounded or acuminate; a base slightly heart-
shaped and oblique; the margin being sinuate or
sinuate-dentate; the upper surface fight olive-
brown to moderate olive-green, with a few stiff
hairs; and the lower surface paler in color, some-
what hairy, with midrib and veins prominent, the
secondary veins running straight to the margin."
N.F. IX. For histology see U.S.P., 24th ed.,
p. 528.

"Powdered Hamamelis Leaf is yellowish brown
to fight yellow; has a slight odor and an astringent,
slightly aromatic and bitter taste. Fragments of
epidermal tissue show narrowly elliptical stomata
from 23 to 35 microns in length with 2 to 4
neighbor-cells. The hairs are stellate, with from
4 to 12 cells united at the base, the individual
cells usually curved, with thick walls, narrow
lumina and are up to 500 microns in length. It
also shows numerous fragments of narrow tracheae
mostly spiral, and associated with narrow, strongly
lignified, porous wood fibers. The calcium oxalate
occurs in monoclinic prisms from 10 to 35 microns
in length and is found in the cells of the mesophyll
or in crystal fibers associated with strongly ligni-
fied pericycfic fibers." N.F. IX.

For details on the history, nomenclature and
modern utilization of American Witch Hazel, see
Fulling, Economic Botany, 1953, 7, 359.

Standards and Tests. — Stems. — Not over 5
per cent of the stems. Foreign organic matter. —
Not over 2 per cent, other than stems. Acid-
insoluble ash. — Not over 2 per cent. N.F. IX.
The B.P. requires not less than 20 per cent of
alcohol (45 per cent)-soluble extractive; the limit
of stems is 3.0 per cent.

The B.P. formerly recognized witch-hazel bark
(Hamamelidis cortex) as well as the leaves. The
bark occurs in "curved or channelled pieces about
one and a half millimetres thick, and from one-
half to two decimetres long, sometimes covered

with a silvery-grey or dark -grey scaly cork marked
with transverse lenticels, but frequently freed
from the cork, and then exhibiting a nearly smooth
reddish-brown outer surface. Inner surface pale
reddish-pink, and finely striated longitudinally;
fracture laminated and coarsely fibrous. In trans-
verse section, a cortex containing prismatic crys-
tals of calcium oxalate, a complete ring of scle-
renchymatous cells, and numerous tangentially
elongated groups of bast fibres. No marked odor;
taste astringent." B.P., 1914.

Constituents. — Hamamelis leaves contain a
considerable amount of tannin; Yosida (Chem.
Abs., 1940, 34, 1130) reported from 2.27 to 9.47
per cent in various species. Mercier (Compt. rend,
soc. biol., 1936, 21, 671) found in the leaves
about 0.2 per cent of choline, besides a saponin
and a glycoside; he states that the fluidextract is
poisonous when injected intravenously.

Uses. — Hamamelis fluidextract is occasionally
employed as a mild atsringent; either it or a dry
extract of the leaf is sometimes used as an in-
gredient of ointments or suppositories for the
treatment of hemorrhoids.

Witch-hazel bark was supposed to have been
used by the North American Indians as an ex-
ternal application in inflammatory conditions.

Dose, as given in the N.F. IX, 2 Gm. (approxi-
mately 30 grains).

Off. Prep. — Dry Extract of Hamamelis;
Liquid Extract of Hamamelis, B.P.; Hamamelis
Water, N.F.

DRY EXTRACT OF HAMAMELIS.
B.P.

Extractum Hamamelidis Siccum

This B.P. preparation is made by exhausting
hamamelis by percolation with 45 per. cent alco-
hol, removing the alcohol, evaporating the residual
liquid to dryness at a low temperature, and pow-
dering the residue.

It is officially recognized for use in preparing
suppositories, each containing 0.2 Gm. of the
extract in a base of theobroma oil, to be employed
in treating hemorrhoids.

LIQUID EXTRACT OF HAMAMELIS.
B.P.

Extractum Ramamelidis Liquidum

Hamamelis Leaf Fluidextract. Fluidextractum Hama-
melidis Folii. Fluidextract of Witch Hazel Leaves. Ex-
tractum Hamamelidis Fluidum. Fr. Extrait fluide d'hama-
melis. Ger. Hamamelisfluidextrakt. It. Estratto fluido di
amamelide. Sp. Extracto de hamamelis, fluido.

The B.P. preparation is made by percolating
moderately coarse hamamelis leaf with 45 per
cent alcohol. The N.F. IX fluidextract was made
as follows: Prepare the fluidextract from hama-
melis leaf, in moderately coarse powder, by
Process B (see under Fluidextracts) , using first
a menstruum of 9 volumes of alcohol and 1 vol-
ume of glycerin, followed by alcohol. Macerate
the drug during 48 hours, and percolate at a mod-
erate rate. N.F. IX.

Alcohol Content. — From 70 to 78 per cent,
by volume, of C2H5OH. N.F. IX.

The tannin content of hamamelis leaf fluidex-
tract is sufficiently high to confer on it a mildly

Part I

Helium

633

astringent action which is occasionally utilized.
The dose is 2 to 4 ml. (approximately 30 to 60
minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F. IX.

Off. Prep. — Ointment of Hamamelis, B.P.

OINTMENT OF HAMAMELIS. B.P.

Unguentum Hamamelidis

This ointment is prepared by mixing, in a warm
mortar, 10 ml. of the B.P. liquid extract of
hamamelis, 50 Gm. of wool fat, and 40 Gm. of
yellow soft paraffin. The ointment is used in the
treatment of hemorrhoids, sometimes being en-
closed in hollow suppositories.

HAMAMELIS WATER. N.F.

Witch-hazel Water, Distilled Witch-hazel Extract,
Aqua Hamamelidis

Witch Hazel Water; Distilled Extract of Witch Hazel;
"Witch Hazel."

After macerating a weighed amount of recently
cut and partially dried dormant twigs of Hama-
melis virginiana for 24 hours with twice their
weight of water, distil not more than 850 ml. of
distillate for each 1000 Gm. of twigs taken, add
150 ml. of alcohol to each 850 ml. of distillate,
and mix thoroughly. N.F.

The water obtained by distillation represents a
solution saturated with the volatile components
of hamamelis ; to this is added alcohol to preserve
the solution against growth of mold.

Description. — "Hamamelis Water is clear and
colorless, having a characteristic odor and taste.
It is free from mucoid or fungus growths and
does not have an acetous odor. Hamamelis Water
is neutral, or acid to litmus paper." N.F.

Standards and Tests. — Specific gravity. —
Not less than 0.979 and not more than 0.982.
Non-volatile residue. — Not over 25 mg. from 100
ml. of hamamelis water, the residue being dried
at 105° for 1 hour. Acetone and isopropyl alco-
hol.— Hamamelis water meets the requirements
of the test for acetone, etc., under Whisky.
Formaldehyde. — No red color is produced on mix-
ing 2 ml. of a 1 in 100 solution of phloroglucinol,
5 ml. of sodium hydroxide T.S. and 2 ml. of hama-
melis water. Methanol. — Hamamelis water meets
the requirements of the test for methanol under
Whisky. N.F.

Alcohol Content. — From 14 to 15 per cent,
by volume, of C2H5OH. N.F.

Scoville (Proc. A. Ph. A., 1907, 55, 448) re-
ported his investigations of a volatile oil of witch-
hazel. The "oil" as received was a soft grease,
occluding water, and had a greenish color and a
strong odor recalling that of hamamelis distillate.
A difference in the odor suggested, however, that,
as in the case of rose distillates, there is some
constituent in the natural oil which is more soluble
in water than in the remaining constituents of the
oil. The oil was found to consist chiefly of a
terpene with about 7 per cent of an alcohol; the
residue on distillation was a waxy solid amount-
ing to over 70 per cent of the weight of the oil.
For analytical data see U.S.D., 22nd ed., p. 174.

Jowett and Pyman (British Pharm. Conference,
1913) found Scoville's analytical data to agree
fairly closely with their own for another sample
of the volatile oil. According to them the chief
constituent is a sesquiterpene; there are also
present a phenolic substance, a mixture of fatty
acids in the free and combined states, and a mix-
ture of solid saturated hydrocarbons.

Uses. — Hamamelis water has been a popular
household embrocation for many years and it
continues to be thus used, although exactly how
it functions and to what degree have not been
clearly established. Mild astringent and local seda-
tive properties have been attributed to it. Official
recognition of the water is for the purpose of
providing specifications to maintain some con-
stancy of its quality, which otherwise might be
quite variable.

Storage. — Preserve "in tight containers and
avoid excessive heat." N.F.

HELIUM. U.S.P., B.P.

[Helium]

"Helium contains not less than 95 per cent by
volume of He, the remainder consisting mainly
of nitrogen." U.S.P. The B.P. requires not less
than 98.0 per cent v/v of He.

Sp. Helio.

Helium was first observed in the spectrum of
the sun by Lockyer in 1868, who named it from
the Greek word meaning sun. It was discovered by
Ramsay in 1895 in the mineral cleveite, and was
subsequently recognized as one of the components
of air, occurring in it to the extent of about
0.0004 per cent by volume. It remained a labora-
tory curiosity until it was discovered that certain
varieties of natural gas in western America con-
tained it in appreciable proportions (up to 2 per
cent). It is extracted by liquefying the natural
gas and fractionating the liquid by appropriate
methods.

Description. — "Helium is a colorless, odor-
less, tasteless gas which is not combustible and
does not support combustion. One liter of Helium
at a pressure of 760 mm. of mercury and at 0°
weighs not less than 174.5 mg. and not more than
232.5 mg., indicating not less than 95 per cent of
He. Helium is very slightly soluble in water."
U.S.P.

Standards and Tests. — Identification. — A
burning splinter of wood is extinguished by
helium. Mixtures of helium and hydrogen are
neither flammable nor explosive when oxygen is
included. Acidity or alkalinity. — Helium, referred
to 760 mm. and 25°, meets the requirements of
the test for Acidity or alkalinity under Oxygen.
Oxidizing substances. — Helium, referred to 760
mm. and 25°, meets the requirements of the test
for Oxidizing substances under Oxygen. Carbon
monoxide. — Helium, referred to 760 mm. and 25°,
meets the requirements of the test for Carbon
Monoxide under Oxygen. U.S.P.

Assay. — While the U.S.P. uses the weight of
a liter of helium as an index of its purity, the
B.P. requires an assay based on the fact that
helium is not absorbed by coconut shell char-

634

Helium

Part I

coal at the temperature of liquid oxygen, while
other gases which may be present with it are.
Specifically, not less than 98.0 per cent v/v of a
given volume of helium subjected to the test
should remain unabsorbed by the charcoal.

Uses.— Barach (J.A.M.A., 1936, 107, 1273)
introduced this gas into medicine. Helium is about
half as soluble in blood as nitrogen is and its dif-
fusibility is about twice that of nitrogen. Sayers
and Yant (Anesth. & Analg., 1926, 5, 127) dem-
onstrated that animals could be released from 10
atmospheres pressure of helium-oxygen in about
one-third of the time required in the case of
nitrogen-oxygen mixtures.

The decompresion from high atmospheric pres-
sures to sea level pressure experienced by deep
sea divers and workers in tunnels, or the rapid
ascent of aviators from atmospheric pressure to
high altitudes results in the release of bubbles of
nitrogen into the blood and tissues, a condition
known as aero-embolism. The bubbles frequently
lodge in joints (causing local pain), in the lungs
(pain, cough and the expectoration of frothy
mucus), in the skin (itching and urticaria), and
in the central nervous system, particularly in the
thoracic and lumbar portions of the spinal cord
(paralysis of the legs). The pain is often so severe
as to cause the patient to bend over and the
syndrome has been referred to as "the bends"
(caisson disease). The formation of bubbles of
nitrogen can be prevented by decompression in
stages (SO per cent reduction at a time) or by
inhaling 100 per cent oxygen to wash the dis-
solved nitrogen out of the blood and tissues. The
use of 100 per cent oxygen has increased the
ability of the human to tolerate considerable
change in pressure but, even with 100 per cent
oxygen, at 4 atmospheres pressure (a diving
depth of about 100 feet) nausea, cerebral dull-
ness and nervous instability develop in about 30
minutes and convulsions ensue on longer expo-
sure. High pressures may interfere with the elim-
ination and transport of carbon dioxide and,
under pressure, nitrogen seems to have a narcotic
action. The use of helium-oxygen mixtures has
made it possible for divers to descend to a pres-
sure of 16 atmospheres with full retention of
their mental capacity (Behnke and Yarbrough,
U. S. Nav. M. Bull., 1938, 36, 542). Helium has
a fat-water solubility ratio approximately one
half that of nitrogen; not only is there twice as
much nitrogen in the fat depots but exercise in-
creases the rate of elimination of nitrogen, but
not of helium, from these depots.

Barach (loc. cit.) found that a mixture of
helium and oxygen, in the same proportions as
nitrogen and oxygen are contained in the air. — i.e.,
21 per cent of oxygen and 79 per cent of helium —
has a density of 0.341, the ordinary atmosphere
being taken as 1. He kept mice for two and
one-half months in this atmosphere with no ap-
parent effect upon their well-being. Helium seems
to be entirely inert in the body. Because of the
lessened pressure required to move this helium-
oxygen mixture he suggested its use for the relief
of various types of obstructive dyspnea, such as
seen in asthma, pneumonia, and heart diseases.

A mixture of helium and oxygen has been found
of service in respiratory obstructions during anes-
thesia by a number of clinicians (see Bonham,
Anesth. & Analg., 1939, 33, 2585). Although in
asthma and other forms of obstructive dyspnea
the inhalation of oxygen is beneficial by increas-
ing the oxygen saturation of the blood, it does not
relieve the sensation of dyspnea because the pri-
mary difficulty is the mechanical effort required
to pull gas through the partially obstructed
points. In fact, oxygen is denser than ordinary
air. Helium-oxygen mixtures not only require
less effort to respire but produce a decrease in the
elevated negative pressures, which exist in the
lungs of asthmatics during inspiration, and there-
by relieve the tendency for blood plasma to pass
into the alveoli of the lungs (pulmonary edema)
and for patchy collapse (atelectasis) of the lung
to develop. However, the degree of anoxia in
many asthmatic patients requires more oxygen
than is provided by the 20 per cent oxygen and
80 per cent helium mixture. An increase in the
percentage of oxygen in the mixture rapidly raises
the density toward that of ordinary air. Barach,
A. L. {Principles and Practices of Inhalation
Therapy, J. B. Lippincott Co., Philadelphia, 1944;
Arch. Int. Med., 1939, 63, 946) restored the
dyspnea-relieving action by administering the
denser mixture in a tight hood under a positive
pressure of 3 to 6 cm. of water; the positive
pressure forces the gas mixture through the par-
tially obstructed bronchi during inspiration, im-
proves the absorption of oxygen, counteracts the
tendency to pulmonary edema and decreases
bronchial constriction during expiration. With the
masks in common use positive pressure can be
maintained only during expiration and the chief
advantage of positive pressure breathing is lost
in the patient with obstructive dyspnea. Dean
and Visscher (Am. J. Physiol, 1941, 134, 450)
disputed Barach's explanation of the mechanism
of action of helium-oxygen mixtures in obstruc-
tive dyspnea but the therapeutic value has been
confirmed by Maytum (/. Allergy, 1939, 10,
266) and others.

Helium-oxygen mixtures have been used for
asphyxia of the newborn (see Am. J. Obst. Gyn.,
1940, 39, 63 and 40, 140), for poisoning due to
lung-irritant gases such as phosgene, for the pre-
vention of post-operative atelectasis of the lung
following an anesthesia which has washed out all
the nitrogen, for pulmonary edema in cases with
partial bronchial obstruction (although positive
pressure is probably of more value than the mix-
ture employed), for cases with paralysis of the
respiratory muscles, as in acute anterior polio-
myelitis, in whom the sensation of dyspnea per-
sists in an artificial respirator breathing air. and
for partial laryngeal or tracheal obstructions.
Cleveland and End (Surg. Gynec. Obst., 1942,
74, 760) reported that headache following en-
cephalography lasted only 3 to 4 hours when
helium was the gas introduced into the sub-
arachnoid space and 100 per cent oxygen was
inhaled after the procedure contrasted with an
average of 58.5 hours when air was used both
for the injection and for respiration.

Part I

Heparin Sodium 635

The administration of helium requires a tight-
fitting mask; the usual oxygen tent cannot be
used because this readily diffusible gas leaks so
rapidly as to be of no benefit to the patient.
Barach et al. (Ann. Int. Med., 1938, 12, 754)
devised a tight-fitting hood which is the most
effective and economical method of administra-
tion and possesses the additional advantage of
making the use of increased pressure possible
during both inspiration and expiration. The car-
bon dioxide excreted by the patient must be
absorbed in any such closed system by soda-lime
or other agent and provision for water vapor in
the gas mixture must be made. Tanks of pure
helium should not be used in conjunction with
tanks of oxygen because asphyxia would result
if the oxygen tank ran out; tanks containing
about 80 per cent helium and 20 per cent oxygen
are used in conjunction with tanks of oxygen
joined beyond the valves on each tank through a
"Y" tube. The administration of helium is a
highly specialized procedure.

By inhalation, the usual dose is determined ac-
cording to the needs of the patient; the usual
concentration is 80 per cent with 20 per cent
oxygen.

Storage. — Preserve "in cylinders." U.S.P.

HEPARIN SODIUM. U.S.P. (B.P., LP.)

Heparin, [Heparinum Sodicum]

"Heparin Sodium is a mixture of active prin-
ciples, having the property of prolonging the
clotting time of blood in man or other animal.
It is usually obtained from the livers or lungs
of domestic mammals used for food by man.
The potency of Heparin Sodium is not less than
110 U.S.P. Heparin Units per milligram, and
not less than 90 per cent and not more than 110
per cent of the potency stated on the label."
U.S.P.

The B.P. and LP. define Heparin as a sterile
preparation containing the sodium salt of a com-
plex organic acid present in mammalian tissues,
having the characteristic property of delaying the
clotting of shed blood; the B.P. requires it to
contain not less than 100 units per mg., calcu-
lated with reference to the substance dried to
constant weight at 60° at a pressure not exceed-
ing 5 mm. of mercury, while the LP. requires the
same potency for the material without providing
any drying specification.

B.P., LP. Heparin; Heparinum.

In 1916 Howell and Holt prepared from liver
a material, which they called heparin, that had
the power of preventing coagulation of blood;
because of the presence of impurities this heparin
was not suitable for medicinal use. Several inves-
tigators have contributed to the process of re-
finement of the material (Schmitz and Fischer,
Ztschr. physiol. Chem., 1933, 216, 264; Charles
and Scott, /. Biol. Chem., 1933, 102, 425; Jorpes,
Biochem. J., 1935, 29, 1817; 1942, 36, 203;
Kuizenga and Spaulding, /. Biol. Chem., 1943,
148, 641, and others). Jorpes (loc. cit.) identi-
fied it as a sulfuric acid ester of mucoitin, a

glycoprotein; its exact composition, however, is
unknown and evidence indicates that it is not a
single compound (for structural data see J.A.C.S.,
1950, 72, 5796). Furthermore, the heparins ob-
tained from different mammalian species are not
absolutely identical.

Heparin occurs in many tissues, especially
those of the liver and lungs. Jorpes' evidence in-
dicates that it exists in the mast cells of Ehrlich,
found chiefly in connective tissue in blood vessel
walls and capillaries.

Units. — In the course of developing standards
for the evaluation of heparin both barium and
sodium salts of highly purified samples of the
substance were prepared. The Toronto unit repre-
sented the anticoagulant activity of 0.01 mg. of
a standard barium heparin employed at the Uni-
versity of Toronto. From this standard a sodium
salt (heparin sodium) was prepared, which was
subsequently used as an international standard;
the international unit represents the activity of
7.7 meg. (0.0077 mg.) of the heparin sodium
standard. The international and the Toronto
units are for practical purposes identical, for the
quantity of heparin represented in the respective
specified amounts of the two standards is identi-
cal. The international standard heparin sodium
represents approximately 130 units of activity
per mg.; the U.S.P. requires not less than 110
U.S.P. units per mg., while the B.P. and LP.
require not less than 100 units per mg. All of the
units are identical.

Description. — "Heparin Sodium occurs as a
white or pale-colored, amorphous powder. It is
odorless, or nearly so, and is hygroscopic. One
Gm. dissolves in 20 ml. of water." U.S.P.

Standards and Tests. — pH. — The pH of a
1 in 100 solution is between 6 and 7.5. Loss on
drying. — Not over 12 per cent, when dried at
60° over phosphorus pentoxide to constant weight.
Residue on ignition. — Not over 41 per cent.
Barium. — No turbidity, not dispelled by diluted
hydrochloric acid, develops on heating a solution
of heparin sodium with ammonia and hydrogen
peroxide, which oxidizes the heparin and allows
the naturally occurring sulfuric acid to interact
with any barium that may be present. Nitrogen
content. — Not over 3.0 per cent, calculated on
the dried basis. Sulfur. — Not less than 9.5 per
cent of S, calculated on the dried basis. Depressor
substances. — A solution of 10 mg. of heparin
sodium per ml. of saline T.S. meets the require-
ments of the official test for depressor substances.
Protein. — Trichloroacetic acid solution produces
no precipitate or turbidity with a solution of
heparin sodium. Pyrogen. — Heparin sodium
meets the requirements of the official test for
pyrogen, the test dose being 2 ml. of a solution
containing 1000 U.S.P. Units of heparin sodium
in 1 ml. of pyrogen-free saline T.S. per Kg. of
body weight. U.S.P.

Assay. — The anticoagulant activity of the hep-
arin sodium under test is compared with that of
U.S.P. Heparin Sodium Reference Standard,
using sheep blood plasma to which calcium chlo-
ride solution is added as the test medium. U.S.P.

Uses. — Heparin sodium is a potent anticoagu-

636 Heparin Sodium

Part I

lant drug, the general indications for its adminis-
tration being the same as those for Bishydroxy-
coumarin (q.v.). It is used in prophylaxis and
treatment of thromboembolic disorders, including
acute thrombophlebitis, pulmonary embolism,
thromboembolic complications of myocardial in-
farction and congestive heart failure, in arterial
embolism, vascular surgery, occlusive vascular
disease and frostbite. Since heparin acts rapidly,
it is often administered during the first 48 to 72
hours of bishydroxycoumarin therapy, before the
latter becomes effective therapeutically. It is
also of value as a substitute for citrate in blood
transfusions, as in the replacement of blood in
infants with erythroblastosis fetalis. It has a
marked effect on the lipids in blood.

Action. — Little is known of the metabolism
and excretion of heparin. It appears to have more
than one anticoagulant action. It prevents con-
version of prothrombin to thrombin and dimin-
ishes the agglutinability of the platelets (Brink-
haus et al., Sciences, 1939, 90, 539). Anlyan and
associates (North Carolina M. J., 1952. 13, 283)
stated that in conjunction with a serum albumin
cofactor it blocks the enzymatic action of throm-
bin in the conversion of fibrinogen to fibrin.
Vinazzer (Acta med. Scandinav., 1952, 142, 468)
noted that in vitro the coagulability of fibrinogen
was decreased when large doses of heparin were
added to oxalated plasma. Heparin carries a nega-
tive electrical charge and its action can be re-
versed immediately by protamine sulfate, which
bears a positive charge, or by toluidine blue,
which precipitates heparin. For a more detailed
description of the normal blood clotting mech-
anism see under Bishydroxycoumarin, which in-
hibits synthesis of prothrombin in the liver.

Another action of heparin which may prove to
be of clinical importance is based upon Hahn's
observation (Science, 1943, 98, 19 ) that it causes
rapid clearing of the alimentary lipemic phase.
Herzstein et al. (Ann. Int. Med'., 1954, 40, 290)
found that in blood samples drawn at intervals
after heparin administration there is an appre-
ciable reduction in plasma total lipids, primarily
in neutral fat content; plasma cholesterol, choles-
terol esters and phospholipid fractions are un-
affected. The existence of a direct relationship
between plasma levels of certain physically dis-
tinct lipoprotein moieties and the incidence of
atherosclerotic lesions was suggested by Gofman
et al. (Science, 1950, 111, 166) (for further dis-
cussion see under Cholesterol). It was reported
by Graham et al. (Circulation, 1951. 4, 666)
that ultracentrifugal studies of the sera of healthy
persons and patients with cardiac infarction re-
veal a decrease in low-density lipoproteins and a
corresponding increase in high-density molecules
after heparin administration. Their findings indi-
cated that patients with moderate to severe an-
gina are relieved of symptoms by a single injec-
tion of 50 to 100 mg. of heparin once or twice
weekly. Tamches (Presse med., 1953, 61, 1382)
considers Graham's explanation of reduction in
size of blood lipoproteins inadequate, since this
would not account for the amelioration of exist-
ing arterial lesions in angina pectoris or cerebral
arteritis. Gilbert and associates (J.A.M.A., 1949,

141, 892) feel that the benefit obtained from
heparin may be due to its vasodilating action
rather than its anticoagulant effect.

Murray and Best (Ann. Surg., 1938, 108, 163)
reported that heparin disappears rapidly from
the blood stream. It must, therefore, be adminis-
tered repeatedly by subcutaneous, intramuscular
or intravenous injection or by continuous intra-
venous infusion. Preliminary reports by Litwins
et al. (Proc. S. Exp. Biol. Med., 1951, 77, 325)
regarding the effectiveness of sublingual absorp-
tion of heparin have not been confirmed. Mc-
Devitt et al. (J. A.M. A., 1952, 148, 1123) found
no significant therapeutic response resulting from
heparin so administered.

Thromboembolism. — According to Loewe
(J.A.M.A., 1946, 130, 386) the fundamental
etiologic factor in production of venous thrombo-
sis is the sudden confinement to bed of an indi-
vidual who has been ambulatory. Increased plate-
let count and various changes in the properties
of blood plasma contribute their effects. Clotting
within small veins may propagate into large
radicals and such thrombi may give rise to fatal
embolic phenomena. Loewe found that heparini-
zation was valuable in the prevention and treat-
ment of this condition. Heparin had been used
similarly by Murray (Arch. Surg., 1940, 40, 307 ),
Priestley and Barker (Proc. Mayo., 1941, 16,
60), Durant (Pennsylvania M. J., 1953, 56, 279)
and many others. Adams (Surg. Clinics N. Amer-
ica, 1943, 23, 835) advised its use, together with
sym pathetic nerve block to relieve vasospasm, in
thrombophlebitis. Many reports have appeared
in the literature regarding the use of heparin in
all types of thromboembolic disorders. De Takats
(J. A.M. A., 1950, 142, 527) found that an intra-
muscular dose of 2 mg. daily of heparin per
pound of body weight was the most satisfactory
treatment for recurrent thrombosis and embol-
ism, half this dose being sufficient in postopera-
tive prophylaxis. In a review of 27,802 patients
undergoing surgery over a five-year period. Rav-
din and Kirby (Surgery, 1951, 29, 334) reported
an incidence of approximately 1 per cent of
thromboembolic complications despite all efforts
to prevent them. They presented their indica-
tions for different types of management, including
anticoagulant therapy. Bauer (Angiology, 1950.
1, 161) reported a mortality rate of only 0.4
per cent in 438 patients treated with heparin for
incipient thrombosis, the death rate having been
18 per cent in a group of 264 patients prior to
the availability of heparin. The prophylactic use
of heparin in the small dosage of 50 mg. twice
daily for a maximum of 10 days after operation
in a large series of patients with operative areas
susceptible to thromboembolic complications,
significantly reduced the incidence of pulmonary
embolism with no risk from hemorrhage in pa-
tients treated by Clovson (J. Internet. Col. Surg.,
1949. 12, 843). Vander Veer and associates (Am.
J. Med. Sc, 1950, 219, 117) and many other
authors agree as to the advisability of prophy-
lactic anticoagulant therapy in susceptible pa-
tients. Anderson et al. (J. Lab. Clin. Med., 1951,
38, 585) claimed that the development of venous
thrombosis was significantly delayed when 10 mg.

Part I

Heparin Sodium 637

of heparin was added to each liter of fluid given
by vein, despite no significant alteration in the
Lee-White coagulation time.

Reports by Homans (Surgery, 1949, 26, 8),
Olivier (Presse med., 1950, 58, 793) and others
indicate the superiority of initial anticoagulant
therapy over femoral vein ligation in postopera-
tive venous thrombosis and thrombophlebitis of
the lower limbs. Experience of Anlyan and asso-
ciates at the Duke Hospital (Arch. Surg., 1952,
64, 200) has been similar. They recommend the
daily injection of heparin sodium, repository
form, if facilities for prothrombin time determi-
nation are not available to guide bishydroxycou-
marin therapy. In patients with venous throm-
bosis during pregnancy, postpartum prophylaxis
with 250 mg. of heparin daily or with adequate
bishydroxycoumarin to provide a prothrombin
index of 40 to 50 is indicated during the initial
five- to eight-day period, according to Jorpes
(Nord. Med., 1950, 43, 199). Merz et al.
(Schweiz. med. Wchnschr., 1951, 81, 565) also
reported good results in obstetrical and gyneco-
logical patients. A very low incidence of phlebo-
thrombosis among urologic patients at the Mayo
Clinic has been attained by following a plan of
heparin administration devised by Culp et al.
(J. Urol., 1952, 68, 845). In the experience of
Brown and associates (Am. J. Med. Sc, 1954,
227, 526) there is no difference in the ability of
the various anticoagulant drugs in prevention of
thromboembolic phenomena, but bleeding occurs
more frequently with heparin, indicating that
heparin should be reserved for those patients re-
quiring rapid initiation of therapy.

Myocardial Infarction. — Wright et al. (Am.
Heart J., 1948, 36, 801; Ann. hit. Med., 1949,
30, 80) summarized the existing experience with
heparin and bishydroxycoumarin in diseases of
the heart and blood vessels. In the first 800 cases
of coronary thrombosis with myocardial infarc-
tion analyzed from the study of the American
Heart Association results indicated that death
from coronary thrombosis can be reduced from
23 to 13 per cent by anticoagulant therapy and
that incidence of thromboembolic complications
can be reduced from 19 to 9 per cent. More
recent reports indicating the value of anticoagu-
lant therapy in this situation include those of
Tulloch and Gilchrist (Brit. M. J., 1950, 2, 965)
and Schilling (J.A.M.A., 1950, 143, 785). In a
report based upon autopsy findings in 132 pa-
tients with myocardial infarction surviving 72
hours after the attack Howell and Kyser (Ann.
Int. Med., 1954, 40, 694) found the incidence of
mural thrombosis less frequent in patients re-
ceiving anticoagulant therapy and the occurrence
of embolism more than twice as frequent in
those with mural thrombosis. They observed that
the degree of prothrombin control did not appear
to influence the development of mural thrombosis.
In a survey of the opinions of 228 internists and
cardiologists in the United States Russek and
Zohlman (Am. J. Med. Sc, 1953, 225, 8) found
that 116 (51 per cent) do not use anticoagulants
routinely in myocardial infarction. Serious hemor-
rhagic complications of treatment were reported
by 104 of the physicians, 64 reporting 122 deaths.

The following indications for anticoagulant ther-
apy in myocardial infarction were listed by the
specialists surveyed: previous infarction, occur-
rence of congestive heart failure, presence of a
large infarct, profound or persistent shock, sig-
nificant cardiac enlargement, previous thrombo-
embolic phenomena, varicosities, arrhythmias,
old age, debility, lethargy, obesity, diabetes,
polycythemia, and any departure from an un-
eventful course.

In a subsequent publication the same authors
(Am. J. Med. Sc, 1954, 228, 133) reported
thromboembolic phenomena in only 3.3 per cent
of 122 "good risk" cases of myocardial infarction
(i.e., those with no poor prognostic signs) and
that preventable mortality under ideal anticoagu-
lant therapy would have been only 0.8 per cent
at best. They contend that the risk of anticoagu-
lant therapy in milder cases outweighs any benefit
that it may confer, but note that the value in
properly selected "poor risk" cases must not be
minimized. McCollum (/. Oklahoma M. A., 1952,
45, 15), Papp et al. (Brit. M. J., 1951, 1, 1471)
and Kissane et al. (Am. J. Med. Sc, 1954, 227,
663) agree that such treatment is unnecessary
in milder cases.

Opinion differs as to the efficacy of heparin in
reducing the incidence of anginal attacks in pa-
tients with coronary artery disease. Engelberg
(Am. J. Med. Sc, 1952, 224, 487) presented
evidence of benefit obtained from the intrave-
nous injection twice weekly of 100 mg. of hep-
arin, based upon exercise electrocardiograms and
ballistocardiograms as well as subjective im-
provement. He attributed the response to the
action of heparin in removing lipoprotein sludge
from the intima of the vessels, with improved
oxygen exchange, rather than tc the anticoagu-
lant or vasodilator action. Chandler and Mann
(New Eng. J. Med., 1953, 249, 1045) agreed
that the number and severity of attacks of angina
pectoris may be decreased by this treatment.
However, no significant effect upon electrocardio-
graphic response to standard exercise following
intermittent injection of heparin was found by
Russek etal. (J. A.M. A., 1952, 149, 1008). Binder
and associates (ibid., 1953, 151, 967) were like-
wise unable to demonstrate any beneficial results.

Congestive Heart Failure. — The addition of
anticoagulant therapy to the usual methods of
treating patients with congestive heart failure has
been shown to reduce the incidence of thrombo-
embolic phenomena in heart disease of all etiolo-
gies except luetic aortitis and cor pulmonale,
according to Griffith et al. (Ann. Int. Med., 1952,
37, 867). Their study in 416 patients indicated
that the different anticoagulant drugs were
equally beneficial. The patients who received
heparin alone were given heparin sodium 50 mg.
intramuscularly every 4 hours or a repository
heparin in initial dosage of 400 mg. followed by
200 mg. every 24 hours for maintenance.

Arterial embolism is an indication for anti-
coagulant therapy. Veal and Dugan (Ann. Surg.,
1951, 133, 603) recommended immediate sympa-
thetic nerve block with a one per cent solution
of procaine (q.v.), to be followed by combined
heparin and bishydroxycoumarin administration

638 Heparin Sodium

Part I

if the circulation is adequate after 30 minutes;
otherwise embolectomy should be performed, fol-
lowed after four hours by heparin injection.
Long-term anticoagulant treatment, even for
periods of months, may be needed subsequently.
Freeman and Gilnllan (Surgery, 1952, 31, 115)
advocated constant intraarterial injection of hep-
arin sodium for 1 to 8 days after thromboendar-
terectomy in patients with occlusive vascular dis-
ease, to be followed by management with bishy-
droxycoumarin. Thrombus formation after ar-
terial suturing operations on arteriovenous fistu-
lae has been reduced by heparin administration
(see Murray, Surg. Gynec. Obst., 1941, 72, 340).

Many papers have appeared regarding the ad-
ministration of anticoagulants in occlusive dis-
ease of the retinal vessels, cavernous sinus throm-
bosis, mesenteric artery thrombosis, and periph-
eral arterial disease. Observations over a 10-year
period led Duff and associates (Arch. Ophth.,
1951, 46, 601) to conclude that short-term in-
tensive heparin therapy is as effective as pro-
longed bishydroxycoumarin treatment in occlu-
sive vascular disease of the retina. Remy et al.
(Presse med., 1953, 61, 961) reported favorably
on the response in severe arteritis of the lower
limbs, even in the presence of trophic disorders
and necrotic lesions, to the intraarterial injec-
tion of heparin directly above the obstruction,
using a total of 400 to 500 mg. daily at the out-
set in acute cases. Nunez (Circulation, 1952, 5,
670) combined anticoagulant therapy with ex-
cision of fixed thrombus and diseased portion of
the arterial intima in artiosclerosis obliterans.
Engelberg and Massell (Am. J. Med. Sc, 1953,
225, 14) stated that in advanced peripheral arte-
riosclerosis the intravenous administration of 100
mg. of heparin sodium two or three times weekly
produced marked improvement in level walking
tolerance and greater digital blood flow as demon-
strated by digital plethysmography. However,
Simon and Wright (J. A.M. A., 1953, 153, 98)
observed no beneficial effects in patients with
intermittent claudication, as tested by an elec-
trically driven treadmill ergometer; Kvale (Proc.
Mayo, 1954, 29, 148) agrees that heparin does
not abate intermittent claudication and is im-
practical in prevention of thrombosis in chronic
occlusive vascular disease, though he favors its
use in acute occlusion.

Frostbite. — Gangrene may be prevented in
frostbite by means of heparinization shortly after
exposure, in amounts sufficient to maintain the
coagulation time above 30 minutes continuously
for at least 5 days (Lange et al., Proc. S. Exp.
Biol. Med., 1950, 74, 1). Earlier studies with
fluorescein demonstrated that gangrene in frost-
bite is due to tremendous increase in capillary
permeability, leading to loss of plasma from the
fine vessels, permitting agglutinated masses of
erythrocytes to obstruct the capillaries. Theis
and associates (J.A.M.A., 1951, 146, 992) treated
cases of frostbite at the Cook County Hospital
by injection of enough heparin to maintain the
Lee-White coagulation time above twice normal
while bishydroxycoumarin therapy is being in-
stituted. Kuhlia (J.A.M.A., 1953, 152, 551) com-
bined heparin therapy with sympathetic nerve

block successfully in two cases of frostbite. Hep-
arin may prove to be of use in treating burns,
in view of the explanation by Dragstedt et al.
(Arch. Surg., 1950, 61, 387) of the sludging
changes in the blood stream following severe
thermal burns in experimental animals. Con-
trolled animal experiments utilizing heparin in
severe thermal burns by Elrod and associates
(Surg. Gynec. Obst., 1951, 92, 35) revealed less
hemoconcentration, less local edema and less
kidney damage in the treated animals as com-
pared with the control group.

The local use of heparin solution may affect
the serous membranes. Beiglbbck and Sickel
(Klin. Wchnschr., 1951, 29, 211) have claimed
marked clinical improvement following injection
of cicatricial contractions, effusions into joints,
hydrocele, and tendon cysts. Howe et al. (Am. J.
Med. Sc, 1952, 223, 258) obtained dramatic
benefit in 5 cases of acute gouty arthritis from
heparin or Paritol, the mechanism being unknown
and apparently not due to the anticoagulant ac-
tion. Van Creveld and Paulssen (Blood, 1952, 7,
710) found heparinized plasma to be superior to
citrated plasma in relieving hemophilia, small
amounts of heparin causing increased consump-
tion of prothrombin. Magner et al. (Arch. Der-
mat. Syph., 1951, 64, 320) treated successfully
a patient with pemphigus by means of heparin
after numerous other measures had failed.

Toxicology. — While hypersensitivity to hep-
arin is rare it has been reported. Chernoff (New
Eng. J. Med., 1950, 242, 315) reported a case
of anaphylactic shock and diffuse macular rash
following intravenous heparin and Gotz (Ann.
Int. Med., 151, 35, 919) described an instance
of anaphylactic shock and giant urticaria. Hauch
et al. (Proc. Mayo, 1952, 27, 163) reported 3
instances of hypersensitivity, all of whom had
itching of the conjunctiva and palate, rhinitis
and bronchial asthma. They observed that the
hypersensitivity phenomenon may be specific for
the animal species from which the heparin is
derived rather than being specific for heparin
itself. Diffuse alopecia 8 weeks after use of hep-
arin is reported (Fischer et al., Schweiz. med.
Wchnschr., 1953, 83, 509).

The possibility of hemorrhage is the most
dangerous complication of heparin therapy. Bleed-
ing may be concealed, as in the case of hemo-
thorax. For this reason strict laboratory control
of dosage is necessary. Hohf (J.A.M.A., 1953,
152, 399) reported 3 cases of retroperitoneal
hemorrhage following lumbar sympathetic block
during anticoagulant therapy. However, Pratt
(ibid., 1953, 152, 903) found no incompatibility
in combining the two types of treatment and be-
lieves such bleeding is traumatic in origin.

Dosage. — Since heparin is not a pure homo-
geneous substance and must be assayed by biologi-
cal methods, the U.S. P. standard of potency is
expressed in terms of units rather than by
weight. One U.S. P. unit is approximately the
quantity of heparin sodium required to main-
tain fluidity in 1 ml. of plasma prepared accord-
ing to the directions of the U.S. P. assay of hep-
arin sodium. While the U.S. P. standard provides
for a minimum potency of 110 U.S. P. heparin

Part I

Heparin Sodium Injection 639

units per mg., it does not limit potency and the
vehicle may contain substances to delay ab-
sorption.

Being inactive orally or sublingually, heparin
is usually injected intravenously, either by con-
tinuous infusion or by single doses repeated at
intervals. For continuous intravenous infusion
10,000 units (100 mg.) to 20,000 units (200 mg.)
of heparin are added to 1000 ml. of sterile iso-
tonic sodium chloride solution or sterile 5 per
cent dextrose solution and the initial rate of
flow should be about 20 drops per minute. The
rate of infusion is adjusted subsequently accord-
ing to the coagulation time of venous blood by
the Lee-White test tube method. For therapeutic
effectiveness a coagulation time of 15 to 20 min-
utes is desired. With the interrupted dosage
method the usual dose is 5000 units (50 mg.)
every 4 hours to a total of 25,000 units (250 mg.)
per day. This method may produce wide fluctua-
tions in coagulation time, with the attendant
danger of hemorrhage, but it does not limit the
patient's movement in bed and avoids local irri-
tation and possible infection from an indwelling
needle.

Aqueous solution of heparin sodium may also
be administered by deep subcutaneous or intra-
muscular injection. It has been reported (Bauer
et al., Acta med. Scandinav., 1950, 136, 188;
Wynn et al., Brit. M. J., 1952, 1, 893) that clini-
cal response by the intramuscular route is in-
ferior to intravenous administration and that
painful hematomata are likely to occur, particu-
larly in the presence of loose connective tissue
with poor elasticity, high venous pressure, if
doses larger than 150 mg. are used, if injections
are made oftener than every 12 hours, and if the
coagulation time exceeds 20 minutes. The tend-
ency of local hemorrhage into tissues can be
minimized by giving deep subcutaneous injections
with a hypodermic needle (25 or 26 gauge).

Solutions containing 1000 units (about 5 mg.),
5000 units (50 mg.), 10,000 units (100 mg.), and
20,000 units (200 mg.) per ml. are available for
subcutaneous administration or for intermittent
intravenous injection. Subcutaneous injection of
10,000 to 12,000 units (100 to 120 mg.) every 8
hours, or 14,000 to 20,000 units (140 to 200 mg.)
every 12 hours is permissible. Injections contain-
ing a high concentration, as 20,000 units or more
per ml., are absorbed slowly from subcutaneous
or intramuscular sites and thus function as re-
pository dosage forms. An aqueous vehicle con-
taining gelatin and dextrose may be used to pro-
long absorption, as in Heparin Repository (Led-
erle), which provides 20,000 units in 1 ml.; anti-
coagulant action commences immediately and
some effect persists for as long as 48 hours (Baker
et al., New Eng. J. Med., 1951, 244, 436). Depo-
Solution Heparin Sodium (Upjohn) and Heparin
in Pitkin Menstruum (Warner) are similar solu-
tions. The vehicle of such solutions contains
about 18 per cent of gelatin and 8 per cent of
dextrose; vasoconstrictors, as epinephrine and/or
ephedrine, may be present. Such a vehicle must
be warmed to about 80° to liquefy it prior to
subcutaneous injection; it has lost favor because
the rate of absorption was unpredictable and it

was found that the concentrated aqueous solu-
tions were slowly absorbed. Beiler et al. {Am. J.
Pharm., 1953, 125, 361) reported that phosphor-
ylated hesperidin prolonged the action of heparin.

Heparin is a strong organic acid and local dis-
comfort may persist for a day or two following
its subcutaneous administration. Pain can usually
be controlled by use of salicylates and local heat.

There is no practical way to predict resistance
or sensitivity to heparin, regardless of its mode
of administration and a baseline pretreatment
clotting time should always be obtained. During
continuous intravenous infusion determinations
of the coagulation time may be needed every 4
hours. With deep subcutaneous administration
the coagulation time must be determined each 12
hours in the first 24 hours and at least each 24
hours thereafter. The safest procedure is to as-
certain the clotting time before each injection.

Administration of heparin must be delayed 4
hours postoperatively to permit hemostasis. Fol-
lowing embolectomy anticoagulant therapy should
be continued for a minimum of 10 days. Heparin
must not be administered in purpura, increased
capillary fragility or blood dyscrasias with bleed-
ing tendency. Hemorrhage necessitates with-
drawal of the drug. Intravenous injection of 10
ml. of a 1 per cent solution of protamine sulfate
(q.v.) will reduce the coagulation time in minutes.
Toluidine blue (q.v.) is also effective in neutraliz-
ing its action.

The U.S. P. gives the usual dose of heparin
sodium as 5000 U.S. P. units parenterally, with a
range of 5000 to 30,000 units, which may be re-
peated according to the changes in the patient's
coagulation time. With the repository form (20,000
units per ml.), the usual dose is 20,000 units
intramuscularly every 12 to 24 hours, with a
range of dose of 20,000 to 40,000 units. The
maximum safe dose varies with the patient.

Storage. — Preserve "in tight containers."
U.S.P.

HEPARIN SODIUM INJECTION.
U.S.P. (B.P., LP.)

"Heparin Sodium Injection is a sterile solution
of heparin sodium in water for injection. It ex-
hibits a potency not less than 90 per cent and
not more than 110 per cent of the potency stated
on the label in terms of U.S.P. Heparin Units. It
may contain a substance or substances intended to
delay the absorption of heparin sodium, for the
purpose of prolonging the period of effectiveness,
and a suitable antibacterial agent." U.S.P.

The B.P. and LP. define Injection of Heparin
as a sterile solution of heparin in injection of
sodium chloride; the injection contains not less
than 90.0 per cent and not more than 110.0 per
cent of the labeled amount of heparin (sodium).
The pH of the solution is to be adjusted between
7.0 and 8.5, and it is to be sterilized by filtration
through a bacteria-proof filter.

Labeling. — "When Heparin Sodium Injection
is the long-acting, or repository, form the label
so indicates." U.S.P.

Storage. — Preserve "in single-dose or in mul-

640 Heparin Sodium Injection

Part I

tiple-dose containers, preferably of Type I glass,
protected from light." U.S.P.

Usual Sizes.— 10,000 and 50,000 Units in
10 ml.; 40,000 Units in 4 ml.; long-acting form,
20,000 Units in 1 ml.

HEXACHLOROPHENE. U.S.P.

2,2'-Methylenehis(3,4,6-trichlorophenol)
OH OH

T J

ci ci

"Hexachlorophene, dried at 105° for 4 hours,
contains not less than 98 per cent of C13H6CU5O2."
U.S.P.

Compound G-ll (Sindar Corp.).

The pronounced , inhibitory effect of soap on
the germicidal action of phenols has made it im-
possible to utilize a monophenol type of germicide
in soap or other locally applied products contain-
ing alkali metal salts of fatty acids. Seeking a
phenolic substance which would not be thus ad-
versely affected Gump (Soap and Sanitary Chem-
icals, 1945, 21, 36, 50) found several diphenols
to retain a substantial portion of their antibac-
terial activity in the presence of soap. One com-
pound especially, now known by the generic name
hexachlorophene, was found to be particularly
well suited for incorporation into compositions
containing soap. A related compound, bithionol,
is official and is used similarly.

Hexachlorophene may be prepared by the con-
densation of two molecules of 2,4,5-trichloro-
phenol with one molecule of formaldehyde
(Gump, U. S. Patent 2,250,480, July 29, 1941).

When hexachlorophene is added to an excess
of alkali only one of its two hydroxyl groups is
neutralized; it is believed that the unchanged OH
group accounts for the germicidal activity when
the compound is incorporated in a soap base.

Description. — "Hexachlorophene occurs as a
white to light tan, crystalline powder. It is odor-
less or has only a slight, phenolic odor. Hexa-
chlorophene is insoluble in water. It is freely
soluble in acetone, in alcohol and in ether. It is
soluble in chloroform and in dilute solutions of
fixed alkali hydroxides. Hexachlorophene melts
between 161° and 167°." U.S.P.

Standards and Tests. — Identification. — (1)
On heating hexachlorophene in a test tube a
colorless to amber liquid is obtained which on
further heating becomes green, blue and finally
purple. (2) A transient purple color develops
immediately when 1 drop of ferric chloride T.S.
is added to a solution of about 5 mg. of hexa-
chlorophene in 5 ml. of alcohol. (3) A yellow-
orange oil, soluble in benzene, in chloroform, and
in ether, is produced on adding a solution of
titanium trichloride to a solution of hexachloro-
phene in acetone. Loss on drying. — Not over 1
per cent, when dried at 105° for 4 hours. Residue
on ignition. — Not over 0.1 per cent. U.S.P.

Assay. — About 1 Gm. of dried hexachloro-

phene is dissolved in alcohol and titrated with
0.1 N sodium hydroxide to a pH of 9.0, deter-
mined potentiometrically. In this titration one of
the OH groups of hexachlorophene is neutralized
with alkali. Each ml. of 0.1 N sodium hydroxide
represents 40.69 mg. of C13H6CI6O2. U.S.P.

Uses. — Hexachlorophene is used as a dis-
infectant agent in soap and other dermatologic
formulations. Gump (loc. cit.) assigned to it a
phenol coefficient of approximately 125. It is ef-
fective especially against gram-positive bacteria;
gram-negative bacteria are more resistant. No
evidence is available as to its efficacy against
acid-fast bacteria, fungi, bacterial spores, viruses,
or spirochetes.

Hexachlorophene is non-irritating to intact
skin (Traub, Arch. Dermat. Syph., 1945, 52, 385;
Udinsky, /. M. Soc. New Jersey, 1945, 42, 15),
though sensitization has been reported (Seastone,
Surg. Gynec. Obst., 1947, 84, 355). Gump (loc.
cit.) reported the substance to be relatively non-
toxic when given orally to guinea pigs, but Price
and Bonnett (Surgery, 1948, 24, 542) found 35
mg. injected intravenously in dogs weighing 7 to
8 Kg. to be fatal.

According to Seastone (loc. cit.), a surgical
scrub procedure utilizing hexachlorophene is
much more effective in reducing the number of
bacteria on the normal skin than is the conven-
tional scrub procedure; a similar observation was
made by Clark et al. (Surgery, 1947, 22, 360).
Seastone and Erickson (Surgery, 1949, 25, 290)
found hexachlorophene to be considerably more
effective as a surgical wash when it is incorpo-
rated in a liquid or a gel soap than when it is
used in a solid soap; they used a liquid soap con-
taining 1 per cent of hexachlorophene in a 20 per
cent solution of potash soap, a gel soap containing
1 per cent of the germicide in a gel prepared by
dissolving 5 per cent of Ivory soap in water, and
a solid soap containing 2 per cent hexachloro-
phene. The liquid soap was preferred over the
gel soap because use of the former led to fewer
complaints of irritation than when the gel soap
formulation was used. The technic of the surgical
wash recommended by Seastone and Erickson is :

(1) Wash hands and arms with ordinary soap for
a minute or more, cleansing the nails thoroughly;

(2) rinse in tap water; (3) apply a large palmful
of liquid hexachlorophenol soap to each hand and
arm and develop a lather during a total time of
contact of a minute or more; (4) rinse thor-
oughly with tap water; (5) immerse hands and
arms in 1:1000 benzalkonium chloride for a few
seconds; (6) dry with a sterile towel.

Freeman (Arch. Surg., 1950, 61, 1145) em-
ployed a liquid soap containing 3 per cent of
hexachlorophene for over one year in a large
hospital service and confirmed its value in main-
taining a low postoperative wound infection rate
and as a rapid, atraumatic, nonsensitizing disin-
fectant-detergent of wide application. His scrub
technic was as follows: (1) Scrape subungual
spaces with the tip of a nail file; (2) wet hands
and arms thoroughly, then wash, using 2 ml. of
detergent on each hand, and rinse completely;

(3) repeat, using a brush, giving each area 15
brush strokes and the nails 25; (4) rinse with

Part I

Hexavitamin Tablets

641

tap water. He also used the same soap for pre-
operative preparation of the patient's skin. Cle-
land (Can. Med. Assoc. J., 1952, 66, 462) de-
veloped a brushless technic after finding that
some cases of dermatitis occurred with the brush;
he emphasized that washing should not be fol-
lowed by an alcohol rinse, which reduces the
effectiveness of hexachlorophene. Nungester et al.
(Surg. Gynec. Obst., 1949, 88, 639) also reported
that alcohol rinse should be avoided. Canzonetti
(Arch. Surg., 1952, 135, 228) found no allergic
reaction to the liquid preparation in more than a
year's use at a general hospital; he used a final
rinse of 1:1000 solution of benzalkonium chlo-
ride. Best et al. (Arch. Surg., 1950, 61, 869)
recommended that hospital personnel, especially
those with operating room duties, use a hexa-
chlorophene-containing bar soap in the daily
toilet. In a histologic study (ibid., 1951, 62, 895)
this group demonstrated that hexachlorophene in
bar or liquid soap caused no tissue reaction on
wounds and burned surfaces, and that wound
healing was not delayed; the use of a liquid soap
containing alcohol showed a more marked reac-
tion in all instances. The recommendation is
made that all wounds and surrounding skin be
washed with a soap containing hexachlorophene,
with a final irrigation with water or saline solu-
tion, and a sterile dressing to reduce early ex-
posure to bacteria.

Dermatologically, hexachlorophene-containing
soaps and detergents are very useful as adjunctive
treatment, active and prophylactic, in the man-
agement of infected, pyogenic dermatoses. Impe-
tigo, folliculitis sycosis of the bearded area, acne,
furuncles, carbuncles, diaper dermatitis, and im-
petiginized eczematous processes are benefited,
with reduction of usual and infecting skin organ-
isms. Glaser et al. (Am. J. Dis. Child., 1951, 81,
329) found a 1 per cent concentration in a
slightly alkaline oil-in-water emulsion effective in
controlling the incidence of impetigo, diaper rash,
and other minor irritations of newborn and older
infants; no contact dermatitis was observed, even
after months of routine hospital use. Grubb et al.
(J.A.Ph.A., 1952, 41, 59) tested a hexachloro-
phene-containing lotion on housewives after dish-
washing, and found after a test period of 7
weeks a 75 per cent reduction in micrococci iso-
lated from hand washings, and no development
of resistance of micrococci to hexachlorophene.

Hexachlorophene has been incorporated in a
number of liquid and solid soap products, in cer-
tain lotions and topically applied preparations,
and even in shaving creams. Gregg and Zopf
(J.A.Ph.A., 1951, 40, 390) found hexachloro-
phene to be freely soluble in propylene glycol,
polyethylene glycol 400, in white wax, in various
vegetable oils, and also in aqueous solutions of
Tween 20 and Tween 80; although these investi-
gators reported that the last-named substance
enhanced the bactericidal power of hexachloro-
phene, Lawrence and Erdlandson (ibid., 1953, 42,
352; also Science, 1953, 118, 274) reported ob-
serving marked inhibition under certain condi-
tions of the bacteriostatic activity of hexachloro-
phene and other closely related compounds (for
example, bithionol) by Tween 80. E

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

HEXACHLOROPHENE LIQUID
SOAP. U.S.P.

"Hexachlorophene Liquid Soap is a solution of
hexachlorophene in a 10 to 13 per cent solution
of a potassium soap. It contains, in each 100 Gm.,
not less than 225 mg. and not more than 260 mg.
of C13H6CI6O2. It may contain suitable water
hardness controls. Hexachlorophene Liquid Soap
may be prepared also in solutions having a larger
concentration of potassium soap. When diluted
according to the directions on the label, such Soap
conforms to the requirements set forth in this
monograph." U.S.P.

Description. — "Hexachlorophene Soap is a
clear, amber-colored liquid. It has a slight, char-
acteristic odor. Its 1 in 20 solution is clear and
has an alkaline reaction." U.S.P.

Standards and Tests. — Identification. — The
tests are based on identification tests (2) and (3)
under Hexachlorophene. Water. — Not less than
86.5 per cent and not more than 90.0 per cent by
weight, determined by distillation with toluene.
Alcohol-insoluble substances. — Not over 3 per
cent. Free alkali hydroxides. — Not over 0.05 per
cent, as KOH. Alkali carbonates. — Not over 0.35
per cent, as K2CO3. U.S.P.

Assay. — For hexachlorophene. — About 10 Gm.
of soap is dissolved in alcohol, barium bromide
is added to precipitate the fatty acids, and the
hexachlorophene in the filtrate is reacted with
ferric chloride to produce a purplish color the
absorbance of which is determined at 550 mix
and quantitatively evaluated by comparison with
standards prepared from known amounts of
U.S.P. Hexachlorophene Reference Standard dis-
solved in a solution of potassium soap. U.S.P.

HEXAVITAMIN CAPSULES. N.F.

Capsulae Hexavitaminarum

"Hexavitamin Capsules contain in each capsule
not less than 1.5 mg. of vitamin A, 10 meg. of
vitamin D, 75 mg. of ascorbic acid, 2 mg. of
thiamine hydrochloride, 3 mg. of riboflavin, and
20 mg. of nicotinamide. The vitamin A and vita-
min D conform to the definitions for vitamin A
and vitamin D under Oleovitamin A and D." N.F.

This formulation of vitamins, formerly official
in the U.S.P., represents one of the earlier bal-
anced combinations of the components in ap-
proximately the minimum daily requirement of
each per capsule. For discussion of tests, assay
and uses see under Decavitamin Capsules, the
U.S.P. successor to Hexavitamin Capusles.

HEXAVITAMIN TABLETS. N.F.

"Hexavitamin Tablets contain in each tablet not
less than 1.5 mg. of vitamin A, 10 meg. of vitamin
D, 75 mg. of ascorbic acid, 2 mg. of thiamine
hydrochloride, 3 mg. of riboflavin, and 20 mg. of
nicotinamide. The vitamin A and vitamin D con-
form to the definitions for vitamin A and for
vitamin D under Oleovitamin A and D." N.F.

642

Hexestrol

Part I

HEXESTROL. N.F.

C2H5 C2H5

"Hexestrol, dried at 105° for 4 hours, contains
not less than 98.5 per cent of C18H22O2." N.F.

p,p'- ( 1 ,2-Diethylethylene) diphenol. Meso-3,4-bis (^-hydroxy-
phenyl) -n-hexane. Dihydrodiethylstilbestrol.

This estrogenic substance represents diethyl-
stilbestrol in which the aliphatic double bond con-
necting the two rings is saturated by addition of
two hydrogen atoms; under certain conditions it
may be prepared by hydrogenation of diethylstil-
bestrol. Another method is to convert anethole
hydrobromide to 3,4-dianisylhexane by treatment
with a metal, followed by hydrolysis to hexestrol.
For a review of various methods of synthesis see
Solmssen (Chem. Rev., 1945, 37, 481).

Description. — "Hexestrol occurs as a white,
odorless crystalline powder. Hexestrol is freely
soluble in ether; soluble in acetone, in alcohol,
and in methanol; slightly soluble in benzene,
and in chloroform; and practically insoluble in
water and in dilute mineral acids. It dissolves in
vegetable oils and in solutions of fixed alkali
hydroxides. Hexestrol melts between 185° and
188°." N.F.

Standards and Tests. — Identification. — (1)
Antimony pentachloride produces with hexestrol
in chloroform solution a purplish red solution.
(2) A solution of 10 mg. of hexestrol in 1 ml. of
sulfuric acid is colorless (diethylstilbestrol pro-
duces an orange color). (3) The diacetate ob-
tained in the assay melts between 137° and 139°.
Acidity or alkalinity. — A solution of 100 mg. of
hexestrol in 5 ml. of 70 per cent alcohol is
neutral to litmus. Loss on drying. — Not over 0.5
per cent, when dried at 105° for 4 hours. Residue
on ignition. — The liimt is 0.2 per cent. N.F.

Assay. — About 500 mg. of dried hexestrol is
converted to hexestrol diacetate by heating with
acetic anhydride in pyridine. Water is added to
hydrolyze the excess acetic anhydride and pre-
cipitate the diacetate, which is filtered on a
Gooch crucible, dried between 75° and 80° for
18 hours, and weighed. The gravimetric factor for
calculating the amount of hexestrol present is
0.7628. N.F.

Uses. — Hexestrol is used for the same condi-
tions for which other estrogenic substances are
employed (Harding, Am. J. Obst. Gyn., 1949, 58,
806) ; it is claimed to cause a lower incidence of
toxic symptoms than does diethylstilbestrol. Fol-
lowing administration of 10 mg. intramuscularly
6.8 per cent was found to be excreted in the
urine as glucuronide (Malpress, Biochem. J., 1948,
43, lvi).

Foss and Gaddum {Brit. J. Pharmacol. Chemo-
ther., 1947, 2, 143) observed hypertrophy of the
nipples of male guinea pigs following inhalation
of hexestrol and suggested that animals be kept
in manufacturing areas to indicate the presence
in air of concentrations potentially toxic to em-
ployees. S

The dose of hexestrol must be individually ad-
justed, as also with other estrogens. For meno-
pausal symptoms it is 2 to 3 mg. daily by mouth
until symptoms are under control, then 0.2 to 1
mg. daily as a maintenance dose, or by injection
1 mg. in oil solution 3 times weekly followed by
a lower maintenance dose. For senile vaginitis
and kraurosis vulvae, 2 to 3 mg. daily by mouth,
or 1 mg. intramuscularly 3 times weekly, may
be given. To suppress lactation 15 mg. is given
by mouth 1 to 3 times daily for 2 or more days,
or 15 mg. of injection once daily for 2 or more
days.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

HEXESTROL INJECTION. N.F.

"Hexestrol Injection is a sterile solution of
hexestrol in oil or in other suitable solvent. It
contains not less than 90 per cent and not more
than 110 per cent of the labeled amount of
C18H22O2." N.F.

Assay. — From an ether solution of the in-
jection hexestrol is extracted with portions of
sodium hydroxide T.S., which is later acidified
and the liberated hexestrol extracted with ether.
After evaporating the ether, the residue is dis-
solved in alcohol and water, and a portion of this
solution reacted with molybdophosphotungstate
T.S., which produces a bluish-green color with
hexestrol. The intensity of the color is measured
at 750 mn and compared with that produced by
a known quantity of hexestrol, similarly treated.
AT.F.

Storage. — Preserve "in hermetic or other
suitable containers." N.F.

Usual Sizes. — 1 and 5 mg. in 1 ml.

HEXESTROL TABLETS. N.F.

"Hexestrol Tablets contain not less than 90
per cent and not more than 110 per cent of the
labeled amount of C18H22O2." N.F.

Usual Sizes. — 1 and 3 mg.

HEXOBARBITAL SODIUM. N.F.
(B.P.) LP.

Sodium 5-(l-Cyclohexenyl)-l,5-dimethylbarbiturate,

[Hexobarbitalum Sodicum]

"Hexobarbital Sodium yields not less than
98.5 per cent and not more than 101 per cent of
Ci2Hi5N2Na03, calculated on the anhydrous
basis." N.F. The B.P. defines Hexobarbitone So-
dium as the mono-sodium derivative of 5-cyc/ohex-
l'-enyl-l :5-dimethylbarbituric acid, obtained by
interaction of hexobarbitone and sodium hydrox-
ide; it is required to contain not less than 98.0
per cent and not more than the equivalent of
101.0 per cent of Ci2His03N2Na, calculated with
reference to the substance dried to constant weight

Part I

Hexobarbital Sodium

643

at 105°. The I.P. specifies the same assay rubric
as the B.P.

B.P. Hexobarbitone Sodium; Hexobarbitonum Sodium.
LP. Hexobarbital Sodium; Hex/obarbitalum Nauicum.
Soluble Hexobarbital; Evipal Sodium (Winthrop-Stearns) ;
Evipan Sodium (Bayer Products) ; Cyclonal Sodium (May
&■ Baker) ; Methexenyl Sodium.

For method of synthesis of hexobarbital see
under Hexobarbitone; the sodium derivative is
obtained by interaction of the acid with sodium
hydroxide.

Description. — "Hexobarbital Sodium occurs
as a white, crystalline, odorless, hygroscopic
powder, with a slightly bitter taste. It becomes
discolored on exposure to air. Hexobarbital So-
dium is very soluble in water, soluble in alcohol,
but practically insoluble in ether. Its solution de-
composes on standing. N.F.

Standards and Tests. — Identification. — (1)
The residue from ignition of hexobarbital sodium
responds to tests for carbonate and for sodium.
(2) A solution of 300 mg. of hexobarbital sodium
in 10 ml. of water is prepared: one portion yields
with mercury bichloride T.S. a white precipitate,
insoluble in an excess of water but partially solu-
ble in an excess of ammonia T.S.; the other
portion yields with silver nitrate T.S. a white
precipitate, soluble in excess water and in excess
ammonia T.S. (3) Ammonia is evolved on heat-
ing hexobarbital sodium in a 1 in 4 solution of
sodium hydroxide. pH. — The pH of a 1 in 10
solution is between 10.5 and 12. Loss on drying. —
Not over 2 per cent, when dried at 105° for 15
hours. Heavy metals. — The limit is 20 parts per
million. N.F. The I.P. and B.P. limit loss on
drying to 5 per cent.

Assay. — Essentially the same procedure that
is employed for Cyclobarbital is used. Each ml.
of 0.1 N bromine represents 12.91 mg. of C12H15-
N2Na03. N.F., I.P. The B.P. assay is based on
release of hexobarbital from the sodium deriva-
tive, the former being extracted with ether and
finally weighed.

Uses. — Hexobarbital is one of the most rapidly
acting of all the barbiturates; according to Ken-
nedy (/. Pharmacol, 1934, 50, 347) in the lower
animals after intravenous injection there is com-
plete anesthesia within 2.5 minutes, which lasts
from 0.5 to 3 hours, according to the dose. Weese
and his associates were the earlier investigators
of the pharmacology of hexobarbital {Deutsche
med. Wchnschr., 1932, 58, 1205; ibid., 1933, 59,
47). It is one of the least toxic of barbiturates
in proportion to its narcotic powers. According to
Findlay and Findlay it has a therapeutic ratio of
4.0, which indicates a margin of safety greater
than for more popular agents of this class {North-
west Med., 1936, 35, 418). The insoluble (acid)
form is used in tablets for the treatment of in-
somnia and as a general sedative in thyroid and
cardiac disease in doses of 250 to 400 mg. (ap-
proximately 4 to 6 grains) at bedtime.

The soluble sodium compound is used as a sur-
gical anesthetic. It has been injected intrave-
nously, as a substitute for inhalation anesthesia,
for all sorts of surgical operations. It acts rapidly
and for a very short time (15 to 30 minutes),
unless repeated. Bush et al. attributed the ultra-

short duration of action of hexobarbital to N-de-
methylation to the correspondingly much less
active nor-hexobarbital {J. Pharmacol., 1953, 108,
104). Betzner in 1935 estimated that 1.5 million
cases of Evipal anesthesia had been reported, with
only 60 anesthetic deaths, which would rank it
close to ether in safety. The chief difficulty in this
use of it is the uncertainty of the dosage and the
fact that for long operations repeated injections
may be necessary. Gwathmey in 1936 advocated
rectal administration of Evipal soluble as a pre-
liminary to inhalation anesthesia, reporting that
by this means there was almost complete absence
not only of the discomfort of induction but also
almost complete absence of after-nausea. Jones
{J. A.M. A., 1938, 110, 1419) employed this
method in 518 cases involving both minor and
major operations; in many of the former no other
anesthesia was necessary. Similarly, Boyan and
Schweizer employed hexobarbital intravenously
in over 100 cases of major surgery with satisfac-
tory results. They indicated as advantages over
other ultrashort barbiturates the low incidence of
laryngospasm and a tendency to produce some
degree of muscular relaxation {N. Y. State J.
Med., 1951, 51, 2651). It has been used with
good results in obstetric anesthesia (Halman, Am.
J. Obst. Gynec, 1935, 30, 118; Thomas, Con-
necticut M. J., 1942, 6, 5). Volpitto and Benton
found the combination of hexobarbital and d-tubo-
curarine to be satisfactory for intravenous prep-
aration of the patient for endotracheal intubation
{Anesthesiol., 1950, 11, 164). Although Henley
confirmed the impression of Volpitto and Benton
regarding the utility of this agent for tracheal
intubation {Bull. N. Y. State Soc. Anesth., 1951,
3, 2), Stephan et al. cautioned against the po-
tentially serious cardiovascular depression that
may attend rapid barbiturate administration for
purposes of laryngoscopy and intubation {Anesth.
& Analg., 1953, 32, 361).

In a study of the effects of barbiturate anes-
thesia upon respiration, Moyer and Beecher
(/. Clin. Inv., 1942, 21, 429) called attention to
several dangerous features of this drug. If anoxia
is present it is possible for overdosage to be com-
pletely masked until sudden, severe respiratory
depression ensues, for the eye and respiratory
signs used by anesthetists are not constant during
use of hexobarbital. It is probable that hexo-
barbital will prove of value in the treatment of
acute convulsions, especially of poisonous origin.
Daly {Anesth. & Analg., 1937, p. 293) reported
a serious case of cocaine poisoning in which life
was apparently saved by intravenous use of Evipal
sodium, (v]

There is no standard dose for anesthesia with
hexobarbital sodium by the intravenous route.
Usually from 2 to 4 ml. of a 10 per cent aqueous
solution will produce unconsciousness in the adult ;
the solution is administered cautiously at the rate
of 1 ml. in 10 seconds. An additional 1 or 2 ml.
may be needed during the course of an operative
procedure. It is unusual that as much as 10 ml. of
the solution, representing 1 Gm. of hexobarbital
sodium, may be necessary; more than this amount
is dangerous.

Storage. — Preserve "in tight containers." N.F.

644 Hexobarbital Sodium, Sterile

Part I

STERILE HEXOBARBITAL
SODIUM. N.F.

"Sterile Hexobarbital Sodium yields not less
than 98.5 per cent and not more than 101 per
cent of Ci2Hi5N2Na03, calculated on the an-
hydrous basis." N.F.

This monograph of the N.F. provides, in addi-
tions to the regular specifications for Hexobarbital
Sodium, the additional requirements of sterility,
completeness of solution in water, and weight
variation in content of containers.

Under the title Injection of Hexobarbitone
Sodium, the B.P. recognizes the same dosage
form, stating that the contents of a sealed con-
tainer of hexobarbitone sodium is dissolved in the
requisite amount of water for injection immedi-
ately before use.

Storage. — Preserve "in hermetic containers."
N.F.

Usual Size. — 1 Gm. (approximately 15
grains). r

HEXOBARBITONE. B.P. (LP.)

Hexobarbitonum
C12H16N2O3

The B.P. defines Hexobarbitone as 5-cyclohex-
r-enyl-l:5-dimethylbarbituric acid and indicates
that it may be obtained by condensation of methyl
a-cyano-a-cyc/ohex-1-enylpropionate with methyl-
urea, followed by hydrolysis of the product. The
LP. calls the same compound Hexobarbital, de-
fining it as l,5-dimethyl-5-cyclohexenyl-l'-bar-
bituric acid and requiring not less than 98.4 per
cent of C12H16O3N2.

I.P. Hexobarbital; Hexobarbitalum. Evipal (Winthrop) ;
Evipan (Bayer Products) ; Cyclonal (May & Baker) ;
Methexenyl.

Synthesis of hexobarbital by condensation of
monomethylurea with methyl-A1-cyclohexenyl-
methylcyanoacetate in absolute alcohol, in the
presence of sodium, is described in U. S. Patent
1,947,944 (1934).

Description. — Hexobarbitone occurs in color-
less crystals, without odor or taste; soluble in
about 3000 parts of water, in dehydrated alcohol,
in chloroform, in ether, and in aqueous solutions
of alkali hydroxides but not of alkali carbonates.
The B.P. gives the melting point as between 145°
and 147°; the I.P. melting range is 144° to 147°.

Standards and Tests. — Hexobarbitone is
identified by preparing its />-nitrobenzyl deriva-
tive, which should melt at about 116°; also by
its forming a bright blue, fiocculent precipitate
on adding copper sulfate and pyridine to a solu-
tion prepared with the aid of sodium hydroxide.
The B.P. allows 2 mg. of neutral and basic sub-
stances per Gm. (the I.P. allows 3 mg. per Gm.) ;
the limit of sulfated ash (B.P.) or residue on
ignition (I.P.) is 0.1 per cent.

Assay. — The principle of the I.P. assay is
the same as that involved in the assay of
Cyclobarbital.

For discussion of uses see under Hexobarbital
Sodium.

The dose of hexobarbitone is 250 to 500 mg.
(approximately 4 to 8 grains).

Storage. — Preserve in a well-closed container.
I.P.

HEXYLRESORCINOL.

[Hexylresorcinol]

U.S.P.

\ /hCH2(CH2)3CH2CH3

"Hexylresorcinol, dried over sulfuric acid for 4
hours, contains not less than 98 per cent of
C12H18O2.

"Caution — Hexylresorcinol is irritating to the
respiratory tract and to the skin, and its solution
in alcohol has vesicant properties." U.S.P.

Caprokol (Sharp and Dohme). Sp. Hexilresorcinol.

Hexylresorcinol may be prepared by condensa-
tion of resorcinol with caproic acid in the pres-
ence of zinc chloride, the resulting caproyl-
resorcinol being reduced to hexylresorcinol (see
Dohme et al., J.A.C.S., 1926, 48, 1688).

Description. — "Hexylresorcinol occurs as
white, or yellowish white, needle-shaped crystals.
It has a faint, fatty odor and a sharp, astringent
taste, and produces a sensation of numbness when
placed on the tongue. It acquires a brownish
pink tint on exposure to light and air. One Gm.
of Hexylresorcinol dissolves in about 2000 ml.
of water. It is freely soluble in alcohol, in meth-
anol, in glycerin, in ether, in chloroform, in ben-
zene, and in vegetable oils. Hexylresorcinol melts
between 62° and 67°." U.S.P.

Standards and Tests. — Identification. — (1)
A light red color is produced when 1 ml. of nitric
acid is added to 1 ml. of a saturated solution of
hexylresorcinol. (2) A yellow, fiocculent precipi-
tation forms when 1 ml. of bromine T.S. is added
to 1 ml. of a saturated solution of hexylresorcinol.
On adding 2 ml. of ammonia T.S. the precipitate
dissolves, leaving a yellow solution. Acidity. — Not
more than 1 ml. of 0.02 N sodium hydroxide is
required for neutralization of a solution of 250
mg. of hexylresorcinol, using methyl red T.S. as
indicator. Residue on ignition. — Not over 0.1 per
cent. Resorcinol and other phenols. — Addition of
3 drops of ferric chloride T.S. to 50 ml. of a
saturated solution of hexylresorcinol in water pro-
duces no red or blue color. U.S.P.

Assay. — From 70 to 100 mg. of hexylresorci-
nol, previously dried over sulfuric acid for 4
hours, is dissolved in methanol and converted to
dibromohexylresorcinol by addition of an excess
of 0.1 N bromine. The excess of bromine is esti-
mated through liberation of an equivalent amount
of iodine followed by titration of the latter with
0.1 N sodium thiosulfate. Each ml. of 0.1 N
sodium thiosulfate represents 4.857 mg of. C12-
H18O2. U.S.P.

Uses. — Hexylresorcinol is an important an-
thelmintic, though it was originally introduced as
an antiseptic.

Part I

Hexylresorcinol 645

Antiseptic. — Hexylresorcinol has the highest
bactericidal effect and lowest toxicity of the alkyl-
substituted resorcinols (Leonard, J.A.M.A., 1924,
83, 2005). Its phenol coefficient has been assigned
various values, from a low of 42 to a high of 108
(Leonard and Feirer, Bull. Johns Hopkins Hosp.,

1927, 41, 216; Salle and Lazarus, Proc. S. Exp.
Biol. Med., 1935, 32, 1119, and 33, 393). Klar-
man (J.A.C.S., 1931, 53, 3397) found a 1 in 7500
dilution to kill staphylococci in 5 minutes and a
1 in 6000 dilution to be similarly effective against
typhoid bacilli. Allen and Wright (Arch. Surg.,

1928, 17, 834) reported, however, that a 1 in
1000 solution required 90 minutes to kill staphy-
lococci and 48 hours to kill Bacillus pyocyaneus.
Its relatively low toxicity has led to its use as a
general antiseptic, especially in the form of a
1 to 1000 aqueous solution containing 30 per cent
glycerin, which solution is known as S.T. 37 (its
surface tension being 37 dynes per centimeter);
it is applied locally to open wounds and to mucous
membranes, being used as a wet dressing, spray,
irrigation or gargle.

The experiments of Leonard (J.A.M.A., 1924,
83, 2005; /. Urol., 1924, 12, 585) led to the use
of hexylresorcinol as a urinary antiseptic; he
found that in urine of pH 6 to 6.4 it killed
Staphylococcus aureus in 1 in 60,000 concentra-
tion in 1 hour while at pH 7.6 to 8.2 a concentra-
tion of 1 in 18,000 was required for the same
effect. Robbins (/. Pharmacol., 1934, 52, 54)
observed that oral administration of hexylresorci-
nol to man resulted in elimination of 18 per cent
of it in the urine, largely in conjugated form, and
64 per cent in feces in the uncombined state.
Notwithstanding these unfavorable factors hexyl-
resorcinol has been used as a urinary antiseptic,
though not with the success attending some other
agents (see Walther, J.A.M.A., 1937, 109, 999).
Mandelic acid, the sulfonamides, and the anti-
biotics are more effective. Hexylresorcinol has
been incorporated in glycerin-gelatin base contra-
ceptive suppositories.

Anthelmintic. — The greater interest in the
internal use of hexylresorcinol is in its anthel-
mintic action. Lamson et al. (J.A.M.A., 1932, 99,
282; /. Pharmacol., 1935, 53, 198) found that
single doses of hexylresorcinol eliminated, in man,
90 to 95 per cent of roundworms, 80 to 85 per
cent of hookworms, and approximately 50 per
cent of whipworms. In Ascaris lumbricoides (a
roundworm) infestation, Williams (Can. Med.
Assoc. J., 1947, 56, 630) reported cure in 88 of
121 cases from administration of 1 Gm. of hexyl-
resorcinol, on an empty stomach, followed in 3
hours by a saline purge; 30 of the 33 remaining
cases were cured by a second dose. Because of its
low toxicity and high efficacy (70 to 80 per cent)
hexylresorcinol is preferred for treatment of
hookworm infestation (J.A.M.A., 1948, 137,
1002) ; children are administered 0.1 Gm. for each
year of age up to 10 years, in the form of gelatin-
coated pills. Sandground (New Eng. J. Med.,
1938, 218, 298), while acknowledging the lower
efficacy of hexylresorcinol against tapeworm, as
compared with aspidium or carbon tetrachloride,
maintained that because of its lower toxicity

hexylresorcinol may be of service particularly in
debilitated patients. Morales and Stevenson
(J.A.M.A., 1950, 142, 368) reported cure in 26
of 28 patients infested with Taenia saginata fol-
lowing a single dose, by duodenal tube, of an
emulsion of 1 Gm. of hexylresorcinol, 1 Gm. of
acacia, and 30 ml. of water. Although the toxicity
of hexylresorcinol is low, because of its poor ab-
sorption repeated doses may cause severe gastro-
intestinal irritation, necrosis of the small bowel,
or injury to the heart and liver.

In a study of the comparative value of various
forms of treatment for oxyuriasis, Wright et al.
(Pub. Health Rep., 1939, 54, 2005) found that
while oral administration of hexylresorcinol was
of little use a 1 to 2000 solution used as an enema
was markedly effective.

For Trichocephalus trichiurus (whipworm) in-
festation, Basnuevo and Hernandez (Arch. med.
inf., 1952, 21, 47) reported successful results
from use of a retention enema containing 0.3 per
cent of hexylresorcinol and 1 per cent of barium
sulfate in lukewarm water, which was carried up
to the cecum under fluoroscopic guidance; this
enema was used in the proportion of 20 ml. per
pound of body weight up to volumes of 1200 to
1500 ml. for an adult, and was retained for 10
minutes. Use of the enema was repeated at inter-
vals of 3 days until ova of the parasite were no
longer found in the feces. The anus and adjacent
skin were well coated with petrolatum to avoid
irritation. Good results from use of enemas were
also reported by Jung and Beaver (Pediatr., 1951,
8, 548). S

Dose. — The usual adult dose, as an anthel-
mintic, is 1 Gm. (about 15 grains), with a range of
0.1 to 1 Gm.; the maximum safe dose is usually
1 Gm. as a single dose in any 24-hour period. For
children the usual dose is 0.1 Gm. for each year
of age up to 10 years. The drug is usually given
orally after an overnight fast. The presence of
food lessens the effectiveness of the drug. It can
be taken in tablets or pills, covered with a tough
gelatin coating, these being swallowed intact with
the aid of water; they should never be chewed
lest they produce a painful ulceration of oral
mucous membrane. No food should be eaten for
5 hours following administration of hexylresorci-
nol. A saline purge should be given the following
morning to clear the bowel of dead worms. Treat-
ment may be repeated after 3 days.

The adult dose of hexylresorcinol as a urinary
antiseptic is 300 to 600 mg. (approximately 5 to
10 grains), administered 3 times daily after meals,
and preferably given in capsules containing a 25
per cent solution in olive oil. Children may be
given a 2.5 per cent solution in olive oil in pro-
portionate quantities.

Supply. — Hexylresorcinol is supplied in soft
capsules each containing 150 mg.; in pills con-
taining 100 mg. or 200 mg.; as a 2.5 per cent solu-
tion in oil for administration to children; as a 1
in 1000 glycerin and water solution for applica-
tion to wounds or for use as a gargle or mouth
wash when diluted with water; as a jelly, con-
taining 1 in 1000 of hexylresorcinol, which is used
as an application in the treatment of vaginitis and

646 Hexylresorcinol

Part I

is said to be efficacious against Trichomonas
vaginitis.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

HEXYLRESORCINOL PILLS. U.S.P.

[Pilulae Hexylresorcinolis]

"Hexylresorcinol Pills consist of hexylresorcinol
covered with a rupture-resistant coating that is
dispersible in the digestive tract. Hexylresorcinol
Pills contain not less than 90 per cent and not
more than 110 per cent of the labeled amount of
C12H18O2." U.S.P.

"Crystoids" Anthelmintic (.Sharp and Dohme). Sp. Pit-
doras de Hexilresorcinol.

Storage. — Preserve "in well-closed contain-
ers." U.S.P.

Usual Sizes. — 100 and 200 mg. (approxi-
mately \l/2 and 3 grains), the former being orange
in color, the latter red.

HISTAMINE PHOSPHATE.
U.S.P. (B.P.) LP.

Histamine Acid Phosphate, Histaminium Acid Phosphate,
[Histaminae Phosphas]

N~~il

CH2CH2NH5

2H2P04"

The B.P., which recognizes this substance as
Histamine Acid Phosphate, defines it as the di-
acid phosphate of histamine, 4-2'-aminoethylimi-
nazole. The LP. defines it as the di-acid phosphate
of 4- (2-aminoethyl) -imidazole.

B.P. Histamine Acid Phosphate; Histaminae Phosphas
Acidus. LP. Histamini Phosphas. /3-Iminazolylethylamine
Acid Phosphate; Histamine Diphosphate. Sp. Fosfato de
Histamina.

Elimination of a molecule of carbon dioxide
from histidine (see Histidine Monohydro chloride)
produces the physiologically important substance
histamine. In the body this decarboxylation seems
to be effected in the presence of an enzyme,
histidine decarboxylase, found in the liver and
other organs; certain bacteria, particularly of the
B. coli group, bring about the same reaction in the
gastrointestinal tract. Histamine is found in every
tissue of the body, the highest concentration
being in the lung. Histamine is also found in
plants; it was first isolated from ergot by Barger
and Dale in 1910.

Outside the body decarboxylation of histidine
may be effected through certain fermentative
processes; by heating, either alone or in the
presence of acid; or by the action of ultraviolet
light.

Histamine may be synthesized from citric acid
by first converting it to diaminoacetone and then
carrying this substance through a five-step process
to the desired compound (see Pyman, /. Chem. S.,
1911, 99, 668, 1386; 1916, 109, 186); Koessler
and Hanke (J.A.C.S., 1918, 40, 1716) reported
a yield of 165 Gm. of histamine dihydrochloride
from 4530 Gm. of citric acid by a modification
of Pyman's method.

The enzyme histaminase, found in the intestinal
mucosa, the kidney, and other tissues, destroys
histamine.

The official histamine phosphate is the salt
formed from one molecule of histamine and two
of phosphoric acid.

Description. — "Histamine Phosphate occurs
as colorless, odorless, long prismatic crystals. It
is stable in air but is affected by light. Its solu-
tions are acid to litmus. One Gm. of Histamine
Thosphate dissolves in about 4 ml. of water."
Histamine Phosphate melts between 127° and
132°." U.S.P. The B.P. and LP. specify that the
salt melts between 130° and 133°, after sintering
at 127°.

Standards and Tests. — Identification. — (1)
A deep red color is produced on adding a solution
of 100 mg. of histamine phosphate in 7 ml. of
distilled water and 3 ml. of sodium hydroxide
T.S. to a mixture of 50 mg. of sulfanilic acid,
10 ml. of distilled water, 2 drops of hydrochloric
acid, and 2 drops of a 1 in 10 solution of sodium
nitrite. (2) Phosphotungstic acid T.S. produces
a precipitate in a 1 in 50 solution of histamine
phosphate. (3) The picrolonic acid salt of hista-
mine melts between 250° and 254°. (4) A 1 in 10
solution of histamine phosphate responds to tests
for phosphate. Loss on drying. — Not over 1.5 per
cent when dried at 105° for 2 hours. U.S.P.

Uses. — Histamine is present in most tissues
of the body, notably the lungs and leukocytes, in
some inactive, bound form (see review by Dale,
Ann. N. Y. Acad. Sc, 1950, 50, 1017). As histidine
is a constituent of many proteins, histamine is
formed in the human intestines. It is excreted in
the free and in a conjugated form following oral
administration to laboratory animals (Williams
et al., J. Pharmacol., 1949, 97, 4). It is absorbed
rapidly after hypodermic injection and by appli-
cation to the skin and mucous membranes. Only
traces appear in the urine. An enzyme, histam-
inase, which inactivates histamine slowly is found
particularly in the intestinal mucosa and the kid-
ney. Histamine first came into medical promi-
nence as one of the ingredients of ergot. It has
continued to attract attention because of its pos-
sible role in several abnormal conditions ; recently
it has been used in the treatment of headache and
certain allergic disorders.

Action. — Knowledge of the physiological action
of histamine has been confused by the differences
in the responses of various species of animals.
Most tissues react to histamine and the actions
given below are those which probably occur in
human beings.

The outstanding physiological effects are dilata-
tion of capillaries, stimulation of gastric secretion
and stimulation of the visceral muscles. It was the
action upon the uterine muscle that formerly led
it to be included among the important constitu-
ents of ergot. Repeated parenteral doses of as
much as 2.75 mg. of histamine diphosphate
exerted no untoward effects in pregnant humans
(McElin and Horton, Am. J. Med. Sc, 1949, 218,
432). So powerful is its effect upon the bronchial
muscles that in some animals, notably the guinea
pig, it may cause a fatal bronchospasm. In the
normal human, bronchial constriction is unim-

Part I

Histamine Phosphate 647

portant (Weiss et al, Arch. Int. Med., 1932, 49,
360), but in patients with bronchial disease even
small doses may cause asthmatic manifestations,
for example as from the amount absorbed per-
cutaneously from the histamine-containing oint-
ments which are popular in the symptomatic
relief of myalgia. Bernheim (/. Pharmacol., 1931,
43, 509) found, contrary to some previous state-
ments, that it stimulates the intestinal muscles in
dogs, cats and guinea pigs, although different por-
tions of the bowel vary in their degree of response.
In man and in the dog it causes a lowering of
blood pressure due to dilatation of the blood
capillaries and also of the arterioles. Not only are
the capillaries increased in size but also in perme-
ability, permitting the escape of fluid and pro-
tein. This action suggested to Dale and Richards
(1918) that the circulatory failure, commonly
known as surgical shock, which occurs immedi-
ately following severe injuries, was due to the
introduction of histamine into the blood stream,
a theory to which many still adhere (see also
Rich, J. Exp. Med., 1921, 33, 287).

When applied to an abraded or scarified area
of the skin or injected intradermally, histamine
gives rise to an urticaria-like eruption. The initial
erythema becomes surrounded by a flare due to
dilatation of the arterioles which is mediated by
a nervous (axone) reflex. Edema (wheal) then
appears in the central area of erythema and
pseudopods of edema may extend outward from
the wheal. The response of the skin to mild injury,
such as scratching with a blunt instrument, re-
sembles this response to histamine.

Lewis {Brit. M. J., 1926, 2, 11) advanced the
theory that trauma released a histamine-like sub-
stance. Ganter and Schretzenmayr {Arch. exp.
Path. Pharm., 1930, 181, 64) observed that in
human beings the reduction of blood pressure
produced by histamine is of relatively short dura-
tion and Benson and Horton {Proc. Mayo, 1945,
20, 113) reported that the continuous intravenous
injection of histamine at a rate of 0.03 mg. per
minute produced a rise in pulse rate of about 20
beats per minute and a decrease in diastolic blood
pressure of about 12 mm. of mercury. The com-
pensatory circulatory mechanisms are active and
histamine is rapidly inactivated in the body. The
blood vessels in the meninges and brain dilate as
a result of histamine action and the pressure of
the cerebrospinal fluid increases roughly parallel
with the time and intensity of the flushing of the
face. Headache develops as the blood pressure
and cerebrospinal fluid pressure return toward
normal (Pickering, Clin. Sc, 1933, 1, 77). Head-
ache appears to be due to stretching of structures
adjacent to the meningeal vessels; it can be
alleviated by any factor which increases cerebro-
spinal fluid pressure or decreases blood pressure.
Histamine did not produce cerebral vasodilatation
nor changes in cerebral oxygen uptake in normal
patients (Alman et al., Arch. Neurol. Psychiat.,
1952, 67, 354). The intravenous infusion to pa-
tients having acute cerebral anemia was claimed
to be transiently beneficial (Furmanski et al.,
ibid., 1953, 69, 104).

According to Essex et al. {Am. Heart J., 1940,
19, 554) histamine increases blood flow in the

coronary arteries of the dog. An intravenous in-
jection of 0.1 mg. of histamine has been used to
measure circulation time but the end-point, which
is flushing of the face, is difficult to determine
with sufficient accuracy.

Allergy. — There is considerable evidence that
histamine is concerned in the production of ana-
phylaxis (Dragstedt, /. Allergy, 1945, 16, 69),
although this theory is not definitely established
(see also J.A.M.A., 1940, 115, 1023; 1944, 124,
362). Farmer (/. Immunol., 1939, 37, 321) ob-
served that guinea pigs, when given repeated in-
jections of histamine, developed a resistance
against not only this substance but foreign pro-
teins as well and, on the theory that allergic con-
ditions are due to histamine, a number of clini-
cians have used it, with more or less favorable
results, in the treatment of various allergic mani-
festations (see Farmer, /. Lab. Clin. Med., 1941,
26, 802). Determinations of nasal mucous mem-
brane content of histamine have not shown a
correlation with allergic disorders nor with the
eosinophil content of the nasal mucus or the
blood (Baxter and Rose, /. Allergy, 1953, 24, 18).
Physical allergy, such as sneezing, etc., in a cold
environment, is commonly associated with flush-
ing of the skin, hypotension and gastric hyper-
acidity as though an excess of histamine were re-
leased in the body as a result of the exposure to
cold (Brown and Barker, Proc. Mayo, 1936, 11,
161). Desensitizing injections of histamine have
been beneficial in physical allergy. Paterson {Can.
Med. Assoc. J., 1945, 52, 400) found histamine
beneficial in vasomotor rhinitis, especially in those
influenced by the weather (see also Thacker,
J.A.M.A., 1946, 131, 1042). Gant et al. {New
Eng. J. Med., 1943, 229, 579) reported good re-
sults in the treatment of vasomotor rhinitis with
the oral administration of histamine ; they started
with 1 drop of a 1:1000 solution of histamine,
given in a glass of water on an empty stomach
three or four times daily before meals, and in-
creased the dose by 1 drop each time until toxic
effects were experienced. The average dose re-
quired for relief was 5 to 7 drops, although some
patients used as much as 25 drops of a 1:100
solution. Bernstein {Proc. Centr. Soc. Clin. Res.,
1945, 18, 63) prolonged the histamine effect by
using a gelatin solution as the vehicle for injec-
tions of histamine and claimed a better thera-
peutic effect in various allergic conditions. (See
also Antihistaminic Drugs, in Part II.)

Headache.— Horton {J. A.M. A., 1941, 116,
377; J. -Lancet, 1952, 72, 92) reported cases of
a peculiar type of headache which was promptly
relieved by histamine. This syndrome, histaminic
cephalgia, has these salient features : it is a brief,
recurrent, violent, unilateral headache involving
the temple, the eye and the neck. Usually noc-
turnal in onset, it is associated with congestion
of the nostril and eye on the affected side, and
profuse lacrimation. Pressure over the swollen
temporal artery or over the common carotid
artery gives transient relief. The syndrome may
be precipitated by alcohol or by histamine. It
may be relieved in the individual attack by epi-
nephrine and may be permanently relieved by
desensitization with histamine. Desensitization is

648 Histamine Phosphate

Part I

conducted as follows: Using a solution containing
0.1 mg. of histamine base per ml., subcutaneous
injections are given twice daily, starting with a
dose of 0.25 ml. and increasing by 0.05 ml. at
each dose, for 10 to 14 days or until a dose of
1 ml. is reached. Subsequently, the maximum dose
attained is given at intervals of about 1 week for
a month or more, if necessary, to maintain hypo-
sensitization. The physiological mechanism of
histamine desensitization has been studied by
Ambrus et al. (Am. J. Physiol, 1951, 167, 268).
Acute duodenal ulcer has been observed in asso-
ciation with attacks of histaminic cephalgia
(Alford and Whitehouse, Ann. Allergy, 1945, 3,
200). Daily intravenous injections of 1 mg. of
histamine, according to the method used for
vertigo (v.i.) were used for migraine with benefit
by Butler and Thomas (J.A.M.A., 1945, 128,
173); injections were given daily for 3 to 5 days.

Vertigo. — Sheldon and Horton (Proc. Mayo,
1940, 15, 17) obtained brilliant results with the
drug in Meniere's disease, giving 1 mg. (approxi-
mately Vw grain) of histamine base in 250 to 500
ml. of isotonic sodium chloride solution by slow-
intravenous injection, over a period of \l/2 hours.
Most patients were completely relieved after one
injection. Rainey (J.A.M.A., 1943, 122, 850)
confirmed this report and advised a rate of injec-
tion of 20 to 30 drops per minute during the first
5 minutes followed by 60 to 70 drops per minute.
Atkinson (J. A.M. A., 1941, 116, 1753), however,
reported that this treatment is useful only in those
types of labyrinthian vertigo which are allergic
in origin. Atkinson (/. M. Soc. New Jersey, 1944.
41, 11) advocated the intradermal injection of
0.005 mg. of histamine base (0.1 ml. of a 1 : 20.000
dilution of histamine base in isotonic sodium
chloride solution) to distinguish the primary
vasodilator group of cases, which respond well to
histamine desensitization, from the primary vaso-
constrictor cases, which are aggravated by hista-
mine treatment but benefited by nicotinic acid
(q.v.) therapy. The histamine-sensitive subject
(primary vasodilator group) shows a greater re-
sponse to the intradermal dose than does the pri-
mary' vasoconstrictor group; the wheal is 1 cm.
or more in diameter, the flare is 3.5 to 4.5 cm. in
diameter and there are one or more pseudopods.
This reaction develops within 5 minutes after
injection and persists for 20 minutes or more.
Browne (/. Allergy, 1942, 14, 19) failed to con-
firm the validity of this intradermal test with
histamine (see also Thomas and Butler. Am. J.
Med., 1946. 1, 39). To avoid hospitalizing the
patient for intravenous injection, Henderson
(Arch. Otolaryng., 1952, 59, March) administered
an intramuscular injection containing 1.1 mg. of
histamine diphosphate and 40 mg. of diphen-
hydramine hydrochloride in 8 ml. every day for
8 days, following this with a rest period of 8 days
and then repeating the course of injections if
indicated.

Neuropathy. — Acute multiple sclerosis was
benefited by intravenous administration of 1 mg.
of histamine according to the technic employed
for Meniere's syndrome (Horton et al., J.A.M.A.,

1944. 124, 800; Benson and Horton. Proc. Mavo,

1945, 26, 113) but Carter (/. Nerv. Ment. Dis.,

1946, 103, 166) failed to confirm the effectiveness
of this treatment. Loomis (Arch. Otolaryng.,
1950, 52, 948) and Skinner (Ann. Otol. Rhin.
Laryng., 1950, 59, 197) employed minute amounts
of histamine subcutaneously or intravenously in
the treatment of paralysis of the facial nerve,
Bell's palsy; encouraging results were obtained.

Gastric Secretion. — Another important phys-
iological action of this drug is a stimulation of
certain glands, increasing notably the salivary,
pancreatic, and gastric secretions (Keeton, Am. J.
Physiol, 1920, 51, 469). Observation of the de-
gree to which the stomach responds to the stimu-
lating effect of food has long been a routine
procedure for the diagnosis of stomach conditions.
As a result of the investigations of Carnot and
co-workers, in 1922, hypodermic injections of
histamine are commonly used as an excitor of
acid secretion (Kay, Brit. M. J., 1953, 2, 77).
Histamine is the most vigorous stimulant of acid
gastric secretion available. The absence of free
hydrochloric acid in the gastric juice after an
injection of histamine indicates the absence of
acid-secreting cells from the stomach. Gastric
achlorhydria after histamine is an essential finding
in the diagnosis of pernicious anemia. Histamine
does not increase the secretion of pepsin. The
response to histamine persists after section of
the vagus nerve (Thornton et al, J. A.M. A., 1946,
130, 764). The histamine test of gastric function
involves the hypodermic injection of about 0.25
to 0.5 mg. of histamine base in the form of a 1 in
1000 solution (approximately equivalent to V250
to M20 grain) to a fasting patient who has just
drunk 300 ml. of fluid. Some base the dose on
body weight, i.e., 0.01 mg. histamine base per
kilogram. The gastric contents are aspirated there-
after even.- 10 or 15 minutes and the acidity de-
termined in the customary manner. While in the
majority of cases this test causes no distress,
larger doses cause flushing of the face, headache,
asthma, and dizziness, with lowering of the blood
pressure. It is probable that epinephrine is the
most efficient means of combating these symp-
toms. Bernstein (Ann. Int. Med., 1947. 26, 852)
reported benefit from histamine desensitizing in-
jections in both the symptomatic and prophylactic
treatment of patients with gastric ulcers.

Pheochromocytoma. — In the diagnosis of this
functioning tumor of the adrenal medulla, par-
ticularly in those patients with intermittent rather
than continuous hypertension, 0.025 mg. of hista-
mine base has been injected rapidly intravenously.
Following a decrease in blood pressure within 30
seconds, a marked rise in blood pressure to a peak
in 1 to 3 minutes, associated with symptoms of
the patient's attacks — pallor, fear, sweating, etc.
— indicates the presence of such a tumor secret-
ing epinephrine and norepinephrine. This test is
dangerous in old persons, or in the presence of
marked hypertension, when phentolamine meth-
anesulfonate is preferred.

Peripheral Vascular Diseases. — Caldwell
and Mayo (Arch. Int. Med., 1931, 47, 403) sug-
gested that the degree of reaction of the skin to
histamine is diagnostic of local circulatory ob-
struction. In this test the skin of the wrist or
ankle, as the case may be, is cleansed with alcohol

Part I

Histidine Monohydrochloride 649

and a drop of a 1 to 1000 solution of histamine
base is placed on it and the skin scarified, as in
smallpox vaccination, or 0.1 mg. of histamine
base is injected intradermally. In normal indi-
viduals a wheal should appear in 2^/2 minutes.
Delay in the reaction is regarded as evidence of
vascular disease. Since the red flare surrounding
the wheal depends on the integrity of the periph-
eral nerve, this test has been used in instances of
suspected hysterical anesthesia or malingering
(Loeser, JAMA., 1933, 110, 2136).

Intra-arterial Injection. — Histamine has been
given by intra-arterial infusion (2.75 mg. of hista-
mine diphosphate in 500 ml. of isotonic sodium
chloride solution for injection, administered under
pressure during 30 to 45 minutes) for relief of
pain and improvement of circulation attending
chronic obliterative diseases of the peripheral
arteries, including intermittent claudication
(Mufson, Ann. Int. Med., 1948, 29, 903; Dixon
et al., Circulation, 1952, 5, 661; Mackey. Brit.
M. J., 1950, 2, 1086). Injections were given once
weekly. Systemic effect of this local injection of
histamine in one extremity was seldom observed.

Iontophoresis. — On the theory that it would
cause local dilatation of blood vessels. Trumpp
{Munch, med. Wchnschr., 1931, 78, 1862) em-
ployed histamine for the relief of myalgia; he
preferred iontophoresis over injection as a means
of administration. For iontophoresis, the gauze
pad connected to the positive pole of the appa-
ratus is moistened with a 1:5000 solution of his-
tamine, or a 2 per cent histamine ointment is
applied to the skin under an anode consisting of
a gauze pad moistened with isotonic sodium chlo-
ride solution; a current of 5 to 15 milliamperes
is applied for 5 to 30 minutes. Loewy (Brit. J.
Phys. Med., 1945, 8, 115) considered this pro-
cedure to be the most effective counterirritant in
treatment of sprains, contusions, fractures, and
fibrositis.

Histamine dihydrochloride is an active ingredi-
ent in several analgesic ointments or creams for
application to the skin, being used in 0.1 to 1 per
cent concentration; Imadyl Unction (Hoffmann-
La Roche) and Rubiguent (Wyeth) are prepara-
tions of this type.

Ernstene and Banks (J.A.M.A., 1933, 100,
328) reported relief from various kinds of itch-
ings following hypodermic infiltration of hista-
mine. Relief from profuse perspiration in patients
with pulmonary tuberculosis following histamine
desensitization injections has also been reported
(Coste et al., Presse med., 1940. 48, 250).

Hapamine (Parke, Davis), a histamine azopro-
tein representing a chemical combination of hista-
mine and despeciated horse serum globulin, is
employed in solution subcutaneously for hista-
mine desensitization; the initial dose of 0.01 ml.
is increased by 0.01 or 0.02 ml. at each dose given
at intervals of 4 or 5 days until a maximum dose
of 1.5 ml. is reached (see /. Allergy, 1947, 18,
1, 7, 13). It is supplied in 5 -ml. multiple-dose
vials.

Dose. — The usual dose of histamine base for
stimulation of gastric secretion is 0.3 mg. (ap-
proximately }4oo grain) subcutaneously, which is
also the maximum that is generally given. For

other purposes (see above) as much as 1 mg.
(approximately Vw grain) may be given. Adminis-
tration may be intramuscular, subcutaneous or,
when diluted with 250 to 500 ml. of isotonic so-
dium chloride solution, intravenous. A solution
containing 2.75 mg. of histamine diphosphate rep-
resents the equivalent of 1 mg. of histamine base.
Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

HISTAMINE PHOSPHATE
INJECTION. U.S.P. (B.P., LP.)

[Injectio Histamine Phosphatis]

"Histamine Phosphate Injection is a sterile
solution of histamine phosphate in water for in-
jection. It contains not less than 90 per cent and
not more than 110 per cent of the labeled amount
of C5H9N3.2H3PO4." U.S.P. The B.P. provides
no rubric; that of the LP. is the same as the
rubric of the U.S.P. Both the B.P. and LP. indi-
cate that the solution may be sterilized by heating
in an autoclave, or by filtration through a bacteria-
proof filter.

B.P. Injection of Histamine Acid Phosphate; Injectio
Histamines Phosphatis Acidi. LP. Injection of Histamine
Phosphate; Injectio Histamini Phosphatis.

Assay. — The U.S.P. and LP. assays are based
on the general colorimetric method for amino
acids proposed by Folin (/. Biol. Chem., 1922,
51, 377) and adapted to the determination of
histamine by Mader et al. (J. A. Ph. A., 1950, 39,
175). This method depends on the fact that
3-naphthoquinone sodium sulfonate produces with
amino acids a striking red color, the intensity of
which follows Beer's law in the range of concen-
tration that may be encountered in the assay.
The intensity of the color is determined by meas-
uring the absorbancy at about 460 mn, and com-
paring this with the intensity of color of a solu-
tion containing U.S.P. Histamine Dihydrochloride
Reference Standard is known concentration.

Storage. — Preserve "in single-dose or in mul-
tiple-dose containers, preferably of Type I glass."
U.S.P.

Usual Sizes. — 1 mg. of histamine base in 1 ml.

HISTIDINE MONOHYDRO-
CHLORIDE. N.F.

Histidinium Chloride, [Histidinae Monohydrochloridum]

H— N n —

-CH2CHC00H'

N+H:

cr.H2o

"Histidine Monohydrochloride contains not less
than 98 per cent and not more than 101.2 per
cent of C6H9N3O2.HCI, calculated to the anhy-
drous basis." N.F.

0-(4-Imidazolyl-alanine Hydrochloride. /3-(4-Imidazolyl)-
a-aminopropionic Acid Hydrochloride. Larostidin {Hoff-
mann-La Roche).

Histidine, an amino acid constituent of nearly
all proteins, was discovered, in 1896, almost
simultaneously, by Kossel in the hydrolysate
of fish roe protamine and by Hedin in the acid

650 Histidine Monohydrochloride

Part I

hydrolysate of casein. The methods of both in-
vestigators have subsequently been developed into
procedures for the preparation of histidine.

Histidine may also be conveniently obtained
from blood corpuscle paste by acid hydrolysis and
precipitation with mercuric chloride (see Foster
and Shemin. Organic Syntheses, Coll. Vol. II,
1943, p. 330). The naturally occurring histidine
is the L-form (for terminology see under Amino
Acids, Part II) ; in this connection it is of interest
that the acid is levorotatory in water and in alkali
solution, but dextrorotatory in acid solution. His-
tidine has been synthesized from the sodium de-
rivative of ethyl chloromalonate and 4-chloro-
methylimidazole ; the resulting racemic histidine
may be resolved by crystallizing the D-tartrate
(see Pyman, /. Chetn. S., 1911, 99, 668, 1386;
1916, 109, 186). Histidine has also been syn-
thesized from imidazolealdehyde and hippuric
acid.

Histidine is capable of forming salts with one
or two molecules of such an acid as hydrochloric;
because the imidazole group of histidine is feebly
basic the salt with two molecules of acid, as
histidine dihydrochloride, hydrolyzes in water to
the monohydrochloride.

Under certain conditions histidine may lose a
molecule of carbon dioxide and be converted to
histamine (see Histamine Phosphate).

Description. — "Histidine Monohydrochloride
occurs as small, colorless crystals which are nearly
odorless and possess a salty taste. A solution of
Histidine Monohydrochloride (1 in 20) is acid
to litmus. One Gm. of Histidine Monohydro-
chloride dissolves in 8 ml. of distilled water. It is
insoluble in alcohol, in ether, and in chloroform."
NJ.

Standards and Tests. — Identification. — (1)
On gently heating 5 ml. of a 1 in 500 aqueous
solution of histidine monohydrochloride to which
bromine T.S. has been added to the appearance
of a yellow color the solution becomes progres-
sively colorless, red and dark red; finally, dark,
amorphous particles separate. (2) A curdy, white
precipitate, insoluble in nitric acid but soluble in
ammonia T.S., forms on adding 1 ml. of silver
nitrate T.S. to a 1 in 10 aqueous solution of
histidine monohydrochloride. Optical rotation. —
The specific rotation, referred to the moisture-
free substance and determined in a solution con-
taining 600 mg. of histidine monohydrochloride
in 23 ml. of 1 N hydrochloric acid, is not less
than +9.7° and not more than +11.2°. Loss on
drying. — Not over 9 per cent, when dried at 130°
for 12 hours. Residue on ignition. — The residue
from 1 Gm. is negligible. Sulfate. — No turbidity
is produced in 2 minutes following addition of
barium chloride T.S. to a 1 in 20 aqueous solution
of histidine monohydrochloride acidified with hy-
drochloric acid. Heavy metals. — The limit is 20
parts per million. Alkaloids. — Addition of mer-
curic-potassium iodide T.S. to a 1 in 25 aqueous
solution of histidine monohydrochloride does not
produce turbidity. Protein. — Heating a 1 in 25
solution of histidine monohydrochloride in an
autoclave at 121.5° for 15 minutes and then cool-
ing it to 25° produces no turbidity, as compared
with water treated similarly. Histamine. — His-

tidine monohydrochloride causes no greater fall
in blood pressure when injected into cats, on the
basis of 10 mg. per Kg., than the equivalent of
0.1 microgram per Kg. of histamine base. N.F.

Assay. — About 400 mg. of histidine mono-
hydrochloride is titrated, in the presence of form-
aldehyde, with 0.1 N sodium hydroxide to a pH
of 9.4. The formaldehyde, by converting the basic
amino group of histidine to a methyleneimino
group and thus depriving it of its basic character,
permits titration of both the carboxyl and HC1
components of the salt. Each ml. of 0.1 N sodium
hvdroxide represents 9.581 mg. of C6H9X3O2.-
HC1. N.P.

Uses. — Histidine is one of the amino acids
essential for the white rat (Bothwell and Wil-
liams, /. Xutrition, October 1951) but probably
not in human nutrition. It is closely related to
histamine (see Histamine Phosphate). During
human pregnancy there is a characteristic his-
tidinuria. The presence of histidine in the urine
of a woman who does not menstruate within three
days thereafter has been proposed as a diagnostic
test for normal pregnancy (see Cheval and Hans.
J.A.M.A., 1952, 148, 1439 and also discussion of
Progesterone). An increased renal clearance of
histidine from the blood in pregnancy seems to
be related to a decrease in tubular reabsorption
and to a oliminished rate of metabolism (Page
et al., Am. J. Med., 1953, 15, 418); in pre-
eclampsia histidinuria decreases because of a de-
creased glomerular filtration rate.

Histidine was suggested as a remedy in the
treatment of peptic ulcer. The early reports were
quite favorable. Although Frohlich (Med. Klin.,
1937, 33, 933) observed, from gastroscopic ex-
aminations, disappearance of inflammatory lesions
of the stomach mucosa, and although numerous
clinicians have reported favorably upon its bene-
ficial action, Upham and Barowsky (J.A.M.A.,
1937, 109, 422), in a careful study of 150 cases,
concluded that it had no direct curative effect
in peptic ulcers (see also Sandweis, J. A.M. A.,
1936, 106, 1452; Hurst. Pract., 1936. 137, 409;
Delario, Am. J. Digest. Dis., 1946. 13, 260).
From 50 to 70 per cent of patients experience
relief of the symptoms of peptic ulcers after 2 to
5 injections, but a similar result is obtainable
with a soft diet and antacid regimen and the inci-
dence of recurrence of symptoms has been greater
with histidine therapy, perhaps because the in-
jections induce a false sense of security in both
physician and patient which results in a neglect
of good hygiene. The complication of hemorrhage
has been reported during the course of injections.
Similar symptomatic results have been reported
with injections of foreign protein. Benedict (Mil.
Surg., 1938, 83, 401) found histidine useful in
ulcerated conditions of the intestines including
even tuberculous enterocolitis. In artereosclerosis
obliterans, Friedell et al. (J. A.M. A., 1948, 138,
1036) reported relief of pain with 5 ml. of a 4
per cent aqueous solution of histidine hydrochlo-
ride injected intravenously and 100 mg. of so-
dium ascorbate given subcutaneously every 6
hours; Weisman and Allen (Circulation, 1950,
1, 127), however, failed to confirm this finding
or to demonstrate any increase in skin tempera-

Part I

ture following the treatment in patients or nor-
mal individuals.

The usual dose is 200 mg. (approximately 3
grains) intramuscularly daily for 20 to 30 days;
the course may be repeated within 6 to 12 months,
if indicated.

Storage. — Preserve "in well-closed contain-
ers." N.F.

HISTIDINE MONOHYDROCHLO-
RIDE INJECTION. N.F.

[Injectio Histidinae Monohydrochloridi]

"Histidine Monohydrochloride Injection is a
sterile solution of histidine monohydrochloride in
water for injection. It yields not less than 92 per
cent and not more than 108 per cent of the
labeled amount of C6H9N3O2.HCl.H2O." N.F.

Storage. — Preserve "preferably in single-dose,
containers, preferably of Type I glass." N.F.

Usual Size. — 200 mg. (approximately 3
grains) in 5 ml.

HOMATROPINE HYDROBROMIDE
U.S.P., B.P., LP.

Homatropinium Bromide, [Homatropinae
Hydrobromidum]

H2C

H2C-

HN — CHj

Br"

" Caution.— H omatropine Hydrobrotntde is ex-
tremely poisonous." U.S.P.

The B.P. recognizes Homatropine Hydrobro-
mide as the hydrobromide of an alkaloid, homa-
tropine, prepared from tropine and mandelic
acid; it is required to contain not less than 76.7
per cent and not more than 77.5 per cent of
homatropine, C16H21O3N. The LP. defines it as
the hydrobromide of 3-tropanyl-DL-hydroxy-
phenylacetate. and specifies the same rubric as
does the B.P.

LP. Homatropini Hydrobromidum. Homatropine Bro-
mide; Homatropine Hydrobromate. Homatropinum Hy-
drobromicum; Homatropinae Bromhydras; Hydrobromas
Homatropini. Fr. Bromhydrate d'homatropine. Ger. Homa-
tropinhydrobromid ; Bromwasserstoffsaures Homatropin. It.
Bromidrato di omatropina. Sp. Bromhidrato de homa-
tropina.

Homatropine is an ester of the cyclic base
tropine with mandelic acid. It differs from atro-
pine in that the latter is the ester of tropine with
<f/-tropic acid. Homatropine may be prepared
by evaporating tropine and mandelic acid in the
presence of diluted hydrochloric acid.

Description. — "Homatropine Hydrobromide
occurs as white crystals, or as a white, crystalline
powder. It is affected by light. It melts between
211° and 215° with slight decomposition. One
Gm. of Homatropine Hydrobromide dissolves in
6 ml. of water, in 40 ml. of alcohol, and in about
420 ml. of chloroform. It is insoluble in ether."
U.S. P. The B.P. gives the melting point as from
214° to 217°, with partial decomposition; the LP.
specifies it as about 214°, with partial decom-
position.

Standards and Tests. — Identification. — (1)

Homatropine Hydrobromide 651

A brown precipitate results when iodine T.S. is
added to a solution of homatropine hydrobro-
mide. (2) To 1 ml. of a 1 in 100 solution of
homatropine hydrobromide add a slight excess of
ammonia T.S., shake the mixture with chloroform,
and evaporate the chloroform solution to dryness
on a water bath. On warming the residue with
1.5 ml. of a solution of 500 mg. of mercuric chlo-
ride in 25 ml. of a mixture of 5 volumes of
alcohol and 3 volumes of water the mixture be-
comes at first yellow, then brick-red (difference
from most other alkaloids except atropine and
hyoscyamine). (3) Homatropine hydrobromide
responds to tests for bromide. Acidity. — Not more
than 0.2 ml. of 0.02 N sodium hydroxide is re-
quired for neutralization of 1 Gm. of homatropine
hydrobromide in 20 ml. of distilled water, using
methyl red T.S. as indicator. Loss on drying. —
Not over 1.5 per cent when dried at 105° for
2 hours. Residue on ignition. — The residue from
200 mg. is negligible. Atropine and other solana-
ceous alkaloids. — On adding a few drops of alco-
holic potassium hydroxide T.S. to the residue
remaining after evaporating to dryness a mixture
of 5 mg. of homatropine hydrobromide and 1 ml.
of nitric acid is not colored violet. Most other
alkaloids. — No precipitate forms on adding tannic
acid T.S. to a 1 in 20 solution of homatropine
hydrobromide. No precipitate forms on adding
platinic chloride T.S. to a 1 in 20 solution of
homatropine hydrobromide. U.S.P.

Assay. — The B.P. and LP. provide a conven-
tional alkaloidal assay procedure in which about
200 mg. of homatropine hydrobromide is dis-
solved in water, the solution alkalinized with am-
monia, the liberated alkaloid extracted with chlo-
roform and, after removing the chloroform and
drying the residue, determining the alkaloid by
residual titration employing 0.05 N solutions of
acid and alkali.

Stability of Solutions. — Pittenger and
Krantz found (/. A. Ph. A., 1928, 17, 1081) solu-
tions of this salt to be quite stable; sterilization
at 15 pounds pressure for fifteen minutes had no
effect on the activity of the solutions, neither did
exposure to ultraviolet light.

Incompatibilities. — Homatropine hydrobro-
mide is precipitated from its solutions by alka-
loidal reagents and by alkali hydroxides and
fixed alkali carbonates.

Uses. — Homatropine hydrobromide is used in
medicine solely as a mydriatic and cycloplegic.
It is much more fleeting in its action than atro-
pine; hence, it is valuable in ophthalmoscopic
examination and in refraction. Where prolonged
mydriasis is sought, as in keratitis and iritis to
prevent the formation of synechia, atropine is
the drug of choice. Whenever the avoidance of
increased intraocular tension for any considerable
time is desired, homatropine is indicated if a
mydriatic is to be used. Glaucoma may follow
the prolonged dilatation of the pupil after atro-
pine in some instances.

For simple mydriasis the use of a 1 per cent
aqueous solution of homatropine hydrobromide
is adequate, but to obtain full paralysis of ac-
commodation the instillation of several drops of
a 2 per cent solution, at intervals of 15 minutes

652 Homatropine Hydrobromide

Part I

for one to two hours, may be required. Much of
the effect vanishes within 24 hours, though 3 or 4
days may elapse before all of its effects have
disappeared. Homatropine is less reliable as a
cycloplegic in children.

The drug is now rarely used internally for
blocking of vagal impulses to the gastrointestinal
tract, atropine or homatropine methylbromide
instead being prescribed. Zulick (/. Pharmacol.,
1915, 6, 473) found that homatropine exerted a
paralyzant effect upon the vagus nerve similar to
that of atropine, although it required much
larger doses.

For external use, a 1 to 4 per cent aqueous
solution is instilled into the conjunctiva. It may
be repeated 3 or 7 times at intervals of 15 min-
utes. Internally, the usual dose is 0.65 to 1.3
mg. (approximately Vioo to Ho grain). The maxi-
mum safe dose is usually 2 mg.

Storage. — Preserve "in tight, light-resistant
containers." U.S. P.

LAMELLA OF HOMATROPINE. B.P.

Lamellae Homatropinae

Lamellae of homatropine are discs of gelatin
with glycerin, each weighing about 2.1 milligrams
('32 grain) and containing 0.65 milligram (Moo
grain) of homatropine hydrobromide, unless an-
other amount of the active ingredient is specified.
The method of preparation is discussed under
Lamella.

HOMATROPINE METHYLBROMIDE
U.S.P.

Methylhomatropinium Bromide, Homatropinae
Methylbromidum

Malcotran (Maltbie); Mesopin (Endo); Methatropin
(Pharmedic) ; Sovatrin (.Campbell Products).

This salt is the methyl bromide reaction prod-
uct of homatropine (see Eomatropine Hydrobro-
mide). Addition of a molecule of methyl bromide
occurs at the nitrogen atom, converting it to a
quaternary ammonium compound.

Description. — "Homatropine Methylbromide
occurs as a white, odorless powder. It slowly
darkens on exposure to fight. Its solutions are
practically neutral to litmus. Homatropine Meth-
ylbromide is very soluble in water, and freely
soluble in alcohol. It is almost insoluble in ether
and in acetone, but is freely soluble in acetone
containing about 20 per cent of water. Homa-
tropine Methylbromide melts between 190° and
and 198°. the temperature at which distinct lique-
faction of the sample is first observed being taken
as the beginning of melting." U.S.P.

Standards and Tests. — Identification. — (1)
A white precipitate is produced on adding mer-
curic-potassium iodide T.S. to a 1 in 50 aqueous
solution of homatropine methylbromide. (2) A
red precipitate forms on adding ammonium
reineckate T.S. to a 1 in 50 solution of homa-
tropine methylbromide. (3) A 1 in 20 aqueous
solution of homatropine methylbromide responds
to tests for bromide. Loss on drying. — Not over
1 per cent when dried at 105° for 3 hours. Residue
on ignition. — The residue from 250 mg. is negli-
gible. Homatropine, atropine, and other solana-
ceous alkaloids. — A 1 in 50 solution of homatro-

pine methylbromide, alkalinized with ammonia, is
shaken with chloroform and the chloroform solu-
tion is evaporated to dryness. The residue does
not yield a yellow or red color when warmed
with a mercuric chloride solution. Nitrogen con-
tent.— About 300 mg. of homatropine methyl-
bromide, previously dried at 105° for 3 hours, is
assayed by the Kjeldahl method. Not less than
3.70 per cent and not more than 3.85 per cent of
N is found. U.S.P.

Uses. — Homatropine methylbromide is used as
an antispasmodic and inhibitor of secretion, par-
ticularly in disorders of the gastrointestinal tract.
Tennenbaum (Arch. exp. Path. Pharm., 1930,
153, 325) found that the degree of action on
the parasympathetic nerve endings was less than
that of homatropine and that the effect on the
nerve centers was much less pronounced. Clini-
cally, it has been considered to be about one-half
as active and one-thirtieth as toxic as atropine.
Quigley (/. Pharmacol, 1937, 61 130). compar-
ing the two drugs, observed that more than twice
as much homatropine methylbromide was re-
quired to produce the same effect on the human
stomach. As much as 8 mg. of homatropine
methylbromide in a single dose seldom caused
dryness of the mouth, disturbance of vision, or
other untoward effects of atropine. According to
Cahen and Tvede (ibid., 1952. 105, 166). how-
ever, who have re-evaluated homatropine methyl-
bromide, it is either more or less potent than
atropine, depending on the test employed.

It is used in the irritable colon, mucous colitis,
spastic constipation syndrome to prevent the
colicky pain, check the hypersecretion of mucus
and alleviate constipation. In peptic ulcer, it
is employed to counteract pylorospasm and de-
crease hyperacidity. In other spastic conditions
of the gastrointestinal tract due either to disease
or to reflex effects arising from disease in other
viscera, such as the heart, kidneys, etc.. it may
relieve the symptoms of pain, flatulence, vomit-
ing, etc. In mild spastic conditions (not severe
colic) of the bile ducts, gall bladder and ureters,
it is often beneficial. It can be instilled into the
conjunctival sac as a mydriatic but is not popu-
lar for this purpose.

Dose. — The usual dose is 2.5 mg. (approxi-
mately Vn grain), with a range of 2.5 to 5 mg.
(approximately ¥u to V12 grain) by mouth, three
times daily before meals. The maximum safe dose
is usually 7.5 mg. and 30 mg. is seldom exceeded
in 24 hours. For infants, the single dose is about
0.3 mg. (approximately 1>.,oo grain) dissolved in
water, which may be repeated five to seven times
daily before feedings. Subcutaneously or intra-
muscularly, 5 mg. (approximately ^ grain) may
be given. The U.S. P., on the basis of new dosage
information, gives the usual oral dose as 10 mg.
4 times a day, with a range of 40 to 160 mg. daily.
Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

HOMATROPINE METHYLBROMIDE
TABLETS. U.S.P.

[Tabellae Homatropinae Methylbromidi]

"Homatropine Methylbromide Tablets contain
not less than 90 per cent and not more than 110

Part I

Honey 653

per cent of the labeled amount of Ci7H24BrN03."
U.S.P.

Assay. — The homatropine methylbromide in a
representative sample of powdered tablets is dis-
solved in water, and in an aliquot portion of this
solution precipitated as the reineckate. The red
precipitate is dissolved in acetone and the ab-
sorbancy of the solution is determined at 525 m|i;
from a comparison with the absorbancy of a solu-
tion of U.S. P. Homatropine Methylbromide Ref-
erence Standard, similarly treated, the content of
the active ingredient in the sample is calculated.
U.S.P.

Usual Sizes. — 2.5 and 10 mg. (approximately
Y2i and % grain) .

HONEY. N.F.

Clarified Honey, Strained Honey, Mel

"Honey is a saccharine secretion deposited in
the honeycomb by the bee, Apis mellijera Linne
(Fam. Apidce). It must be free from foreign sub-
stances such as parts of insects, leaves, etc., but
may contain pollen grains." N.F.

Purified Honey; Mel Depuratum. Fr. Miel blanc; miel.
Ger. Honig. It. Miele. Sp. Miel.

For description of Apis mellijera see under
Yellow Wax. Besides the official species other
bees are used as honey makers. The extremely
vicious, blackish-brown Apis fasciata was kept by
the ancient Egyptians on floating apiaries, which
as the season progressed slowly drifted down the
Nile, following the successive opening of the
flowers. In Senegal, Apis adansonii, and in south-
ern Africa, Apis caffra and Apis scutellata produce
honey; while the Apis unicolor of Madagascar
has been domesticated in that island and intro-
duced into other parts of the world. In India,
honey is made in large quantities by Apis dorsata
{Apis indica, Apis florea), the largest bees known.

From the nectaries of various flowers the bee
and other insects extract a thin, aqueous fluid,
nearly without flavor and insipidly sweet, usually
known as nectar. The precise composition of
nectar varies in different plants and the compo-
sition and the flavor of the honey will vary ac-
cordingly. Honey made late in the summer from
the flowers of the buckwheat is comparatively dark
in color. The honey made by bees which have fed
on the nectar from poisonous flowers may be quite
toxic; this applies especially to the flowers of the
mountain laurel, of the jimson weed, and of the
yellow jessamine. The honey made from the
nectar of the white clover blossom is very highly
esteemed, as is also that from the raspberry blos-
som and the basswood flowers. Many apiarists
specialize in honey gathered from certain definite
species of aromatic flowers.

The nectar, when taken in by the bee, is
changed by secretions from glands in the head
and thorax; levulose, dextrose, and, rarely, sucrose
are formed. The finest honey is that which is
allowed to drain from the comb. As beeswax is a

» valuable product in itself, centrifugal extractors
are now employed by apiculturists to separate the
honey from the comb, after cleanly slicing off the
ends of the cells with a sharp knife. Centrifuged
honey is much cleaner than that produced by

other methods. If obtained from hives that have
never swarmed, it is called virgin honey. An in-
ferior kind is procured by submitting the comb
to pressure, and if heat is employed previous to
expression, the product is still more impure.

Description. — "Honey is a thick, syrupy
liquid of a light yellowish to reddish brown color.
It is translucent when fresh, but frequently be-
comes opaque and granular through crystallization
of dextrose. It has a characteristic odor and a
sweet, faintly acrid taste. Honey is levorotatory,
and it is acid to litmus paper. When Honey is
diluted with twice its weight of distilled water,
the mixture is only moderately turbid, is not
stringy, and has a specific gravity of not less than
1.099." N.F.

Standards and Tests. — Residue on ignition.
— Not over 0.3 per cent, when 10 Gm. is ignited
in the presence of a few drops of olive oil to
prevent spattering. Chloride. — The limit is 150
parts per million. Sulfate. — The limit is 200 parts
per million. Artificial honey. — On triturating
about 1 Gm. of honey with 20 ml. of ether, filter-
ing the mixture and evaporating the ether from
the filtrate, the residue produces with 1 drop of
freshly prepared resorcinol T.S. at most a pink
color which disappears in 30 seconds, but not an
orange, reddish orange, or reddish brown color.
This test depends on the detection of hydroxy-
methyljur jural, which is formed in perceptible
amounts on acid hydrolysis of sucrose; it is said,
however, that honey heated to 160° F. or stored
for a long time will give a positive reaction. Azo
dyes. — A reddish color is not produced immedi-
ately following addition of a few drops of hydro-
chloric acid to 5 ml. of a 1 in 2 aqueous solution
of honey. Starch or dextrins. — No blue, green, or
reddish color is produced on boiling 2 Gm. of
honey with 20 ml. of distilled water, cooling, and
adding 2 drops of iodine T.S. Acidity. — Not more
than 0.5 ml. of 1 N sodium hydroxide is required
for neutralization of 10 Gm. of honey dissolved
in 50 ml. of distilled water, using phenolphthalein
T.S. as indicator. N.F.

Constituents. — Honey varies somewhat in its
composition. The principal constituents are a mix-
ture of dextrose and levulose in the same propor-
tions as present in artificial invert sugar and in an
amount ranging from 65 per cent to nearly 80 per
cent. Sucrose is present in a concentration of 0.5
per cent to 8 per cent; dextrin, from less than
1 per cent up to 10 per cent. The ash of honey
varies from 0.03 per cent to 0.50 per cent and
the water from 12 per cent to 33 per cent. In a
standard honey the sucrose should not be over
8 per cent, the water not over 25 per cent nor
the ash over 0.25 per cent. Honeys obtained by
bees feeding upon the saccharine exudations of
coniferous trees have been found to contain dex-
trose as the preponderating sugar and to have a
dextrorotatory optical rotation instead of levo-
rotatory, as in the ordinary varieties. Such honeys
usually come from foreign countries, although
several specimens have been reported from the
western part of the United States, and one speci-
men containing melezitose was reported from
Pennsylvania, this rare carbohydrate having origi-
nated as an exudation on the twigs of Pinus vir-

654 Honey

Part I

giniana. For composition of American honeys
from various floral sources and for methods of
detecting adulterations see Brown and Zerban
(Physical Methods of Sugar Analysis, 1941).

Uses. — Honey is a valuable carbohydrate food-
stuff, particularly so because it consists largely
of sugars that are rapidly absorbed. It is often
more acceptable to the stomach, especially in
ailing persons, than cane sugar. Honey is some-
times used as a flavoring agent for medicines,
especially gargles. It is sometimes employed as
an excipient for preparing pills and masses, being
used thus in preparing ferrous carbonate mass, in
which product its reducing action in maintaining
iron in the ferrous state is also utilized. Honey is
also an ingredient of the formerly official mercury
mass, where it served to facilitate the dispersion
of metallic mercury, to obtain the consistency of
a mass, and to prevent oxidation of the mercury.

Dose, 4 to 15 ml. (approximately 1 to 4
flui drachms).

Storage. — Preserve "in well-closed contain-
ers.*' X.F.

Off. Prep. — Ferrous Carbonate Mass. X.F.

HYALURONIDASE FOR INJECTION.

U.S.P.

"Hyaluxonidase for Injection is a sterile, dry.
soluble, enzyme product prepared from mam-
malian testes and capable of hydrolyzing muco-
polysaccharides of the type of hyaluronic acid.
Its potency, in U.S.P. Hyaluronidase Units, is not
less than the labeled potency. Hyaluronidase for
Injection contains not more than 0.25 micro-
gram of tyrosine for each U.S.P. Hyaluronidase
Unit. It may contain a suitable stabilizer." U.S.P.

Alidase (Searle) ; Enzodase (.Squibb) ; Hyalase (Benger) ;
Hyazyme (Abbott) ; Rondase (Evans); Wydase (fVyeth).

While hyaluronidase occurs in many tissues it
is obtained commercially from bovine testes by
extraction processes involving fractionation with
ammonium sulfate.

Description. — "Hyaluronidase for Injection
is a white, amorphous solid. Its solutions are
colorless and odorless." U.S.P.

Standards and Tests. — Tyrosine. — This is
determined in a sample of hydrolyzed hyaluroni-
dase by measuring the intensity of the red color
produced with nitrous acid, quantitative com-
parison being made with a solution of tyrosine.
Pyrogen. — 1 ml. of a solution containing 150
U.S.P. Hyaluronidase Units meets the official
requirements. Sterility. — The product meets the
official requirements. US.P.

Assay. — The official assay is based on the
depolymerizing effect of hyaluronidase on hyalu-
ronic acid (provided by potassium hyaluronate\
which effect is accompanied by a reduction of
the turbidity of the reaction mixture; the greater
the concentration of hyaluronidase. the greater
the reduction of turbidity for a given amount of
hyaluronic acid. The turbidity of a series of dilu-
tions of a test solution of the hyaluronidase
sample is determined, measurements being made
in a suitable electrophotometer at 620 mu; quan-
titative comparison is made by observing the
effect of a series of solutions prepared from

U.S.P. Hyaluronidase Reference Standard under
identical conditions. U.S.P.

Prior to the establishment of a Hyaluronidase
Unit by U.S.P. XV, the activity of various com-
mercial preparations of hyaluronidase was stated
in terms of several different units, as viscosity-
reducing units, turbidity-reducing units, Benger
units, Schering units, etc. While no accurate
comparative figures seem to have been published,
the following relationships provide an approxi-
mate comparison of the several units: 1 U.S.P.
unit is approximately equivalent to 1 turbidity-
reducing unit (Wydase), to 3 viscosity-reducing
units (Alidase). to 1.5 Benger units (Hyalase),
and to 0.033 Schering A.G. units (Kinetin).

Although preparations of hyaluronidase de-
rived from bovine testes have been obtained with
activity as high as 2000 U.S.P. units per mg. of
protein these preparations are less stable than
less concentrated ones; most commercial prep-
arations contain less than 1000 U.S.P. units per
mg. Lactose, sodium chloride or other filler, as
well as a preservative, such as thimerosal. are
commonly added to such preparations.

Action. — Hyaluronidase is the enzyme which
depolymerizes hyaluronic acid (Meyer, Physiol.
Rev., 1947. 27, 335). The latter is a viscous
mucopolysaccharide found in the interstitial sub-
stances of tissues, the highest concentration oc-
curring in synovial fluid and skin. Hyaluronic
acid, first isolated by Meyer and Palmer (J. Biol.
Chem., 1934. 107, 629) from bovine vitreous
humor, may also be extracted easily from the
Wharton's jelly of the umbilical cord as the
sodium salt (Kaye. Nature, 1950, 166, 478).
Hyaluronic acid contains equimolar quantities of
acetylglucosamine and glucuronic acid and seems
to be a repeating unit of glucuronido-X-acetyl-
glucosamine. polymerized by relatively stable
glucosidic linkages. Hyaluronidase is also found
in many tissues, in some bacteria and certain
snake venoms. By depolymerizing hyaluronic
acid hyaluronidase reduces the viscosity of the
former and facilitates spreading of substances
through the intercellular substance of tissues.
Chain and Duthie (Brit. J. Exp. Path., 1940, 21,
showed that hyaluronidase was the "spread-
ing factor" described bv Duran-Revnals (Compt.
rend. soc. biol, 192S. 99, 6; J. Exp. Med., 1929,
50, 32 7; Bad. Rev., 1942, 6, IT

An enzyme which acts on the ground substance
of most all tissues possesses extensive scientific
import and therapeutic application (The Ground
Substance of the Mesenchyme and Hyaluronidase,
Ann. X. V. Acad. Sc, 1950. 52, 943-1196). Like
ascorbic acid, it is related to the function of all
tissues and an enormous literature has accumu-
lated. In addition to the viscous mucopolysac-
charide hyaluronic acid, another one — chondroitin
sulfate — is an important component of ground
substance. The latter is less viscous and has less
capacity to bind water or function as an ion
exchanger but it is the predominant component
of cartilage. Still other mucopolysaccharides have
been identified. Glycoproteins appear essential to
fibril formation in connective tissue. Fibroblasts
seem related to collagen fibers and mast cells to
the amorphous ground substance. This amorphous

Part I

Hyaluronidase for Injection 655

and hence unintelligible ground substance of the
histologist of the past century is now recognized
as an actively functioning and essential physio-
logical and pathological entity. Hyaline, fibrinoid,
amyloid, etc., changes had been described in tis-
sues and related to certain diseases — rheumatic
fever, lupus erythematosus, etc. — by pathologists
and clinicians. The discovery of cortisone and its
anti-inflammatory action in many diseases focused
attention on mesenchymal tissues and provided
a physiological tool for the biological experi-
menter. Cortisone inhibits connective tissue for-
mation whereas the thyrotropic and growth
hormones of the anterior hypophysis stimulate
connective tissue formation and the latter pro-
motes collagen fiber formation. Hyaluronidase
increases the permeability of synovial membrane
and cortisone decreases it (Seifter et al., Proc. S.
Exp. Biol. Med., 1949, 72, 277). Synovial fluid in
rheumatoid arthritis contains an increased amount
of partly depolymerized (low-viscosity) hyaluro-
nate; cortisone therapy results in less, but more
viscous, mucopolysaccharide (Ekman et al.,
Scand. J. Clin. Lab. Invest., 1953, 5, 175). Many
major dermatologic and ophthalmologic disorders
consist chiefly of ground substance and connec-
tive tissue abnormalities. Atherosclerosis com-
mences with an increase in chondroitin sulfate in
the ground substance in the intima of the vessels
(Taylor, Am. J. Path., 1953, 29, 871). Wound
healing is accomplished by the formation of new
connective tissue. Cortisone in large doses in-
hibits healing. The healing of fractures and the
formation of peritoneal adhesions involves a
similar process. The spreading of infection is re-
lated to the degree of permeability of ground
substance which may be increased by hyaluroni-
dase producing bacteria or diminished by the
action of cortisone. Cortisone inhibits the spread-
ing action of hyaluronidase by changing the char-
acter of the ground substance rather than by any
direct antagonism between the steroid and the
enzyme. In other words the initial injection of
cortisone will be spread and absorbed more rap-
idly in the presence of hyaluronidase but in the
presence of hypercortisonism, either endogenous
or exogenous, hyaluronidase has less spreading
effect. The administration of salicylates likewise
inhibits the spreading action of hyaluronidase
(Shuman, Am. J. Med. Sc, 1950, 220, 665).
Inflammation is primarily a phenomenon of con-
nective tissue.

Uses. — Hyaluronidase has found its therapeu-
tic application in increasing the permeability of
tissues to facilitate absorption of injected fluids
or of certain transudates or even exudates or hem-
orrhages into tissue as a result of injury or dis-
ease. Hyaluronidase for injection is relatively but
not entirely pure ; it contains to a variable degree
other enzymes, such as beta-glucuronidase, pres-
ent in the testes from which the extract is de-
rived (Chauncey et al., Science, 1953, 118, 219).
The spreading action of the enzyme is presumably
due to partial depolymerization of the viscous
hyaluronate in the tissue. The more rapidly and
extensively spread fluid comes into close contact
with more capillaries and lymphatics and is ab-
sorbed more rapidly. External pressure, as from

an elastic bandage, and a decreased venous pres-
sure, as produced by elevation of the part, favor
spreading and absorption and should be utilized
to obtain the best therapeutic result with the
enzyme. Seifter and Baeder (Proc. S. Exp. Biol.
Med., 1954, 85, 160) showed that partially de-
polymerized hyaluronic acid itself facilitates
spreading and absorption of injected fluid; in
other words the enzyme needs only to depolym-
erize some hyaluronate to facilitate spreading.
An incompletely evaluated action following sub-
cutaneous injection of hyaluronidase is the in-
crease in excretion of a dispersing colloid in the
urine (Butt, /. Urol., 1954, 72, 337; Wohlzogen,
Wien. klin. Wchnschr., 1952, 64, 562; Puntriano,
J.A.V.M.A., 1954, 124, 55). In this connection,
Baker et al. (J. Urol., 1954, 71, 511) claimed
that the status of the connective tissue in the
kidney was more important than hypercalcemia
in the production of nephrocalcinosis in patients
with hyperparathyroidism. These observations re-
call the unsolved question of the relative im-
portance of disturbances in colloids or of crystal-
loids in the genesis of urolithiasis. With refer-
ence to a general, systemic, action of subcutane-
ous injections of hyaluronidase, Seifter et al.
(Proc. S. Exp. Biol. Med., 1953, 83, 468) re-
ported that fat-cholesterol fed rabbits with hyper-
cholesterolemia showed a return of the elevated
blood cholesterol levels toward normal when
daily injections of hyaluronidase were given;
autopsy, however, showed an increased degree of
atheromatosis and lipidosis in these animals. The
injection of hyaluronidase or the feeding of par-
tially depolymerized hyaluronic acid, as well as
the injection of heparin, released a lipemia-clear-
ing factor in the blood of the animals and the
administration of cortisone antagonized the re-
lease of this clearing factor (Seifter and Baeder,
ibid., 1954, 86, 709). Normal blood contains a
nonspecific antihyaluronidase which is present in
a concentration resembling that of heparin in
blood (Glick and Ochs, ibid., 1952, 81, 363). In
rheumatic fever, acute glomerulonephritis and
some other conditions a specific antistreptococcal-
hyaluronidase is found in the blood in increased
amounts and generally parallel with the titer of
antistreptolysin O (Rantz et al., Am. J. Med. Sc,
1952, 224, 194). It is obvious that mucopolysac-
charides play a most important but inadequately
understood role in metabolism and disease. Cur-
rent therapeutic applications, however, depend
upon the spreading action of hyaluronidase.

Hypodermoclysis. — Use of 150 U.S. P. units
of hyaluronidase per 1000 ml. of parenteral fluids,
such as saline, dextrose, Ringer's, sodium lactate,
plasma, etc., speeds absorption and minimizes the
discomfort from local distention of tissue with
the fluid (Hechter et al., J. Pediatr., 1947, 30,
645; Burket and Gyorgy, Pediatrics, 1949, 3,
56; Schwartzman and Levbarg, /. Pediatr., 1950,
36, 79; Gaisford and Evans, Lancet, 1949, 2,
505; Jaworski and Farley, Am. J. Dis. Child.,
1950, 79, 59). In infants under 2 years of age
receiving 125 ml. of saline-dextrose solution, or
200 ml. if over 2 years of age, Burket and
Gyorgy found the average time required for ab-
sorption decreased from 173 minutes in controls

656 Hyaluronidase for Injection

Part I

to 107 minutes with hyaluronidase; furthermore,
the control sites became so distended that flow
had to be discontinued four times on the average
during the injection. Webb (Arch. Surg., 1952,
65, 770) found that the rate of absorption was
approximately doubled in adults. Abbott et al.
(Surgery, 1952, 32, 305) recalled that subcu-
taneous infusion of 5 or 10 per cent dextrose
injection in patients already depleted in sodium
and chloride may result in further hypochloremia,
hemoconcentration and circulatory failure (elec-
trolyte depletion shock described by Danowski
et al., J. Clin. Inv., 1947, 26, 887) and reported
that addition of hyaluronidase to the electrolyte-
free infusion solution did not prevent this loss
of electrolytes from the blood stream into the
pool of fluid injected subcutaneously. Mateer
et al. (Am. J. Med. Sc, 1953, 226, 139) demon-
strated on humans that the electrolyte abnormali-
ties were due to the lack of electrolyte in the
parenteral fluid rather than to the presence of
hyaluronidase as' had been implied editorially
(J.A.M.A., 1953, 151, 644). In small children
excessive doses of fluids by hypodermoclysis
must be avoided. Usually, in patients under three
years of age, a single clysis should not exceed
200 ml. and for small or premature infants the
dose of fluid should not exceed 25 ml. per Kg. of
body weight and the rate of infusion should not
exceed 2 ml. per minute in these small infants.

Other Injections. — The addition of hyalu-
ronidase to a variety of substances (Britton and
Habif, Surgery, 1953, 33, 917), such as anti-
biotics, steroids, alkaloids, tissue extracts, anti-
sera (Boquet et al., Compt. rend. acad. sc, 1952,
234, 482), etc., will speed absorption and onset
of systemic action. Preliminary injection of hyal-
uronidase will even facilitate absorption and
diminish the discomfort of subsequent heparin
injection (Tuchman and Moolten, Am. J. Med.
Sc, 1950, 219, 147); if the two are mixed in the
syringe, the heparin will inactivate the hyaluroni-
dase. Hyaluronidase has been combined with in-
sulin in psychotic patients to increase the pro-
portion of cases of successful shock therapy and
to speed absorption so that the shock occurs
during the day when adequate nursing personnel
are available to care for the patient (Straccia and
Scheflen, Am. J. Psychiat., 1952. 108, 702; Gysin
and Wilson, Dis. Nerv. System, 1954, 15, May).

Local Anesthesia. — For infiltration anesthesia
with procaine or pontocaine, Kirby et al. (Sur-
gery, 1949, 25, 101) found that addition of 150
to 300 units of hyaluronidase increased the area
of skin anesthesia by 40 per cent; the duration
of anesthesia was shortened unless 0.5 ml. of
1 : 1000 epinephrine hydrochloride solution was
added per 25 to 50 ml. of the anesthetic solu-
tion. Addition of the vasoconstrictor does not
interfere with the spreading action of hyaluroni-
dase but it does inhibit absorption into the blood
stream. Britton and Habif (Surgery, 1953, 33,
917) and Cliffton (Am. J. Med. Sc, 1954, 228,
568) reviewed the clinical applications of hyalu-
ronidase. Facilitation of local infiltration anes-
thesia has been reported in dentistry (Looby and
Kirby, /. Am. Dent. A., 1949, 38, 1), pud'endal
block in obstetrics (Heins, Am. J. Obst. Gyn.,

1951, 62, 658; Baum, ibid., 1950, 50, 1356;
Alvarez and Gray, Obst. Gyn., 1954, 4, 635),
tonsillectomy (Heinberg, Eye, Ear, Nose &
Throat Monthly, 1951, 30, 31), rhytidectomy
and other plastic surgical procedures (Thale,
Plast. Reconstruct. Surg., 1952, 10, 260), minor
procedures on the eyelids or by cone injection for
iridectomy in glaucoma, cataract extraction, etc.
(Atkinson, Arch. Ophth., 1949, 42, 628; Leben-
sohn, Am. J. Ophth., 1950, 33, 865), sprains,
fractures and other orthopedic procedures (Mac-
Ausland et al., J. Bone Joint Surg., 1953, 35-A,
604; Thorpe, Lancet, 1951, 1, 210; Gartland and
MacAusland, Arch. Surg., 1954, 68, 305), ath-
letic injuries (Delarue, Can. Med. Assoc. J., 1954,
70, 408), painful (spastic) flat feet (Locke, /.
Nat. A. Chiropodists, November 1952), speeding
the onset and depth of anesthesia of the ear
drum (Hussarek, Ztschr. Laryng. Rhin., 1954,
33, 18) and speeding the onset of pharyngeal
anesthesia with a spray in preparation for laryn-
geal intubation (Howland and Papper, Anesth.,
1951, 12, 688). For nerve block anesthesia,
Moore (Anesth., 1950, 11, 470) and Eckenhoff
and Kirby (ibid., 1951, 12, 27) found little ad-
vantage with hyaluronidase compared to the
marked benefit in infiltration anesthesia. In-
creased absorption of penicillin from the maxil-
lary antrum with hyaluronidase was reported
(Som et al., Proc S. Exp. Biol. Med., 1949, 70,
96).

Resorption of Hemorrhage and Transu-
dates.— Infiltration of hyaluronidase solution in
sterile saline or local anesthetic solution around
or into areas of traumatic or postoperative edema
or hematoma followed by application of an elastic
pressure bandage and elevation of the part re-
sults in much more rapid absorption than can be
obtained by any other practical procedure in post-
operative edema in eye surgery (Tassman, Am. J.
Ophth., 1952, 35, 683), hematoma and lymph-
edema (Britton and Habif, Surgery, 1953, 33,
917), paraphimosis (Williams and Nichols, /. M.
A. Alabama, 1952, 21, 233), pretibial myxedema
(Rosman, N. Y. State J. Med., 1950, 50, 1939),
dental conditions (Benzer and Schaffer, Oral
Surg. Med. Path., 1952, 5, 1315), hemarthroses
in hemophilia (MacAusland and Gartland, New
Eng. J. Med., 1952, 247, 755; Blattner, /.
Pediatr., 1953, 42, 392), nasal surgery (Cottle
et al., Arch. Otolaryng., 1950, 52, 369). The in-
flammatory reaction following extravasation of
50 per cent dextrose, neoarsphenamine or other
irritant solutions into tissues is minimized by
immediate infiltration of the area with hyaluroni-
dase in sodium chloride injection or procaine
hydrochloride injection (Petrus and Pisetsky,
Am. J. Psychiat., 1952, 109, 303).

Miscellaneous. — Space does not permit the
recital of other applications of an enzyme which
increases the permeability of the ground sub-
stance of tissue. Cornbleet (J.A.M.A., 1954, 154,
1161), for example, used injections of hyaluroni-
dase in combination with surgical removal or
roentgen irradiation of keloids. Weinberg (/.
Thoracic Surg., 1951, 22, 517) injected hyaluroni-
dase with a water-soluble blue dye (Direct Sky
Blue, 4 per cent, Wyeth) into the wall of the

Part I

Hydnocarpus Oil 657

stomach or the hilum of the lung at the start of
operation for neoplasm to stain the regional
lymph nodes blue and thereby facilitate their
recognition for removal. Kurtin (Arch. Dermat.
Syph., 1954, 69, 368) injected hyaluronidase
solution under the finger or toe-nail to facilitate
surgical avulsion. In Panama, Carriker (Am. J.
Ophth., 1952, 35, 1765) reported that 2 or 3
weekly subconjunctival injections of 50 units of
hyaluronidase in 0.3 ml. of 1 per cent procaine
hydrochloride injection corrected early lesions.
In chronic, indolent ulcers of the leg, Popkin
(Angiology, 1952, 3, 335) reported healing with
hyaluronidase solution applied by iontophoresis
and Spier and Cliffton (Surg. Gynec. Obst., 1954,
98, 667) described good results with a water-
miscible preparation containing plasminogen,
streptokinase-streptodornase, hyaluronidase, baci-
tracin and oxytetracycline. IS

A stabilized solution of hyaluronidase, Solu-
tion Wydase (Wyeth) is recognized by N.N.R.
This is available in 1 or 10 ml. multiple dose
vials containing 150 U.S. P. units per ml., pre-
served with 0.01 per cent thimerosal, stabilized
with 0.1 per cent of disodium calcium ethylenedi-
aminetetraacetic acid and buffered with 0.14 per
cent of sodium phosphate.

Toxicology. — Hyaluronidase is a protein en-
zyme and hence large and repeated doses may
stimulate antibody formation and cause allergic
reactions. However, hyaluronidase is a very ac-
tive enzyme effective in doses of less than 1 mg.
and it is a weak antigen. Furthermore most pa-
tients do not have repeated need for hypodermo-
clysis or infiltration anesthesia. Daily use of
very large doses in animals will eventually result
in sensitization. In the daily injection of many
patients with urolithiasis (Butt et al., loc. cit.)
or with chronic lymphedema (Britton and Habif,
loc. cit.), local reactions — erythema, edema —
have rarely appeared. Intravenous administration
of even 75,000 units (500 times the usual thera-
peutic dose) of hyaluronidase in animals causes
no significant change in blood pressure, respira-
tion, body temperature, kidney function and no
histological changes in the tissues (Seifter, Ann.
N. Y. Acad. Sc, 1950, 52, 1141). It has no effect
on the spread of localized infection provided it
is not injected into the infected area (Hechter
et ah, loc. cit.) and it has even been combined
with antibiotic solutions for injection into areas
of cellulitis to facilitate penetration of the anti-
biotic. No deleterious effect on bacterial or viral
infections has been recognized from systemic use.
It is now recognized that the spreading of infec-
tion described with crude testicular extracts
(Duran-Reynals, loc. cit.) depended upon the
presence of other substances in the extracts since
these results are not obtained with the currently
employed purified hyaluronidase preparations
(Warren, Ann. N. Y. Acad. Sc, 1950, 52, 1157).

Dose. — The usual dose for hypodermoclysis
is 150 U.S.P. iinits, with a range of 15 to 1500
units. The maximum safe dose is unknown; more
than 3000 units in 24 hours is rarely exceeded.
The 150 units may be dissolved in sodium chlo-
ride injection for injection into the site of hypo-
dermoclysis prior to commencing the infusion,

or it may be injected into the rubber tubing of
the clysis equipment close to the needle penetrat-
ing the skin, or it may be added to the bottle of
fluid in the proportion of 150 units to 1000 to
2000 ml. of fluid. For infiltration anesthesia, 150
units is used per 25 to 50 ml. of local anesthetic
solution, which may also contain epinephrine if
indicated. For hematomas and other traumatic
exudates, 150 to 500 or even 3000 units in a
volume of sodium chloride injection appropriate
to the size of the area to be infiltrated is used.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass, in a cool, dry place."
U.S.P.

Usual Sizes.— 150 and 1500 U.S.P. Hyalu-
ronidase Units.

HYDNOCARPUS OIL. B.P., LP.

Oleum Hydnocarpi

Hydnocarpus Oil is the fatty oil obtained by
cold expression from the fresh, ripe seeds of
Hydnocarpus wightiana Blume. B.P. The LP.
recognizes also the sources included in the N.F.
IX (see below).

N.F. IX. Chaulmoogra Oil ; Oleum Chaulmoograe. Lep-
rosy Oil. Fr. Huile de chaulmoogra. Get. Chaulmugraol;
Gynokardiaol. It. Olio di chaulmoogra. Sp. Aceite de chaul-
mugra.

Long official in the U.S.P. and later in the
N.F., under the title Chaulmoogra Oil, this oil
was not admitted to N.F. X. In the preceding
revision it was defined as "the fixed oil expressed
from the ripe seed of Taraktogenos Kurzii King,
Hydnocarpus Wightiana Blume, or Hydnocarpus
anthelmintica Pierre (Fam. Flacourtiacece) . The
fixed oil expressed from the ripe seed of other
species of Hydnocarpus (Fam. Flacourtiacece),
when designated as such and when conforming to
the description and physical properties and meet-
ing the requirements of the tests prescribed be-
low, may be used."

It was at one time believed that chaulmoogra
oil was derived from Gynocardia odorata R. Br.,
but Desprez in 1899 demonstrated the fallacy of
this belief. In the following year Prain attributed
the seeds to Hydnocarpus heterophylla Bl., which
is more properly known as the Taraktogenos
Kurzii King (Fam. Flacourtiacece) . In 1922 J. F.
Rock (Bull. 1057 U. S. Dept. Agriculture) pub-
lished the results of an extensive exploration
through Burma and Assam. He found that the
seed sold in Burma as from the kalaw was from
the fruit not only of Taraktogenos Kurzii but
also of Hydnocarpus castanea Hf. and Th. and
perhaps other allied species. It has since been
discovered that the seeds of a number of species
of Hydnocarpus yield an oil similar to that ob-
tained from seed of Taraktogenos, and Hydno-
carpus species are now the most abundant sources
of chaulmoogra oil. Among those best known are
H. Wightiana Blume and H. anthelmintica Pierre.

Hydnocarpus Wightiana Bl. is an Indian species
commonly known to the natives as kastel or
kantel. It is a tall tree with slightly pubescent
branchlets, thinly coriaceous, elliptic to oblong-
lanceolate, acuminate, often deeply serrate leaves,
from 4 to 9 in. long, white flowers with ciliate

658 Hydnocarpus Oil

Part I

petals having ovate, fimbriate scales at their
bases. The fruit is tomentose and from 2 to 4 in.
in diameter. This species is reported by Brandis
to be common along the western Ghats from the
Konkan southwards and also below the Ghats in
Malabar and Kanara. Its fruit is used locally to
intoxicate fish and its seeds in skin diseases.

For descriptions of Taraktogenos Kurzii King,
of Hydnocarpus anthelmintica Pierre, and other
Hydnocarpus species, see U.S.D., 24th ed., p. 249.

A number of other plants of the Flacourtiacece
yield oils which contain chaulmoogric acid.
Among the more important of them are Oncoba
echinata 01. of West Africa, known as gorli or
katoupo; Asteriastigma macrocarpa Bedd. of
Madras; and Carpotroche brasiliensis, which
yields the so-called Brazilian chaultnoogra oil.
For description of these oils see Andre (Compt.
rend. acad. sc, 1925, 181, 1081, and Quart. J. P.,
1928, 1, 235). The oil of Gynocardia, from Gyno-
cardia odorata contains neither hydnocarpic nor
chaulmoogric acids.

Rock (loc. cit.) reported that the oil is ex-
tracted by cold expression from seeds which have
been washed, dried in the sun, shelled, crushed
and then submitted to hydraulic pressure; the
expressed oil is filtered.

Description. — Hydnocarpus oil is a yellowish,
or brownish-yellow, oil, or soft cream-colored
fat. Its odor is slight and characteristic; its taste
is somewhat acrid. The oil is partially soluble in
alcohol; miscible with ether, with chloroform,
and with carbon disulfide. Its weight per ml., at
25°, is between 0.946 and 0.956. The melting
point is between 20° and 25°. B.P.

Standards and Tests. — Refractive index. —
Between 1.472 and 1.476, at 40°. Specific rota-
tion.— Not less than 53°, in a 10 per cent w/v
solution in chloroform. Acid value. — Not greater
than 6. Iodine value. — 97 to 103 (iodine mono-
chloride method). Saponification value. — 198 to
204. B.P.

Constituents. — Hydnocarpus oil contains
small amounts of the glycerides of oleic and
palmitic acids, but its most important fatty acids
are chaulmoogric, CsH7(CH2)i2COOH and hyd-
nocarpic, C5Ht(CH)ioCOOH. Both of these are
cyclopentenyl derivatives of normal fatty acids
(tridecanoic and undecanoic, respectively). In
both cases the cyclopentenyl group is substituted
on the carbon atom farthest from the carboxyl
group.

According to Cole and Cardoso (J.A.C.S., 1939,
61, 2351) the mixture of the fatty acids of the
oil from Hydnocarpus Wightiana, which is the
one most commonly used, has the following per-
centage composition: hydnocarpic, 48.7; chaul-
moogric, 2 7.0; gorlic (an unsaturated derivative
of chaulmoogric acid), 12.2; oleic, 6.5; palmitic.
1.8; certain lower homologues of chaulmoogric
acid make up the remainder. Both chaulmoogric
and hydnocarpic acid have been synthesized (see
Perkins and Cruz, J.A.C.S., 192 7,' 49, 1070, also
Bokil and Nargund, Proc. Indian Acad. Sci., 1940,
11A, 409).

Uses. — Prior to the availability of the sulfones
(see under Sulfoxone in Part I) and dihydrostrep-
tomycin, chaulmoogra oil and its derivatives pro-

vided the only effective, albeit unsatisfactory,
therapy for leprosy. Chaulmoogra oil has been
used by the natives of India since time imme-
morial. An Indian legend relates that a King of
Benares, by the name of Rama, some 3000 years
ago, afflicted with leprosy retired to the jungles,
where he lived largely on the fruit of the Kalaw
tree and became cured of his leprosy. The
Asiatics used chaulmoogra oil both by oral ad-
ministration and by local application to the ex-
ternal lesions of leprosy.

Because of its local irritant effects on the diges-
tive tract it is almost impossible to continue the
administration of chaulmoogra oil by mouth for a
sufficient length of time to produce the best clini-
cal results. In modern practice it is usually ad-
ministered by intramuscular injection, but even
here its local irritant action is a hindrance to its
use. Various formulas have been suggested to
lessen the undesirable local effects. Among the
mixtures which were suggested for this purpose
that of Heiser enjoyed at one time a large use;
this consisted of: resorcin, 4 Gm.; camphor, 6
Gra.; olive oil, 60 ml.; chaulmoogra oil, 60 ml.;
of this solution the beginning dose was 1 ml.
injected weekly. For parenteral use the esters
were better tolerated (see Ethyl Chaulmoo grate).

The mode of action of chaulmoogra in leprosy
is uncertain. Stanley (/. Pharmacol., 1932, 45,
121) found that all strains of Mycobacterium
leprce were killed by a 1 : 50,000 solution of mixed
hydnocarpic and chaulmoogric acids. On the other
hand, Walker and Sweeney (/. Prevent. Med.,
1929, 3, 325) found that the characteristic fatty
acids disappeared rapidly from the blood stream
and since clinical experience has demonstrated
that long-continued use of the drug is essential
the bactericidal explanation of its curative effect
appears to be inadequate. Another hypothesis
suggests that the waxy coating of the bacterium
is damaged and that there is enhanced resistance
of the body to the infection. The lepra reaction,
which resembles the Herxheimer reaction during
the treatment of syphilis with active antiluetic
drugs, suggests that chaulmoogra damages the
bacterium and causes a release of substances
from the bacterium which stimulate the immune
processes of the body. While in a large propor-
tion of patients with the maculo-anesthetic vari-
ety of the disease there is a complete remission
of clinical evidence of the disease, it is as yet
uncertain whether the apparent cures are perma-
nent (Hollmann, Arch. Dermat. Syph., 1922. 5,
94; Hopkins and Faget, I. A.M. A., 1944, 126,
937). Schujman (Prensa mid. Argent., 1945, 32,
2159) reported that chaulmoogra was of definite
benefit in both tuberculoid and lepromatous cases
but that it could not be considered a fully satis-
factory therapeutic agent. Latapi {Prensa med.
Mexicana, 1946, 11, 1), however, reported very
little therapeutic value.

On the ground that the tubercle bacillus, like
the lepra micrococcus, is an acid-fast organism,
various investigators have experimented with
chaulmoogra oil in different types of tuberculosis.
No definite benefit has been demonstrated (for
literature see Fischl and Schlossberger, Handbook
of Chemotherapy, 1933, 1, 56). Sarmiento and

Part I

Hydnocarpus Oil, Ethyl Esters of 659

Mastronardi (Semana medica, 1948, 55, 569)
found local application of the oil to be beneficial
in tuberculous laryngitis. Stanley (Med. Ann.
District of Columbia, 1939, 8, 31) reported fa-
vorable results from chaulmoogra oil in chronic
arthritides. Chaulmoogra has been used as a
counterirritant application (30 per cent in lano-
lin) for bruises and sprains and as a local treat-
ment in various sores and inflammations of the
skin.

Toxicology. — Read (/. Pharmacol., 1924,
24, 221) studied the toxic effects of chaulmoogra
on dogs and rabbits. In the former, whether
given by mouth or by injection, it caused vomit-
ing and loss of appetite, which appeared to be
chiefly of central origin. Large doses also have
a marked hemolytic effect. In fatal intoxications
there were fatty changes of the liver and evi-
dences of irritation of the kidneys. In addition
to the irritation at the site of injection, vertigo,
substernal pain and a choking sensation are not
uncommon. Albumin and casts often appear in
the urine. Malaise, fever, anorexia, abdominal
pain and a burning sensation of the skin may
occur. Two cases of fatty embolism of the lung
were reported by Castel from hypodermic in-
jection.

Dose. — The usual dose is 0.3 ml. (about 5
minims) 3 times daily after meals orally, gradu-
ally increased to a total of 4 ml. (approximately
60 minims) daily.

Storage. — Preserve "in well-filled, tight, light-
resistant containers." N.F. IX.

INJECTION OF HYDNOCARPUS
OIL. B.P.

Injectio Olei Hydnocarpi

The B.P. defines the injection as hydnocarpus
oil sterilized by heating at 150° for a period suffi-
cient to ensure that the whole is maintained at
that temperature for one hour.

The official dose by intramuscular or subcu-
taneous injection is given as 2 ml. (approximately
30 minims), gradually increased to 5 ml. (approx-
imately 75 minims).

ETHYL ESTERS OF HYDNOCARPUS
OIL B.P., LP.

Oleum Hydnocarpi .ffithylicum

The B.P. defines Ethyl Esters of Hydnocarpus
Oil as a product consisting mainly of the ethyl
esters of chaulmoogric and hydnocarpic acids,
obtained by esterifying the fatty acids of hydno-
carpus oil with ethyl alcohol, or with industrial
methylated spirit, the crude product being
washed with a solution of sodium carbonate to
remove fatty acids, and finally purified by distil-
lation under reduced pressure. The LP. recog-
nizes, under the same title, a mixture of the ethyl
esters of chaulmoogric, hydnocarpic, and gorlic
acids and other fatty acids obtained from hydno-
carpus oil.

I.P. Aethylis Hydnocarpas. N.F. VIII. Ethyl Chaul-
moograte; iEthylis Chaulmoogras. Chaulmestrol {Win-
throp); Moogrol {Burroughs Wellcome). Chaulmoogri et
Hydnocarpi ^thylicum. Fr. Esters ethyliques des acides
de l'huile de chaulmoogra; Hyrganol. Sp. Chaulmugrato
de etilo.

The therapeutic activity of chaulmoogra oil
(including the B.P. hydnocarpus oil) appears to
reside in the characteristic component acids
known as chaulmogric and hydnocarpic acids.
The N.F. VIII recognized, under the title ethyl
chaulmoo grate, the mixed ethyl esters of all the
fatty acids of the oil, consisting principally of
ethyl chaulmoograte and ethyl hydnocarpate, but
including other esters as well. The B.P. product
differs from this only in limiting the source of
the acids (see under Hydnocarpus Oil), but is of
essentially the same composition.

Description and Tests. — The B.P. describes
the product as a colorless, or faintly yellow,
limpid oil, having a characteristic odor and a
slightly acrid taste. It is soluble, at 15.5°, in not
less than 6 volumes of 90 per cent alcohol; it is
miscible with solvent ether, with chloroform,
and with carbon disulfide. The constants are as
follows: Acid value, not greater than 1.0; iodine
value, between 88 and 94 (iodine monochloride
method); optical rotation, not less than +45°;
refractive index, at 20°, from 1.458 to 1.462;
saponification value, 190 to 196; weight per ml.,
at 20°, between 0.900 and 0.905.

Uses. — The therapeutic properties of ethyl
esters of hydnocarpus oil (ethyl chaulmoograte)
are those of chaulmoogra oil. The ethyl ester
preparation has the advantages over the oil of
being less objectionable to the taste and less irri-
tant when injected. Ethyl chaulmoograte has
some value in sarcoidosis (Schaumann's disease)
but corticotropin is a more useful therapeutic
agent.

Good results in the treatment of leprosy in the
Hawaiian Islands using intragluteal injections
starting at 1 ml. and increasing by 1 ml. every
second or third injection until a maximum dose
of 5 ml. is reached were reported by Hollmann
and Dean (Arch. Dermat. Syph., 1922, 5, 94).
Injections were given once or twice a week for
periods of 2 to 5 years, with suitable rest pe-
riods. Determinations of erythrocyte sedimenta-
tion rate should be made about every 2 weeks
and injections discontinued temporarily if the
rate is rapid. Intracutaneous injections of a mix-
ture of 75 parts of ethyl esters of hydnocarpus
oil, 1 part of creosote or thymol, and olive oil
to 100 parts were recommended by Cochrane
(Med. Press, May 9, 1945) for treatment of the
following: chronic tuberculoid leprosy, macular
lesions in neural leprosy, and lepromatous lep-
rosy. He employed a dose of 0.5 ml., increasing
by 0.5 ml. weekly until 5 ml. was administered.
From 6 to 12 punctures were made for each ml.
injected. The lesions are treated systematically,
avoiding the same area for a month or longer.
Simultaneous subcutaneous injections are advised
in lepromatous leprosy.

Orally the drug is administered in doses gradu-
ally increasing from ^ to 2 ml. three times daily
after meals with a lump of sugar and warm milk,
hot tea or carbonated water. In some patients
severe gastric irritation prevents continuation of
therapy.

Dose, either orally or by injection, from 0.3
to 5 ml. (approximately 5 to 75 minims).

Storage. — Preserve in a well-closed container,

660 Hydnocarpus Oil, Ethyl Esters of

Part I

protected from light, and stored in a cool place.
B.P.

INJECTION OF ETHYL ESTERS OF
HYDNOCARPUS OIL. B.P.

Injectio Olei Hydnocarpi jEthylici

This consists of the B.P. Ethyl Esters of
Hydnocarpus Oil sterilized by heating to 150°
for a period sufficient to ensure that the whole
is maintained at that temperature for one hour.
For uses, see the preceding monographs.

HYDRASTIS. N.F.

Goldenseal, [Hydrastis]

"Hydrastis consists of the dried rhizome and
root of Hydrastis canadensis Linne (Fam.
Ranuncidacece) . Hydrastis yields not less than
2.5 per cent of the anhydrous ether-soluble alka-
loids of Hydrastis." N.F.

Golden Seal; Hydrastis Rhizome; Yellow Root; Orange
Root; Yellow Puccoon; Indian Turmeric; Eye Balm; Eye
Root. Rhizoma Hydrastis; Radix Hydrastidis. Fr. Hydrastis.
Ger. Hydrastisrhizome; Gelbwurzel; Goldsiegelwurzel; Blut-
krautwurzel. It. Idraste. Sp. Rizoma de hidrastis.

Hydrastis canadensis was known to the Chero-
kee Indians long before the discovery of America.
They employed its underground portion alike for
dyeing and as an internal remedy and made the
early settlers acquainted with most of its valuable
properties. It is a small, herbaceous, perennial
plant, with a thick, fleshy, yellow rhizome, from
which numerous long rootlets arise, and an erect,
simple, pubescent stem from six inches to a foot
or more in height. There are usually but two
leaves, which are unequal, one sessile at the top
of the stem, the other attached to the stem a short
distance below by a thick roundish footstalk,
causing the stem to appear as if bifurcate near
the summit. The leaves are pubescent, rounded-
cordate, with from three to seven, but generally
five, lobes, which are pointed and unequally ser-
rate. A solitary greenish-white flower stands upon
a peduncle rising from the base of the upper leaf.
It is without corolla, but with a greenish-white
calyx, the sepals of which closely resemble petals,
and are very caducous, falling very soon after the
flower has expanded. The fruit is a globose, com-
pound crimson berry, half an inch or more in
diameter, composed of many fleshy carpels, each
tipped with a short curved beak, and containing
one or rarely two seeds. The plant is native to
moist, rich woodlands of eastern North America,
and at one time was abundant in the territory
bordering the Ohio River from Illinois to Vir-
ginia. Most of the wild growing plants are now
nearly exterminated, a few stands persisting in
West Virginia, Ohio, Kentucky and Indiana. The
fruit bears a close resemblance to the raspberry,
but is not edible. The Indians employed it for
cuticle staining and dyeing their garments yellow
under the name of yellow puccoon, and it is said
to impart a rich and permanent yellow, and with
indigo a fine green, to wool, silk, and cotton.
There is but one other species of Hydrastis known
— viz., H. jezoensis Sieb. et Zucc. which is found
in northern Japan.

As the natural supplies of hydrastis are becom-

ing limited many experiments in the cultivation of
hydrastis have been made. It can be grown from
cuttings of the rhizome and from seed. It further-
more can be grown with the natural shade of the
woodlands or by means of artificial shade. The
important articles on the cultivation of hydrastis
are: Van Fleet and Klugh, Circ. No. 6, Bureau
of Plant Industry, U. S. Department of Agricul-
ture; Baldwin, Am. J. Pharm., 1913, p. 147, and
Hirose and Langenhan (/. A. Ph. A., 1930, 19,
349). Most of the commercial supplies are now
obtained from cultivated plants. The most ex-
tensive area of hydrastis cultivation is the Skagit
Valley farm in Washington, which is stated to
account for 60 per cent of the total cultivated
production of golden seal root in the United
States. Small collections are made in West Vir-
ginia, Tennessee, North Carolina, Ohio, Kentucky
and Indiana.

Description. — "Unground Hydrastis shows a
flexuous, subcylindrical rhizome, from 1 to 5 cm.
in length and from 2 to 10 mm. in thickness;
more or less annulate and wrinkled longitudinally;
brown to dusky yellowish orange; marked by
numerous stem-scars or occasional stem or leaf
bases and numerous roots, the latter frequently
broken, leaving circular yellowish brown to yellow
scars or short protuberances. The fracture is short
and waxy. The roots are numerous, filiform, up
to 35 cm. in length and 1 mm. in diameter; curved,
twisted, and matted together or broken. The frac-
ture is short and brittle, and the roots and rhi-
zomes are weak yellowish orange to moderate
greenish yellow internally. Hydrastis has a dis-
tinctive odor and a bitter taste." N.F. For his-
tology see N.F. X.

"Powdered Hydrastis is dark yellow to moder-
ate greenish yellow. It shows fragments of starch-
bearing parenchyma and fibrovascular bundles;
small tracheae with simple pores or spiral thicken-
ings; lignified fibers from 200 to 300 n in length
with thin walls and simple pits; fragments of
tabular-celled cork, and numerous starch grains
from 2 to 15 ji in diameter, nearly spherical,
mostly simple, a few 2- to 6-compound, the larger
grains showing a central cleft. Calcium oxalate
crystals are absent." N.F.

Standards and Tests. — Identification. — (1)
When moistened with water and mounted in sul-
furic acid, hydrastis exhibits formation of numer-
ous acicular crystals, some attaining a length of
200 n. (2) When viewed in ultraviolet light,
filtered through a Corex No. 986 or equivalent
filter, broken or abraded surfaces of hydrastis
exhibit a brilliant yellow fluorescence. Foreign
organic matter. — Not over 4 per cent. Acid-
insoluble ash. — Not over 3 per cent. N.F.

Gillis and Langenhan reported extensive phyto-
chemical studies of hydrastis (J. A. Ph. A., 1931,
20, 210 and 339).

Assay. — A 10-Gm. sample of hydrastis, in fine
powder, is macerated with 100 ml. of ether in the
presence of ammonia, and the alkaloids in 50 ml.
of the ether solution extracted with 1 per cent sul-
furic acid. The acid solution is made ammoniacal
and the alkaloids transferred to ether; extraction
with which is continued until a 5-ml. portion of
the last portion leaves a residue of not more than

Part I

Hydriodic Acid, Diluted 661

0.6 mg. ; the combined ether extract are filtered,
evaporated and the residue dried at 105° for 2
hours. Specifications of the final extraction with
ether have been developed with a view to limiting
the amount of berberine extracted to a small
amount; the residue by this method consists
chiefly of hydrastine. For details of the develop-
ment of this assay see Copley, Bull. N. F. Com.,
1946, 14, 149; also Bull. N. F. Com., 1944, 12,
169; 1945, 13, 125.

Constituents. — Hydrastis contains — besides
albumen, starch, fatty matter, resin, yellow color-
ing matter, sugar, lignin, and various salts — three
alkaloids: hydrastine (see under Hydrastine Hy-
drochloride), berberine (see under Berberis) and
canadine. Berberine is usually the most abundant,
commonly being present in proportions of from
2 to 4 per cent.

Canadine was discovered by E. Schmidt in
1888. Gadamer (Arch. Pharm., 1901, 239, 648)
demonstrated that canadine from Hydrastis is
levorotatory tetrahydroberberine. The alkaloid
discovered by Hale, and obtained later by Burt
and by Lerchen, and which was named xantho-
puccine, is considered to be identical with cana-
dine.

Adulterants. — Because of the high price usu-
ally commanded by hydrastis the temptation to
adulteration is very strong. Among the adulter-
ants which have been reported are the berberine-
containing rhizomes of Coptis teeta, Xanthorrhiza
simplicissima, Poeonia officinalis, all of the Ranun-
culacecB, and also the Jeffersonia diphylla (L.)
Pers., commonly called Twin Leaf. For further
account of the adulterants of this drug see Blague
and Maheu, Bull. sc. Pharmacol., 1926, 33, 375.
Uses. — The effects of hydrastis are, probably,
chiefly those of hydrastine and, to a lesser extent,
of berberine; canadine is of minor importance.

Summarizing his review of the literature per-
taining to the pharmacology and therapeutics of
hydrastis and its alkaloids Shideman (Bull. N.F.
Com., 1950, 18, 3) states as follows: (1) Hy-
drastis appears to have little effect on the central
nervous system unless given in toxic doses, when
it produces convulsions; (2) parenteral adminis-
tration of the fluidextract produces little or no
effect in the possible therapeutic dose range
unless it is given intravenously when hypotension
results, this hypotensive action being probably
due to a direct myocardial depressant effect of
the crude drug; (3) although no conclusions may
be drawn in regard to its uterine action, all re-
ported results agree that it produces depression
of intestinal smooth muscle.

Clinical usage of hydrastis is based largely on
empiric observations; the available evidence is
sometimes conflicting and in other instances sug-
gests the uncertainty and variability of the effects
produced by the drug. Hydrastis has been em-
ployed to check internal hemorrhage, as a bitter
stomachic, and locally in the treatment of "ca-
tarrhal" conditions, particularly of the genito-
urinary tract. If it is true, as has been claimed,
that hydrastis increases the tonus and excites
rhythmic contractions of the uterus it is conceiv-
able that it exercises a uterine hemostatic effect
through compression of blood vessels.

Dose, of hydrastis, from 1 to 2 Gm. (approxi-
mately 15 to 30 grains).

HYDRASTIS FLUIDEXTRACT. N.F.

Goldenseal Fluidextract, [Fluidextractum Hydrastis]

"Hydrastis Fluidextract yields, from each 100
ml., not less than 2.25 Gm. and not more
than 2.75 Gm. of the ether-soluble alkaloids of
hydrastis." N.F.

Extractum Hydrastis Fluidum. Fr. Extrait fluide d'hy-
drastis. Get. Hydrastisfluidextrakt. It. Estratto fluido
di idraste. Sp. Extracto de hidrastis, fluido.

Prepare the fluidextract from hydrastis, in mod-
erately coarse powder, by Process A, as modified
for assayed fluidextracts (see under Fluidex-
tracts), using a menstruum of 2 volumes of alco-
hol and 1 volume of water. Macerate the drug
during 48 hours, then percolate slowly. Adjust the
concentrated liquid to contain, in each 100 ml.,
2.5 Gm. of the ether-soluble alkaloids of hydrastis,
and 54 per cent, by volume, of C2H5OH. N.F.

Alcohol Content. — From 51 to 57 per cent,
by volume, of C2H5OH. N.F.

This preparation is probably equivalent to
hydrastis in therapeutic activity. The dose is 2 ml.
(approximately 30 minims).

Storage. — Preserve "in tight, light-resistant
containers and avoid exposure to direct sunlight
or to excessive heat." N.F.

DILUTED HYDRIODIC ACID. N.F.

[Acidum Hydriodicum Dilutum]

"Diluted Hydriodic Acid is a solution contain-
ing, in each 100 ml., not less than 9.5 Gm. and
not more than 10.5 Gm. of HI. and not less
than 600 mg. and not more than 1.0 Gm. of
HPH2O2. "Caution.— Diluted Hydriodic Acid
must not be dispensed or used in the preparation
of other products if it contains free iodine." N.F.

Sp. Acido Yodhidrico Diluido.

Hydriodic acid, discovered by Clement and
Desormes in 1813, may be prepared in a num-
ber of ways. The usual method consists in passing
hydrogen sulfide into an aqueous suspension of
iodine until the latter has been consumed in the
following reaction:

H2S + I2 -» 2HI + S

The precipitated sulfur is removed by filtration,
and excess hydrogen sulfide expelled by heating
the filtered hydriodic acid. Purification is effected
by distillation. Another method of preparation
involves hydrolysis of phosphorus triiodide, which
is made by direct combination of red phosphorus
and iodine. Hydriodic acid may also be formed
by direct combination of hydrogen and iodine,
using a palladium or platinum catalyst.

The U.S. P. formerly specified a process for pre-
paring a 10 per cent acid. In that method potas-
sium iodide was reacted in molecular proportions
with tartaric acid in a hydroalcoholic medium.
Potassium bitartrate, relatively insoluble in the
solvent, precipitated, leaving hydrogen iodide dis-
solved :

662 Hydriodic Acid, Diluted

Part I

2KI + 2H2C4H4O6 -> 2KHC4H4O0 + 2HI

The solubility of the bitartrate was further de-
creased by cooling. After filtering the solution,
heating it to expel alcohol, and adjusting to the
proper strength by dilution, hypophosphorous acid
was added as a preservative.

As Husa has pointed out (/. A. Ph. A., 1931,
20, 759) the official acid may be made from
hydriodic acid now commercially available as a
forty-five per cent acid. This commercial acid is
also preserved by hypophosphorous acid.

Constant boiling hydriodic acid boils at 127°
under a pressure of 774 mm., has a specific gravity
of 1.708 and contains 57.0 per cent HI.

Description. — "Diluted Hydriodic Acid is a
colorless or not more than pale yellow, odorless
liquid. Its specific gravity is about 1.1." U.S. P.

Standards and Tests. — Identification. — Di-
luted hydriodic acid responds to tests for iodide.
Residue on ignitiqn. — Not over 100 mg. of resi-
due from 5 ml. of the acid. Chloride. — The limit
is 700 parts per million. Free iodine. — Addition
of starch T.S. to diluted hydriodic acid produces
no blue color. Sulfate. — The limit is 90 parts
per million. Arsenic. — The limit is 0.4 part per
million. Barium. — No turbidity develops on add-
ing diluted sulfuric acid to diluted hydriodic
acid. Heavy metals. — The limit is 10 parts per
million. Limit of hypophosphorous acid. — 5 ml.
of diluted hydriodic acid is treated with hydrogen
peroxide solution, which oxidizes the hydriodic
acid to iodine and the hypophosphorous acid to
phosphoric acid. The mixture is heated to vola-
tilize the iodine, and the phosphoric acid is pre-
cipitated as ammonium phosphomolybdate ; the
amount of the latter is determined by dissolving
it in a measured excess of 0.5 N sodium hydroxide
and titrating the excess alkali with 0.5 N sulfuric
acid. U.S.P.

Assay for hydriodic acid. — The Volhard
method is employed in determining the concentra-
tion of hydriodic acid; an excess of 0.1 N silver
nitrate is added to 5 ml. of diluted hydriodic acid,
the mixture heated until the precipitate has a
bright yellow color and, after cooling, the residual
silver nitrate is estimated by titration with 0.1 N
ammonium thiocyanate using ferric ammonium
sulfate T.S. as indicator. Each ml. of 0.1 N silver
nitrate represents 12.79 mg. of HI.

Incompatibilities. — Diluted hydriodic acid is
incompatible with oxidizing agents in general,
such as chlorates, nitrates, permanganates, hy-
drogen dioxide, etc., which liberate iodine. It is
also incompatible with salts of mercury, bismuth,
and cupric and ferric salts.

Uses. — Diluted hydriodic acid was introduced
into use as a medicine by Andrew Buchanan, of
Glasgow. The acid is capable of producing the
effects of iodide ion, but its acidity is a serious
objection to the use of the large amounts which
would be required. An additional objection is its
instability. In the form of the syrup it is used
for its expectorant effect.

The acid has been given in doses of 0.6 to 1.3
ml. (approximately 10 to 20 minims) three times
daily, well diluted.

Storage.-^'Preserve "in tight containers, at a
temperature not above 30°." N.F.

HYDRIODIC ACID SYRUP. N.F.

[Syrupus Acidi Hydriodici]

"Hydriodic Acid Syrup contains, in each 100
ml., not less than 1.3 Gm. and not more than 1.5
Gm. of HI." N.F.

Mix 140 ml. of diluted hydriodic acid with 550
ml. of purified water, and dissolve 450 Gm. of
sucrose in this mixture by agitation. Add enough
purified water to make 1000 ml. and filter. N.F.
It is a known fact that in the absence of hypo-
phosphorous acid aqueous solutions of hydriodic
acid do not liberate free iodine if sucrose is pres-
ent; this is because the dextrose produced by the
inversion of sucrose in the acid medium reduces
any free iodine that may be produced. But such
solutions do show discoloration because of decom-
position of the levulose formed by the inversion;
the same reaction occurs also in the official syrup
made with diluted hydriodic acid containing hypo-
phosphorous acid. Since the latter effectively
stabilizes hydriodic acid against the liberation of
iodine it is apparent that the use of sucrose for
this purpose is unnecessary. Husa and Klotz (/. A.
Ph. A., 1935, 24, 45) accordingly investigated the
possibility of using dextrose, which does not pro-
duce the discoloration observed with levulose, as
the means of conferring the properties of a syrup
on this preparation; they found that greatly in-
creased stability results if sucrose is replaced by
700 Gm. per liter of dextrose. Ewing and Graves
(Bull. N. F. Com., 1951, 19, 102) found the
formula of Husa and Klotz to be the most stable
of many which have been proposed; the former
recommended, however, a syrup containing 600
Gm. of dextrose per liter as more nearly approxi-
mating the specific gravity, viscosity and sweet-
ness of the official syrup. Ewe (/. A. Ph. A., 1931,
20, 360) reported that replacement of the sugar
with glycerin also produces a permanent colorless
preparation.

Description. — "Hydriodic Acid Syrup is a
transparent, colorless, or not more than pale,
straw-colored, syrupy liquid. It is odorless and has
a sweet, acidulous taste. Hydriodic Acid Syrup
has a specific gravity of about 1.18." N.F.

Standards and Tests. — Identification. — On
mixing 5 ml. of hydriodic acid syrup with a few
drops of starch T.S. and adding 3 drops of chlo-
rine T.S. the liquid acquires a deep blue color.
Free iodine. — No blue color is produced in hy-
driodic acid syrup by starch T.S. U.S.P.

Assay. — A 25-ml. portion of hydriodic acid
syrup is assayed by the method described in the
preceding monograph. U.S.P.

Incompatibilities. — Hydriodic acid syrup is
decomposed by oxidizing agents which liberate
from it elemental iodine. When used as a vehicle
for a high concentration of a codeine salt precipi-
tation, probably of a codeine hydriodide, may
occur, especially at lower temperatures.

Uses. — Hydriodic acid syrup possesses the
general therapeutic properties of the iodides, when
used in a sufficient dose. As it contains 1.4 per

Part I

Hydrochloric Acid 663

cent w/v of absolute hydriodic acid, for practical
purposes a teaspoonful may be considered to rep-
resent somewhat more than 60 mg. (approxi-
mately 1 grain) of potassium iodide. It is evident
that the doses in which it is usually administered
are too small. The syrup is frequently employed
as an expectorant vehicle. It should be well diluted
at the time of administration, to prevent the possi-
bility of injury to teeth.

Dose, from 4 to 8 ml. (approximately 1 to 2
fluidrachms) .

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 25°." N.F.

HYDROCHLORIC ACID.
U.S.P., B.P., LP.

[Acidum Hydrochloricum]

"Hydrochloric Acid contains not less than 35
per cent and not more than 38 per cent, by
weight, of HC1." U.S.P. The B.P. and LP. rubrics
are the same.

Muriatic Acid; Chlorhydric Acid. Acidum Muriaticum;
Acidum Chlorhydricum Solutum Depuratum; Acidum Hy-
drochloratum. Fr. Acide chlorhydrique officinal; Acide
chlorhydnque pur; Solution aqueuse officinale d'acide chlor-
hydrique. Ger. Salzsaure ; Chlorwasserstoffsaure. It. Acido
cloridrico. Sp. Acido clorhidrico; Acido hidroclorico.

Hydrochloric acid, an important normal con-
stituent of the gastric juice of all mammals, occurs
also in volcanic exhalations and in the waters of
streams in volcanic regions.

The acid was originally described by Valentine
in the 15th century. He obtained it by distilling
a mixture of sodium chloride and ferrous sulfate,
calling the distillate spirit of salt.

For years hydrochloric acid was obtained on a
commercial scale as a by-product of the LeBlanc
process for the production of alkali from common
salt. Sodium chloride, when reacted with sulfuric
acid, produces sodium sulfate and hydrogen chlo-
ride gas. The former was used to produce sodium
hydroxide by suitable reactions and the latter,
when absorbed in water, formed hydrochloric
acid. At the time when this process was important
economically, the production of hydrochloric acid
exceeded the consumption and methods were de-
vised by Weldon and Deacon for converting the
acid into chlorine gas which in turn was used
chiefly in the production of bleaching powder.

The alkali industry, however, has undergone
considerable change and the LeBlanc process is
operated only for the production of "salt-cake"
(sodium sulfate) which is used chiefly in the glass
and paper pulp industries. The major portion of
the hydrochloric acid of commerce is no longer a
by-product of this process.

Alkalies are manufactured at the present by the
Solvay process and by the electrolytic process.
The latter method consists in passing an electric
current through a solution of common salt. So-
dium hydroxide solution forms at the negative
electrode (the cathode) as hydrogen gas is
evolved, and chlorine gas is liberated at the posi-
tive electrode (anode). The two elements con-
stituting hydrogen chloride are thus the by-prod-
ucts of the electrolytic alkali process. Much of
the acid of commerce is now made by direct union

of the elements by the burning of chlorine in
hydrogen. Special types of burners, which re-
semble Bunsen burners, are used; and two pro-
cedures may be followed: one in which the burn-
ing is conducted with an excess of hydrogen which
is regained after absorption of the hydrogen chlo-
ride, and the other in which the excess hydrogen
is allowed to burn in air. The latter procedure is
free from the dangers of explosion. Ihe hydrogen
chloride so produced is of a high degree of purity
and hydrochloric acid of reagent grade may be
prepared. This fact, in itself, is a decided advan-
tage since the hydrochloric acid of the LeBlanc
process is frequently contaminated, particularly
with arsenic compounds which are derived from
the sulfuric acid used in the reaction. Other meth-
ods for the manufacture of hydrochloric acid in-
clude its production from chlorine and steam,
using iron compounds as catalysts; it is also ob-
tained as a by-product in the chlorination of
hydrocarbons such as pentane and benzene.

Constant boiling hydrochloric acid boils at 110°,
at a pressure of 760 mm., and has a specific
gravity of 1.10 and a content of 20.24 per cent
of hydrogen chloride. Its composition remains
unchanged on evaporation under normal atmos-
pheric pressure; solutions containing less than
20.24 per cent HC1 become stronger on evapora-
tion, those containing more HC1 become weaker
until, in both cases, the composition correspond-
ing to that of the constant boiling acid is reached.

Description. — "Hydrochloric Acid is a color-
less, fuming liquid having a pungent odor. The
fumes and odor of the Acid disappear when it is
diluted with 2 volumes of water. It is acid to
litmus even when highly diluted. The specific grav-
ity of Hydrochloric Acid is about 1.18." U.S.P.

Standards and Tests. — Identification. — Hy-
drochloric acid responds to tests for chloride.
Residue on ignition. — Not over 2 mg. of residue
remains when 20 ml. of hydrochloric acid is evapo-
rated to dryness and ignited after adding 2 drops
of sulfuric acid. Bromide or iodide. — Addition of
chlorine T.S. to a dilute solution of hydrochloric
acid does not liberate bromine or iodine, as evi-
denced by failure to produce a yellow, orange or
violet color in chloroform. Free bromine or chlo-
rine.— No violet color is produced in chloroform
when the latter, together with potassium iodide
T.S., is added to a dilute hydrochloric acid solu-
tion. Sulfate. — No turbidity or precipitate forms
in an hour on adding barium chloride T.S. to a
dilute hydrochloric acid solution. Sulfite. — Neither
turbidity nor decoloration of iodine results when
0.1 N iodine is added to the liquid from the pre-
ceding test. Arsenic. — The limit is 0.6 part per
million. Heavy metals. — The limit is 5 parts per
million. U.S.P.

Pure hydrogen chloride is a colorless gas pos-
sessing a very pungent odor. Under a pressure of
40 atmospheres, and at a temperature of 10°, it
changes to a transparent liquid.

Muriatic acid, thus named by Priestley (from
murum, the old name of chlorine, which in turn
was derived from the Latin murias, brine), is a
commercial form of hydrochloric acid. It has a
yellowish color from the presence of ferric chlo-

664 Hydrochloric Acid

Part I

ride, or of a minute proportion of organic matter,
such as cork, wood, etc. It usually contains traces
of sulfuric acid, sometimes free chlorine and
nitrous acid, and other impurities. It is much used
industrially but is entirely unfit for medicinal use.

Assay. — A 3-ml. sample of hydrochloric acid
is weighed in distilled water, and the acid titrated
with 1 A' sodium hydroxide, using methyl red T.S.
as indicator. Each ml. of 1 N sodium hydroxide
represents 36.46 mg. of HC1. U.S.P.

Uses. — Hydrochloric acid is used medicinally
only in the form of diluted hydrochloric acid (see
the following monograph).

Toxicological Properties. — Hydrochloric
acid is highly irritating and corrosive, but less so
than sulfuric or nitric acid. When swallowed it
produces hiccough, retching, and agonizing pain
in the stomach. There is much thirst, with great
restlessness, a dry and burning skin, and a small
pulse. At first white vapors having a pungent odor
will be emitted from the mouth. The best anti-
dote is milk of magnesia; sodium bicarbonate is
dangerous because the large quantity of CO2 gas
evolved in reacting with the acid may cause
perforation and peritonitis. In the course of the
treatment, bland and mucilaginous drinks must be
freely given. Milk, egg-white and gruel may be
employed as demulcents.

Schwartz (Arch. Dermat. Syph., 1944, 50, 25)
reported acute dermatitis with melanosis, photo-
sensitization and chloracne due to industrial ex-
posure to hydrochloric acid.

Storage. — Preserve "in tight containers."
US.P.

DILUTED HYDROCHLORIC ACID.
N.F. (B.P., LP.)

[Acidum Hydrochloricum Dilutum]

"Diluted Hydrochloric Acid contains, in each
100 ml., not less than 9.5 Gm. and not more than
10.5 Gm. of HC1." N.F. Both the B.P. and the
LP. require for Dilute Hydrochloric Acid a 10
per cent w, w content of HC1 (limits, 9.5 to 10.5) ;
this is somewhat more concentrated than the
U.S. P. preparation, which is calculated on a w/v
basis.

B.P., LP. Dilute Hydrochloric Acid. Acidum Chlor-
hydricum Dilutum; Acidum Hydrochloratum Dilutum. Fr.
Acide chlorhydrique dilue ; Solution aqueuse, au dixieme,
d'acide chlorhydrique. Ger. Verdunnte Salzsaure. It. Acido
cloridrico diluito. Sp. Acido clorhidrico diluido.

Diluted hydrochloric acid may be prepared by
mixing 234 ml. of hydrochloric acid with sufficient
purified water to make 1000 ml. N.F.

Description. — '"Diluted Hydrochloric Acid is
a colorless, odorless liquid. Its specific gravity is
about 1.05." N.F.

The standards, tests, and assay are the same as
those described under Hydrochloric Acid, allow-
ance being made for the difference in concentra-
tion.

Uses. — Action. — Hydrochloric acid is secreted
by the glands of the stomach; it is essential for
the activation of pepsinogen. Cannon showed that
free acid in the pyloric portion of the stomach
leads to a relaxation of the pylorus and that when
the duodenal contents have become acid through

discharge of the gastric contents there is a clos-
ing of this orifice. Moreover, hydrochloric acid
forms with the duodenal mucous membrane a
hormone known as secretin, and perhaps also
others (Ivy, Fhila. Med., 1944, 40, 467; which
stimulate the pancreas. In some cases of gastric
indigestion, and probably also of intestinal indi-
gestion, the cause of the disturbance is a diminu-
tion in the amount of hydrochloric acid secreted.

Achlorhydria. — The most important use of
hydrochloric acid in medicine is in the treatment
of the achlorhydria or hypochlorhydria gastrica
in atrophic gastritis, primary pernicious anemia,
superficial gastritis, etc. It may improve the di-
gestion, and thereby the nutrition in chronic
febrile diseases, such as phthisis and undulant
fever, during convalescence from acute illnesses
and in other forms of malnutrition. With the
advent of specific antibacterial therapy and the
shortening of most febrile illnesses, the increased
knowledge of nutrition, and the availability of
parenteral solutions and vitamins, slow convales-
cence and prolonged secondary malnutrition are
much less common in medical practice. The need
for, and hence the use of, non-specific digestive
aids has become infrequent. Achlorhydria gas-
trica is found in about 4 per cent of young adults
and in from 25 to 30 per cent of persons after
45 years of age (Ann. Int. Med., 1939, 12, 1940).
Despite the absence of free hydrochloric acid in
the gastric juice, even after the hypodermic in-
jection of histamine, many of these persons ex-
perience no digestive symptoms. In a study of
210 patients with achlorhydria, Bockus et al.
{Am. J. Med. Sc, 1932, 184, 185) observed in-
termittent diarrhea in 10 per cent, constipation
in 35 per cent, and an abnormally rapid rate of
gastric emptying in 40 per cent. Upper abdominal
distress after meals, simulating the symptoms of
peptic ulcer, may be associated with achlorhydria.
Failure of the gall bladder (atonic biliary dys-
kinesia) or the pancreas to function normally has
been demonstrated in some of these patients. In
the majority of patients, diarrhea or the other
symptoms are relieved by administration of di-
luted hydrochloric acid. The acid combines rapidly
with food and does not remain as "free acid."
To produce an acidity sufficient to activate pep-
sinogen (pH 2 or less) or to approach the usual
acidity of 0.2 to 0.3 per cent hydrochloric acid
in the gastric juice during digestion often re-
quired impractical doses of as much as 35 ml. of
diluted hydrochloric acid (Ann. Int. Med., 1943,
18, 182). On this basis the frequently prescribed
and often effective doses of 5 to 10 drops seem
futile.

Pernicious Anemia. — Numerous authors con-
cur in the value of hydrochloric acid in pernicious
anemia. It is not obvious how the drug acts but
clinical experience indicates its value, if given in
sufficient doses, in the relief of dyspeptic symp-
toms which persist despite adequate dosage of
liver (Med. Clin. North America, 1945, 28, 229).
In some patients use of diluted hydrochloric acid
aggravates, or may actually induce, dyspeptic
symptoms. It should be prescribed for all cases
showing evidence of combined sclerosis of the
spinal cord. Otherwise, it is prescribed only for

Part I

Hydrocortisone 665

patients with persisting dyspeptic symptoms de-
spite correction of the anemia. The dose of 2 to
8 ml. should be diluted with 200 to 250 ml. of
cold water or citrus fruit juice and sipped through-
out the meal rather than taken at one time. To
avoid the effect of acid on the teeth, a straw
should be used. Some deny the efficacy of this
therapy {Ann. Int. Med., 1944, 74, 45).

Antiseptic Action. — Hydrochloric acid, like
other strong acids, is actively germicidal. Loessl
{Zentralbl. Chir., 1929, 56, 2762) recommended
a 1 in 20,000 solution as a surgical antiseptic. He
claimed this solution to be non-irritating and
clinically superior to the surgical solution of
chlorine. Meyer and Vicher {Arch. Surg., 1943,
47, 468) found a 0.5 per cent solution to be an
efficient germicide on the skin. Mellanby {Brit.
M. J., 1942, 2, 1) reported that the treatment of
scabies with sodium thiosulfate and hydrochloric
acid was troublesome and unsatisfactory.

Miscellaneous Uses. — In 1931 Ferguson
stated that the intravenous injection of hydro-
chloric acid stimulated leukocytosis and was val-
uable in the treatment of various infections. The
reaction is probably of the same type as that
which follows the injection of foreign proteins
(for literature, see J.A.M.A., 1934, 102, 535).
McGilvra asserted that the intravenous injection
of a few drops of diluted hydrochloric acid
causes rapid recovery from anesthesia. Sham-
baugh and Boggs {J. A.M. A., 1934, 102, 1292),
however, were unable to demonstrate any effect
of the acid in narcosis of ether, tribromethanol,
or pentobarbital. lY]

The usual dose of diluted hydrochloric acid is
4 ml. (approximately 1 fluidrachm), with a range
of 0.6 to 8 ml.; the dose should be well diluted.

Storage. — Preserve "in tight containers." N.F.

HYDROCORTISONE. U.S.P.

17-Hydroxycorticosterone; A4-Pregnene-1 1/5,1 7a, 21 -triol-3,-
20-dione. Kendall's Compound F. Reichstein's Substance
M. Cortef (Upjohn); Hydrocortone (Sharp & Dohme).

The isolation of hydrocortisone from adrenal
glands and the possibility that it is the predomi-
nant glycocorticoid secreted by the mammalian
adrenal cortex is discussed under Uses, in this
monograph. It has been produced commercially
by biosynthesis from minced hog adrenals, which
are sprayed with desoxycorticosterone (prepared
from vegetable steroids), aerated, and incubated,
after which hydrocortisone and other hormones
are extracted (see Chem. Eng. News, 1951, 29,
4000). It may also be prepared by synthesis, by
one method being prepared in 7 steps from 20-
cyano-17-pregnene-21-ol-3,ll-dione (see Wendler
et al., J.A.C.S., 1950, 72, 5793; also Sarett, ibid.,
1948, 70, 1454).

Hydrocortisone differs structurally from corti-
sone in that the ketone group at carbon atom 11
in cortisone has been reduced to an alcohol
group, thereby adding two atoms of hydrogen,
for which reason the reduced product is called
hydrocortisone.

Description. — "Hydrocortisone is a white to
practically white, odorless, crystalline powder.
Hydrocortisone is insoluble in water. One Gm.
dissolves in 40 ml. of alcohol and in about 80 ml.
of acetone. It is slightly soluble in chloroform, and
practically insoluble in ether. Hydrocortisone
melts between 212° and 220°." U.S.P.

The solubility of hydrocortisone (free alcohol)
has been reported by Macek et al. {Science, 1952,
116, 399) to be as follows: in water, 0.28 rug.
per ml.; in human plasma, 0.70 mg. per ml.; in
human synovial fluid, 0.25 mg. per ml. The cor-
responding solubilities of hydrocortisone acetate
are 0.01 mg., 0.02 mg., and 0.04 mg., per ml.,
respectively, in the liquids mentioned.

Standards and Tests. — Identification. — (1)
On heating a methanol solution of hydrocortisone
with a sulfuric acid solution of phenylhydrazine
a yellow color is produced. (2) A solution of 2
mg. of hydrocortisone in 2 ml. of sulfuric acid
has a yellow to brownish yellow color with a
green fluorescence (cortisone acetate gives a
colorless solution at first, becoming yellow in
about a minute, but shows no green fluorescence).
Specific rotation. — Not less than +150° and not
more than +156°, when determined in a dioxane
solution containing 100 mg. in 10 ml. and calcu-
lated on the dried basis. Absorptivity. — The ab-
sorptivity (1%, 1 cm.) at 242 mn, determined
in a methanol solution containing 0.01 mg. of
hydrocortisone in each ml. but calculated on the
dried basis, is between 428 and 450. Loss on dry-
ing.— Not over 1 per cent, when dried in vacuum
at 100° for 4 hours. Residue on ignition. — The
residue from 100 mg. is negligible. U.S.P.

Uses. — The glycocorticoid hormone hydro-
cortisone has qualitatively the same actions and
uses as cortisone. Both the free alcohol and the
acetate of hydrocortisone are used medicinally;
the acetate has the advantage of greater chemical
stability but the disadvantage, apparently arising
from its substantially smaller solubility in aqueous
media and hence probable lesser absorption, of
being considerably less potent than hydrocor-
tisone when administered orally. Hydrocortisone
(the free alcohol) is therapeutically active when
given orally, being more effective than cortisone
acetate; hydrocortisone acetate, on the other
hand, is considerably less effective than hydro-
cortisone (alcohol form) and somewhat less effec-
tive than cortisone acetate, the comparison of
these substances being on the basis of oral ad-
ministration in each case. Moreover, hydrocor-
tisone acetate is practically unabsorbed and in-
effective when administered intramuscularly.
When required for acute crises of adrenal insuffi-
ciency in Addison's disease or during surgical
adrenalectomy procedures intravenous adminis-
tration of the alcohol form of hydrocortisone pro-
vides the most rapid and effective dosage form
of glycocorticoid action. For topical application
to the conjunctiva, skin and synovial cavities

666 Hydrocortisone

Part I

hydrocortisone acetate not only possesses greater
inherent therapeutic activity than cortisone ace-
tate but its low solubility and slow absorption
enhance its local action.

Isolation and Occurrence. — Hydrocortisone
was isolated from adrenal tissue by Reichstein
(Helv. chim. acta, 1937, 20, 953), Mason et al.
(J. Biol. Chetn., 1938, 124, 459), and Kuizenga
and Cartland (Endocrinology, 1939, 24, 526). It
was isolated from the urine of a patient with
Cushing's syndrome (Mason and Sprague, J. Biol.
Chem., 1948, 175, 451) and also from normal
human urine (Schneider, ibid., 1952, 199, 235).
It is the principal corticoid found in perfusates
of isolated beef adrenal gland (Hechter et al.,
Recent Progress in Hormone Research, 1951, 6,
215) and in adrenal venous blood in vivo (Reich
et al., J. Biol. Chem., 1950, 187, 411; Bush,
/. Endocrinol., 1953, 9, 95), and in peripheral
blood (Savard et al., Endocrinology, 1952, 50,
366). Hence there is reason to believe that hydro-
cortisone is the predominant glycocorticoid se-
creted by the mammalian adrenal cortex. Of the
13 ± 6 micrograms of 17-hydroxy corticosteroids
per 100 ml. of plasma found in normal humans
(Bliss et al., J. Clin. Inv., 1953, 32, 818) the
predominant constituent is hydrocortisone. In pa-
tients with Addison's disease no 17-hydroxy-
corticosteroids can be demonstrated in blood
plasma, while in cases of Cushing's syndrome the
concentration is increased above the normal range
(Perkoff et al., Arch. Int. Med., 1954, 93, 1). In
a variety of other diseases, including disorders of
other endocrine glands, the content of 17-hydroxy-
corticosteroids is within the normal range except
during the hours just before death. In normal
individuals the concentration of these steroids is
highest in the morning and decreases during the
day.

Absorption. — Certain aspects of absorption
have been referred to in the opening paragraph
of this section. Comparative data concerning ab-
sorption of the alcohol and acetate forms of
hydrocortisone and cortisone are not complete,
and certain of the published reports are difficult
to reconcile with clinical experiences. As was men-
tioned, hydrocortisone acetate has practically no
systemic action following intramuscular injection
(Salassa et al., J. Clin. Inv., 1952, 31, 658). Being
only about one-seventh as soluble as cortisone
acetate in body fluids may explain the poor ab-
sorption of hydrocortisone acetate (Hollander
et al., I.A.M.A., 1951, 147, 1629). On the other
hand, however, Conn et al. (J. Lab. Clin. Med.,
1951, 38, 799) reported the metabolic effects of
hydrocortisone acetate after oral administration
to be equal in intensity to those following oral or
intramuscular administration of the alcohol form
of hydrocortisone. On continuous intravenous ad-
ministration of the alcohol forms of hydrocorti-
sone and cortisone, respectively, Ingle et al.
(Proc. S. Exp. Biol. Med., 1951, 78, 79) found
the former to be about twice as active on work
performance of adrenalectomized rats; this has
been confirmed in man by Thorn and his associ-
ates (New Eng. I. Med., 1953, 248, 417) on the
blood eosinophil response and on other metabolic
criteria (Conn, Tr. Third Con}. Adrenal Cortex,

J. Macy Jr. Found., 1952, p. 187). The plasma
17-hydroxycorticosteroid concentration following
oral administration of either hydrocortisone or its
acetate rises to a peak at about 1 hour and re-
turns to the initial level in 4 to 8 hours but no
rise was detected after intramuscular injection of
the acetate (Nelson et al., J. Clin. Inv., 1952,
194, 407).

Intermediary Metabolism. — The probability
that hydrocortisone is the principal corticoid se-
creted by the mammalian adrenal cortex has
been mentioned. Its concentration in the different
tissues in which it is found is increased following
the action of corticotropin. It is formed from
acetate, as demonstrated by use of the radioactive
carbon- 14-labeled compound, by slices of hog
adrenal tissue (Haines, Recent Progress in Hor-
mone Research, 1952, 7, 255) and in perfusion
of beef adrenal glands (Hechter et al., loc. cit.);
it is formed to an even greater extent from
cholesterol, under the same conditions. These ob-
servations suggest that there may be different
pathways of synthesis. Furthermore, both pro-
gesterone and ll-desoxy-17-hydroxycorticosterone
(see under Desoxycorticosterone Acetate) increase
the production of hydrocortisone in perfusion ex-
periments and in adrenal homogenates. Hydro-
cortisone is rapidly metabolized by homogenates
of rat liver or by perfusion through rat liver, the
ketonic group of ring A being reduced to alcohol
and the side chain at carbon atom 17 being de-
graded. Following administration of hydrocor-
tisone, cortisone or corticotropin the reduction
product pregnane-3a,llp,17a.21-tetrol-20-one and
the reduced and degraded compound etiocholane-
3a,ll3-diol-17-one, particularly the latter, are
found in urine, along with hydrocortisone itself
and llp-hydroxyandrosterone (Burstein et al.,
Endocrinology, 1953, 52, 448).

Excretion. — Administration of hydrocortisone
to patients with Addison's disease, or in large
doses to normal humans, increases urinary excre-
tion of 17-ketosteroids and also of steroids with
an a-ketol side chain at carbon atom 17. As is
also the case when cortisone is administered to
the normal person, the content of 17-ketosteroids
may decrease after giving small doses of hydro-
cortisone. As has been noted, hydrocortisone is
found in the urine of normal humans, patients
with Addison's disease, patients with Cushing's
syndrome, and in normal subjects receiving cor-
tisone. Also, administration of hydrocortisone
results in increased amounts of cortisone in the
urine. Both cortisone and hydrocortisone undergo
similar modifications in body tissues. In Thorn's
castrated and adrenalectomized patient with car-
cinomatosis, a greater increase in urinary andro-
genic activity followed the use of hydrocortisone
than when cortisone was employed but the activity
was still much less than that in a normal male
(Munson et al., cited bv Thorn et al., New Eng.
J.Med., 1953,248,376).

Action. — The metabolic action of hydrocor-
tisone differs only quantitatively from that of
cortisone (Pearson et al., J. Clin. Inv., 1951, 30,
665; Fourman et al., ibid., 1950, 29, 1462; Perera
et al., Proc. S. Exp. Biol. Med., 1951, 77, 326:
Conn et al., Science, 1951, 113, 713). Consider-

Part

Hydrocortisone 667

ing the potent topical action of hydrocortisone
and its greater systemic activity, Pincus (/. Clin.
Endocrinol, 1952, 12, 1187) suggested that cor-
tisone may be converted to hydrocortisone in the
body, or that when locally applied hydrocortisone
is converted more readily than cortisone to some
more active substance; it may be noted, however,
that cortisone is to some extent effective on
topical application. As with cortisone, hydrocor-
tisone causes decreased carbohydrate tolerance,
glycosuria, increased excretion of nitrogen and
uric acid, retention of sodium and chloride and
water, and increased excretion of potassium and
calcium and phosphorus. It corrects the abnormal
response of the patient with Addison's disease to
a large dose of water, inhibits pituitary function
in the adrenogenital syndrome (Wilkins et al.,
J. Clin. Endocrinol., 1952, 12, 257; Jailer et al.,
J. Clin. Inv., 1952, 31, 880), and depresses up-
take of iodine (measured with radioactive iodine-
131) by the thyroid (Relman and Schwartz, ibid.,
656). In rheumatoid arthritis Clark et al. {ibid.,
621) reported less euphoria than with cortisone.
Woodbury (/. Clin. Endocrinol, 1952, 12, 924)
reported a lesser effect on the electroshock thres-
hold of rats.

Similar to cortisone, hydrocortisone has anti-
inflammatory action (Dougherty, Recent Progress
in Hormone Research, 1952, 7, 307; Boland,
J.A.M.A., 1952, 150, 1281), and antiallergic ac-
tion (Goldman et al, ibid., 30; Rosenthal et al,
Lancet, 1952, 1, 1135), and it dissolves lymphoid
tumors (Pearson and Eliel, Recent Progress in
Hormone Research, 1951, 6, 373).

Therapeutic Applications. — Since hydrocor-
tisone has the same metabolic and antiphlogistic
actions as cortisone, it has also the same thera-
peutic indications. For example, it is effective in
providing symptomatic relief in patients with
rheumatoid arthritis, being more potent than cor-
tisone acetate in this respect (Boland, J.A.M.A.,
1952, 148, 981; ibid., 1952, 150, 1281); it is
also effective in controlling experimental ocular
tuberculosis (Woods and Wood, Arch. Ophth.,
1952, 47, 2 77), and in replacement therapy of
acute adrenal insufficiency (Thorn et al, New Eng.
J. Med., 1953, 248, 420). Schwartz (/. Allergy,
1954, 25, 112) reported relief in 38 of 39 cases
with bronchial asthma and in all 10 cases of rag-
weed hay fever using an initial daily dose of 80
mg. orally, in divided amounts, rapidly reduced
to a maintenance dose of 40 to 60 mg. daily.
Arbesman and Richard (ibid., 306) reported satis-
factory results using a dose two-thirds that re-
quired with cortisone acetate.

Hydrocortisone Acetate. — The relative insolu-
bility of hydrocortisone acetate and its high
degree of activity are advantages which have been
effectively utilized in topical application of this
hormone without producing the untoward systemic
effects of excessive glycocorticoid action. For
topical use, microcrystalline suspensions or oint-
ments of hydrocortisone acetate are employed.
For intraarticular injection in the treatment of a
variety of arthritic conditions, Hollander (Ann.
Int. Med., 1953, 39, 735) used a saline suspension
containing 25 mg. of hydrocortisone acetate per
ml. in a dose of 10 to 50 mg., according to the

size of the joint injected; he administered over
8000 such injections to 852 patients. Relief of
symptoms and signs of inflammation in joint tis-
sues was obtained within a few hours, persisting
for 3 days to several weeks, in cases of rheumatoid
arthritis, osteoarthritis, traumatic arthritis, bur-
sitis, gout, tenosynovitis, lupus erythematosis,
etc. Such local therapy is most useful for mono-
articular cases or for incapacitating joint condi-
tions in patients in whom the systemic action
of cortisone or hydrocortisone is contraindicated;
the antiinflammatory action is obviously non-
specific. The technic of intraarticular injections
is described in detail by Hollander (Comroe,
Arthritis and Allied Conditions, 5th edition, 1953).
The microcrystals of hydrocortisone acetate dis-
appear from the synovial fluid within 2 hours
after injection, being adsorbed on the surface of
the synovial membrane. The same joint has been
injected as many as 47 times over a period of
2 years. Efficacy of the treatment has been con-
firmed (Stevenson et al, Ann. Rheum. Dis., 1952,
11, 112; Kersley and Desmarais, Lancet, 1952, 2,
269). Untoward responses were observed in 2.3
per cent of Hollander's injections, the only com-
mon one being an exacerbation of the inflamma-
tion for from 2 hours to 3 days, this usually being
followed by improvement over the pre-treatment
state. The only contraindications are the presence
of infection in or near the joint, or such wide-
spread disease as to make local therapy imprac-
tical. It has not appeared to be practical to at-
tempt injection of the multiple small articulations
of the spine although small amounts injected into
the vicinity of these joints may relieve pain. In
acute and chronic cases of subdeltoid bursitis,
injection of 25 mg. of hydrocortisone acetate into
the inflamed bursa brought relief of pain and
resolution of the condition usually after the first
injection (Orbach, /. Internal Col. Surg., August
1952) and Becker (Ind. Med., 1953, 22, 555)
reported disappearance of 87 per cent of 30
ganglia (cystic dilatation of a tendon sheath)
following injection of 8 to 12 mg. of hydrocor-
tisone acetate in sterile suspension form in the
ganglion.

In ophthalmologic inflammatory lesions, par-
ticularly of the anterior segment of the eye, the
topical efficacy of hydrocortisone is of perhaps
even greater clinical importance since vision is
conserved (Steffensen et al, Am. J. Ophth., 1952,
35, 933). For this purpose a suspension contain-
ing 25 mg. per ml. may be diluted with 4 volumes
of 0.85 per cent sterile aqueous sodium chloride
solution or a 1:5000 aqueous solution of benzal-
konium chloride and 1 to 2 drops of this prepara-
tion instilled into the conjunctival sac every hour
during the day and every 2 to 4 hours during the
night. As with intraarticular injections, hydro-
cortisone is more effective than cortisone. A 1.5
per cent ointment of hydrocortisone acetate was
employed by McDonald et al. (Arch. Ophth.,
1953, 49, 400). Topical therapy is effective in
conjunctivitis or keratitis from a variety of
causes, also in milder types of iritis (see table of
therapeutic uses under Cortisone). Ointments or
suspensions containing also an antibiotic, such as
neomycin, are used similarly. Baer and Lott

668 Hydrocortisone

Part I

(J. A.M. A., 1954, 155, 973) used ear drops con-
taining 15 mg. of hydrocortisone acetate, 5 mg.
of neomycin sulfate, and 0.2 mg. of myristyl-Y-
picolinium chloride per ml. of aqueous suspension
effectively in treating otitis externa. For inflam-
matory lesions of deeper portions of the eye,
systemic therapy alone or in addition to local
treatment is required.

Dermatitis due to various causes (see under
Cortisone) often responds to topical application
of an ointment containing 2.5 per cent of hydro-
cortisone acetate; the vehicle may contain lanolin,
liquid petrolatum and white petrolatum where
lubrication is desired, and polyethylene glycol,
propylene glycol, zinc stearate and water where
softening is needed (Sulzberger and Witten, Med.
Clin. North America, March 1954). In atopic and
contact dermatitis, and in pruritus ani and vulvae
an ointment of hydrocortisone acetate has been
found to be particularly effective (see also Alex-
ander and Manheim, /. Invest. Dermat., 1953, 21,
223). Beneficial results have been obtained also
in chronic lichen simplex and in certain other
exudative dermatoses. Improvement usually ap-
peared within 2 to 7 days, but patients often
relapsed about 5 days after discontinuing the
applications. No benefit was observed in psoriasis,
chronic discoid lupus erythematosus, pemphigus
vulgaris and alopecia areata. Robinson and Rob-
inson (J.A.M.A., 1954, 155, 1213) reported relief
during use of hydrocortisone acetate topically in
144 of 172 cases of atopic dermatitis, in 49 of 71
cases of contact dermatitis, in 15 of 17 cases of
stasis dermatitis, and in 45 of 50 cases with
pruritus ani and vulvae ; only in 2 of 14 cases of
discoid lupus erythematosus was benefit obtained
and none was observed in lichen planus, acne
vulgaris, or pityriasis rosea. A 2.5 per cent lotion
of hydrocortisone acetate in a vehicle containing
glycerin, isopropyl alcohol, diglycol stearate, pet-
rolatum, wax. sodium methylparahydroxybenzoate
and water has also been used. Eskind et al. {Arch.
Dermat. Syph., 1954, 69, 410) found that hydro-
cortisone acetate ointment was no more effective
than a placebo in relieving the pruritus, erythema
and vesiculation of ivy poisoning. Goldman and
Preston (JAMA., 1954, 154, 1348) likewise
found the ointment ineffective but described relief
in 36 of 47 patients following oral administra-
tion of 20 mg. of hydrocortisone 5 times daily
for 2 days, followed by the same dose 4, 3 and 2
times daily on the third, fourth and fifth days,
respectively.

Of practical utility for persons who take daily
subcutaneous injections (as of insulin) is the
observation of Cornbleet (J.A.M.A., 1954. 156,
1274) that intracutaneous injection of 2.5 mg. of
hydrocortisone acetate produces an area of hypal-
gesia persisting for 10 to 14 months. Goldman
(ibid., 1952, 149, 265) reported prevention of
severe irritation in the skin of a sensitive person
following mosquito bites for 4 months after intra-
dermal injection of 0.2 ml. of a 2.5 per cent sus-
pension of hydrocortisone acetate into an area.
Intradermal injection of hydrocortisone inhibits
the tuberculin reaction (Goldman et al., ibid.,
1952, 150, 30). E

Toxicology. — Hydrocortisone has no untoward
effects other than those of hyperadrenocorticism
if excessive doses are employed systemically; for
precautions in its use see Untoward Effects under
Cortisone Acetate. Following topical therapy with
hydrocortisone acetate, untoward responses may
arise from sensitivity to components of the
vehicles used in the dosage forms.

Keitzer and Cheek (Arch. Int. Med., 1954, 94,
326) caution that a patient under oral cortisone
acetate therapy should not be changed abruptly
to oral hydrocortisone therapy; while a dosage
equivalence, for systemic action, of 65 mg. of
hydrocortisone and 100 mg. of cortisone acetate
was found, these clinicians urge gradual discon-
tinuance of cortisone acetate when it is to be
replaced by hydrocortisone.

Dose. — The usual dose of the alcohol form of
hydrocortisone orally is 10 mg. two to four times
daily, with a range of 5 to 20 mg. The maximum
safe dose is generally 30 mg., and the total dose
in 24 hours seldom exceeds 80 mg. The XX. R.
states that studies thus far indicate that the
clinically effective oral dosage ratio of hydrocor-
tisone (alcohol) to cortisone (acetate) is approxi-
mately 1:1.6 (see also the preceding paragraph).
Since hydrocortisone is so active when taken
orally, intramuscular use is seldom practiced. In
the treatment of the crisis of adrenal insufficiency
the alcohol form of hydrocortisone may be given
intravenously in a dose of 25 mg., which is dis-
solved in a small volume of a hydroalcoholic solu-
tion, dispersed in about 120 ml. of isotonic sodium
chloride solution for injection and administered
at a rate of about 12 mg. per hour; ampuls con-
taining 100 mg. of the alcohol form of hydro-
cortisone, dissolved in 50 per cent ethyl alcohol
to a volume of 20 ml., are commercially available.

For topical uses, including intraarticular injec-
tion, the relatively more insoluble hydrocortisone
acetate is preferred and used.

Fluorohydrocortisone Acetate. — The four
9a-halogen derivatives (fluoro-, chloro-, bromo-,
and iodo-) of hydrocortisone and cortisone have
been prepared and found to have adrenocortical-
like activity (Fried and Sabo, J.A.C.S., 1954. 76,
1455; Callow et al., Lancet, 1954, 2, 20; Liddle
et al., Science, 1954, 120, 496). The derivatives
of hydrocortisone are more active than those of
cortisone, with fluorohydrocortisone being the
most active. It is more active than desoxycorti-
costerone acetate in effecting sodium retention
in the adrenalectomized dog and more potent that
cortisone in causing liver glycogen deposition in
adrenalectomized rats and in producing eosino-
penia in adrenalectomized dogs. Both the fluoro-
and chloro-derivatives are more active in the
treatment of Addison's disease than either hydro-
cortisone or desoxycorticosterone (Lancet, 1954,
2, 26). Fluorohydrocortisone has antirheumatic
action in patients with rheumatoid arthritis
(Boland and Headley. Ann. Rheum. Dis., De-
cember 1954, 13; Bunim. ibid., Bayles, ibid.).
Good antirheumatic effect with the very small
doses of 1 or 2 mg. orally, every 6 hours, was
reported (Ward et al., Proc. Mayo, 1954, 29,
649) but there was also troublesome retention of

Part I

Hydrocortisone Acetate Suspension, Sterile 669

sodium, chloride and fluid (edema) and loss of
potassium which precludes successful therapeutic
use except topically in ointments or for intra-
articular injection.

Under the trade-marked name Alflorone Ace-
tate (Sharp & Dohme) there have been made
available ointments containing 0.1 or 0.25 per
cent of 9 a-fluorohydrocortisone acetate (also
known by the generic name fludrocortisone ace-
tate) for use in the same manner as ointments of
hydrocortisone acetate. The fluoro-derivative is
claimed to have a degree of inflammatory activity
which makes it as effective as hydrocortisone
acetate in Vio the concentration of the latter. Be-
cause of the smaller amount of active principle
required the new ointments are more economical
to use than those of therapeutically effective con-
centrations of hydrocortisone acetate. Other prep-
arations of the same agent include F-Cortef Oint-
ment (Upjohn), available in 0.1 and 0.2 per cent
concentration, and Florinef Ointment and Lotion
(Squibb), likewise supplied in 0.1 and 0.2 per
cent strength.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

sone the absorptivity is 395 ± 10. Loss on drying.
— Not over 1 per cent, when dried in vacuum at
60° for 4 hours. Residue on ignition. — The residue
from 100 mg. is negligible. U.S. P.

Uses. — This relatively insoluble and poorly
absorbed ester of hydrocortisone has, neverthe-
less, a high degree of adrenal glycocorticoid ac-
tivity in localized areas when it is applied topically
to the skin or conjunctiva or when it is injected
intraarticularly. For application to skin an oint-
ment or lotion is commonly employed; for use
in the eye a suspension or ointment is used; for
intraarterial injection an aqueous suspension is
employed. For uses see under Hydrocortisone.

The usual dose of hydrocortisone acetate by
intraarticular injection is 25 mg., with a range
of 5 to 50 mg., according to the size of the joint
injected. The maximum single dose injected into
a joint is usually 50 mg. but several joints may
be injected simultaneously. For external applica-
tion ointments, suspensions or lotions containing
0.5 to 2.5 per cent of hydrocortisone acetate are
used.

Storage. — Preserve "in tight, light-resistant
containers." U.S. P.

HYDROCORTISONE TABLETS.
U.S.P.

"Hydrocortisone Tablets contain not less than
90 per cent and not more than 110 per cent of the
labeled amount of C21H30O5." U.S.P.

Assay. — The content of hydrocortisone in the
tablets is determined by measuring the intensity
of the red color produced with triphenyltetra-
zolium chloride in alcohol solution. U.S.P.

Usual Sizes. — 10 and 25 mg.

HYDROCORTISONE ACETATE.
U.S.P.

C23H32O6

Hydrocortisone acetate is the acetate ester of
hydrocortisone, the primary alcohol group of
carbon atom 21 being the one esterified; accord-
ingly, hydrocortisone 21-acetate is a more specific
designation of the compound. Hydrocortisone
acetate is considerably less soluble than hydro-
cortisone in aqueous media (see solubility data
under Hydrocortisone), for which reason it is
more slowly absorbed than the free alcohol and
finds greater utility than hydrocortisone for topi-
cal application and intraarticular injection, where
delayed absorption is desirable.

Description. — "Hydrocortisone Acetate occurs
as a white, to practically white, odorless, crystal-
line powder. Hydrocortisone Acetate is insoluble
in water. One Gm. dissolves in 230 ml. of alcohol
and in 150 ml. of chloroform. Hydrocortisone
Acetate melts between 216° and 222°." U.S.P.

Standards and Tests. — Identification. — The
tests described under Hydrocortisone are em-
ployed, also the test for acetate described under
Cortisone. Specific rotation. — Not less than +158°
and not more than +165°, when determined as
directed under Hydrocortisone. Absorptivity. —
When determined as directed under Hydrocorti-

HYDROCORTISONE ACETATE
OINTMENT. U.S.P.

"Hydrocortisone Acetate Ointment contains not
less than 90 per cent and not more than 110 per
cent of the labeled amount of C23H32O6." U.S.P.

Ointments containing from 0.5 to 2.5 per cent
of hydrocortisone acetate have been variously
used in medicine; for information concerning
their composition and use see under Hydro-
cortisone.

STERILE HYDROCORTISONE
ACETATE SUSPENSION. U.S.P.

"Sterile Hydrocortisone Acetate Suspension is
a sterile suspension of hydrocortisone acetate in
a suitable aqueous medium. It contains not less
than 90 per cent and not more than 110 per cent
of the labeled amount of C23H32O6." U.S.P.

The pH of the suspension is required to be
between 5 and 7, and it must meet the require-
ments for Injections.

Assay. — The procedure described under Cor-
tisone Acetate in Water Injection is employed,
except that quantitative comparison is made
with U.S.P. Hydrocortisone Acetate Reference
Standard.

Uses. — The specifications of the U.S.P. for
this preparation are such as to recognize suspen-
sions which may be used in one of two ways : for
intraarticular injection or for ophthalmic appli-
cation. An available suspension suitable for intra-
articular injection contains 25 mg. of hydro-
cortisone acetate per ml., the vehicle being sodium
chloride injection containing also 0.9 per cent
benzyl alcohol, along with some polysorbate and
sodium carboxymethylcellulose to effect suitable
suspension of the hormone.

For information concerning uses of both types
of suspensions see under Hydrocortisone Acetate.

670 Hydrogen Peroxide Solution

Part I

HYDROGEN PEROXIDE SOLUTION.

U.S.P. (B.P.)

Hydrogen Dioxide Solution, Liquor Hydrogenii Peroxidi

"Hydrogen Peroxide Solution contains, in each
100 ml., not less than 2.5 Gm. and not more than
3.5 Gm. of H2O2. Suitable preservatives, totaling
not more than 0.05 per cent, may be added."
US. P. The B.P. solution is required to contain
not less than 5.0 per cent w/v and not more than
7.0 per cent w/v of H2O2, corresponding to about
20 times its volume of available oxygen.

B.P. Solution of Hydrogen Peroxide. Hydrogen Perox-
ide; "Peroxide." Hydrogenium Peroxydatum Solutum;
Solutum Hydrogenii Peroxydati Officinale; Solutio Bioxydi
Hydrogenii. Fr. Solute officinal d'eau oxygen6e; Eau
oxygenee officinale. Ger. Wasserstoffsuperoxydlosung.
It. Acqua ossigenata; Biossido d'idrogeno. Sp. Soluci6n
de bidxido de hidrogeno; Agua oxidenada; Solution de
Peroxido de Hidrogeno.

Hydrogen peroxide was first prepared by
Thenard, in 1818, by treating barium peroxide
with hydrochloric acid. The same reaction, but
using either sulfuric or phosphoric acid so as to
precipitate the barium ion, was for many years
employed in the commercial production of hydro-
gen peroxide solution. A somewhat similar reac-
tion between sodium peroxide and sulfuric acid
has also been utilized commercially, the by-prod-
uct sodium sulfate being precipitated with the
aid of sodium fluoride.

The most important method, however, for pre-
paring hydrogen peroxide in large quantities and
high concentrations involves electrolysis of solu-
tions of sulfuric acid containing one or more of
its salts. Thus, by electrolysis of a concentrated
solution containing potassium bisulfate, ammo-
nium sulfate and sulfuric acid, oxidation of sulfate
to persulfate occurs at the anode and solid potas-
sium persulfate is separated. Treatment of this
salt with strong sulfuric acid and steam hydrolyzes
the persulfate with formation of hydrogen perox-
ide which may be distilled off, in concentrations
as high as 35 per cent H2O2. If desired, further
concentration may be effected through two stages
of distillation, the final product containing up to
90 per cent of H2O2.

Such high test peroxide was developed during
World War II, principally by the Germans, as a
source of energy for the operation of submarine
engines and for propulsion of rockets, torpedoes
and other military missiles. It is claimed that in
the presence of suitable catalysts it dissociates in-
stantly into 5000 times its volume of steam and
oxygen. Under standard conditions of tempera-
ture and pressure one volume of 90 per cent hy-
drogen peroxide releases 413 volumes of oxygen;
the official hydrogen peroxide solution releases
approximately 10 times its volume of oxygen. The
high-test peroxide can be shipped in aluminum
drums and tank cars ; if the liquid is not permitted
to become contaminated no decomposition occurs.
If allowed to come in contact with combustible
matter a fire may result. It is miscible with many
organic liquids with which the official solution is
immiscible. For data on corrosion and stability
studies of concentrated hydrogen peroxide see
Bellinger et al. (hid. Eng. Chetn., 1946, 38, 310).

Absolute H2O2 has been obtained by extraction
with ether and evaporation of the latter under
reduced pressure and at low temperature. The
melting point of the pure compound is about — 2°
and the boiling point is 152.1°.

Because of the instability of hydrogen peroxide
various stabilizing agents are commonly added.
Small concentrations of such substances as acet-
anilid, oxyquinoline, tetrasodium pyrophosphate
and acids serve to stabilize all concentrations of
hydrogen peroxide solutions. Various metals and
metallic salts, on the other hand, catalyze the de-
composition of the substance; alkalinization also
accelerates decomposition.

The official hydrogen peroxide solution may be
prepared by diluting any of the stronger solutions,
sufficient preservative being incorporated to stabi-
lize the diluted solution. Even the 3 per cent solu-
tion is a powerful oxidizing agent, reacting with
many oxidizable substances. On the other hand,
in the presence of a stronger oxidant, hydrogen
peroxide solution serves as a reducing agent; thus,
potassium permanganate is reduced by it, oxygen
being evolved from the peroxide.

Hydrogen peroxide forms with urea a solid com-
pound called "urea peroxide" or "carbamide perox-
ide" capable of yielding over 35 per cent of H2O2.
In some countries the compound finds use as a
preservative for milk; 0.1 per cent of it is said
to keep milk for 72 hours. Under the name
Thenardol (named for Thenard, discoverer of hy-
drogen peroxide) a solution of this substance in
anhydrous glycerin, stabilized with 8-hydroxy-
quinoline, has been found useful in treating infec-
tions of the eye, ear, mouth and skin (Brown
et al, New Eng. J. Med., 1946, 234, 468; Ann.
Allergy, 1946, 4, 33; J. -Lancet, 1947, 67, 405;
Arch. Otolaryng., 1948, 48, 327; and others).
The action of the compound depends on the evo-
lution of hydrogen peroxide when in contact with
water. It is supplied as Glycerite of Hydrogen
Peroxide with Carbamide (International Pharma-
ceutical Corp.). Urea peroxide is used in industry
as an oxidizing, bleaching and polymerizing agent
in non-aqueous solutions.

Description. — "Hydrogen Peroxide Solution
is a colorless liquid, odorless, or having an odor
resembling that of ozone. It is acid to litmus and
to the taste and produces a froth in the mouth. It
usually deteriorates upon standing or upon pro-
tracted agitation, and rapidly decomposes when
in contact with many oxidizing as well as reduc-
ing substances. When rapidly heated, it may de-
compose suddenly. It is affected by light. Its
specific gravity is about 1.01." U.S.P.

Standards and Tests. — Identification. — On
adding a drop of potassium dichromate T.S. to a
mixture of 1 ml. of hydrogen peroxide solution, 10
ml. of water containing 1 drop of diluted sulfuric
acid, and 2 ml. of ether, an evanescent blue color
is produced in the aqueous layer; on agitation and
standing the color passes into the ether layer.
Non-volatile residue. — Not over 30 mg. from 20
ml. of hydrogen peroxide solution, the latter being
evaporated on a water bath and the residue dried
1 hour at 105°. Acidity. — 25 ml. of solution re-
quires not more than 2.5 ml. of 0.1 N sodium

Part I

Hydrogen Peroxide Solution 671

hydroxide for neutralization, using phenolphthal-
ein T.S. as indicator. Arsenic. — The limit is 2
parts per million. Barium. — No turbidity results
on adding 2 drops of diluted sulfuric acid to 10
ml. of hydrogen peroxide solution. Heavy metals.
— The limit is 5 parts per million. Limit of pre-
servative.— Not more than 50 mg. from 100 ml.
of hydrogen peroxide solution on extracting the
latter with a mixture of chloroform and ether.
U.S.P.

Assay. — A 2-ml. portion of hydrogen peroxide
solution is mixed with water and diluted sulfuric
acid and titrated with 0.1 N potassium permanga-
nate. The following reaction takes place: 5H2O2
+ 2KMn04 + 3H2SO4 -* SO2 + 2MnS04 +
K2SO4 + 8H2O. Each ml. of 0.1 N potassium
permanganate represents 1.701 mg. of H2O2.
U.S.P.

Incompatibilities. — Hydrogen peroxide is de-
composed by reducing agents including most or-
ganic matter. It reacts with oxidizing agents to
liberate oxygen. Metals, metallic salts, light, agi-
tation and heat increase its decomposition.

Uses. — Hydrogen peroxide is used as an anti-
septic, wound cleanser and deodorant. In solution
it is slowly decomposed, liberating a portion of
its oxygen. All tissues, including pus aid blood,
contain an enzyme, catalase, which releases oxy-
gen. Evidently this nascent oxygen has a powerful
oxidizing effect and thereby destroys many forms
of organic matter. In the presence of these
catalyzing agents, the antibacterial powers of the
drug are greatly reduced. Effervescence is much
more rapid on wounds, denuded areas and mucous
membranes than on unbroken skin. Upon the sys-
tem generally hydrogen peroxide does not, and
cannot, exert any physiological action, because it
cannot exist in the blood. Studies of intravenous
administration in hypoxic animals failed to dem-
onstrate any value and often the condition was
aggravated by gas embolism or methemoglobin
formation (Lorincz et al., Anesthesiology, 1948,
9, 162).

Antiseptic. — The most important use for this
agent is as an antibacterial agent. The germicidal
activity of hydrogen peroxide is generally greatly
overestimated; it persists only as long as oxygen
is being released. Although in relatively dilute
solution it will eventually destroy many of the
pathogenic microorganisms, its action is extremely
slow, unless the solution be fairly concentrated.
Gifford found that a neutral solution containing
15 per cent by volume of H2O2 (therefore stronger
than the official solution) would destroy anthrax
spores after 5 minutes' exposure, and pyogenic
cocci in 1 minute, but that the same solution
when diluted with 4 parts of water did not kill
the pyogenic cocci after 30 minutes. Traugott
found that 1 per cent by weight of H2O2 killed
typhoid bacilli in 5 minutes and staphylococci in
15 to 30 minutes. On the other hand, if allowed
sufficient time, relatively small quantities are
highly efficient. Heinemann (J.A.M.A., 1913, 60,
1603) reached the conclusion from his experi-
ments that 3 teaspoonfuls of the official solution,
after 6 hours' exposure will destroy 99 per cent
of the bacteria present in a liter of drinking

water; this quantity makes about a 1:1000 solu-
tion of hydrogen peroxide. In the presence of
organic matter the compound is so rapidly broken
down that it is much less efficient (see review by
Haase, Pharmazie, 1950, 5, 436).

The addition of hydrogen peroxide solution has
been recommended as an emergency method for
the preservation of milk. It effects a partial or
complete sterilization of the milk and quickly
disappears, being dissociated into water and oxy-
gen. The use in milk and cream has been com-
mon in Great Britain. As it was first suggested
by Budd, products so preserved are sometimes
called "buddized."

Cleanser. — Hydrogen peroxide solution is
used in medicine as a means of cleansing wounds,
suppurating ulcers, and the like. Its value in these
conditions is probably more due to removing
organic detritus, which forms a breeding place
for the microorganisms, than to its antibacterial
action. Its styptic effect — probably due to the
activation of the fibrin ferment of the blood and
consequent more rapid coagulation — as well as its
relatively harmless nature make it a very popular
antiseptic for household use. In inflammatory
conditions of the external auditory canal, a dilu-
tion with 3 parts of water is a valuable cleanser
prior to the instillation of the appropriate thera-
peutic agent according to the etiology of the
condition. Without thorough cleansing of the
canal, no chemotherapeutic agent can be effec-
tive. In cases with fecal impaction, after rectal
instillation of warm liquid petrolatum at bed
time, an enema of hydrogen peroxide solution
diluted with 3 parts of water is often useful. In"
root canals of teeth or other dental pulp cavities,
hydrogen peroxide diluted with an equal volume
of water is used; zinc peroxide (q.v.) is also em-
ployed. It has sometimes been injected into deep
cavities for the purpose of cleansing by irrigation
and determining the presence of pus, which will
be signalized by effervescence; the method, how-
ever, must be used with caution, because if there
is not a free vent for the gas sufficient pressure
may be generated within the cavity to cause
serious local results and even air embolism. Be-
cause of its lack of toxicity it is a favorite
disinfectant for application to various mucous
membranes (see also use of "urea peroxide"
above), especially those of the nose and throat.
In diphtheria or tonsilitis the official solution may
be applied undiluted, by means of either an atom-
izer or cotton applicator. Diluted with equal parts
of water it is often employed as a gargle in
pharyngitis, or as a mouth wash in stomatitis, but
prolonged use causes irritation of the buccal mu-
cous membrane. Diluted with 1 or more parts of
water it has been used as a vaginal douche. In-
ternally the solution has been used with success
by Goodman {Pennsylvania M. J., 1910) and
others, in the treatment of hyperchlorhydria
(gastritis). It has been claimed that it diminishes
the acidity of the gastric juice, increases the secre-
tion of mucus and exercises an antiseptic action
in the stomach.

Campbell and Cherkin {Science, 1945, 102,
535) found that heating pyrogenic solutions of

672 Hydrogen Peroxide Solution

Part I

gelatin at 100° for 1 to 2 hours in the presence of
0.1 molar concentration of hydrogen peroxide
resulted in destruction of the pyrogens; this find-
ing has been applied practically in preparing cer-
tain non-pyrogenic solutions.

For bleaching hair, the undiluted official solu-
tion is used, but with care. Prolonged contact
with skin causes erythema, which is transient,
but a concentrated solution, as one of 30 per
cent, causes a burn with a white eschar. H

For external use. hydrogen peroxide solution is
applied topically as required to skin and mucous
membranes. It should be noted that the B.P.
solution is approximately twice the strength of
the U.S. P. preparation and should be diluted with
at least an equal volume of water for most uses.
When taken internally, the usual dose is 4 ml.
(approximately 1 fluidrachm) of the U.S. P. solu-
tion.

Storage. — Preserve "in tight, fight-resistant
containers, preferably at a temperature not above
35°." U.S.P.

HYDROXYAMPHETAMINE HYDRO-
BROMIDE. U.S.P.

p-(2-Aminopropyl) phenol Hydrobromide,
Hydroxyamphetaminium Bromide

H0 \ /-CH2CHCH,

Br'

Paredrine Hydrobromide (Smith, Kline & French Labs.).

The base of this sympathomimetic agent dif-
fers from amphetamine only in having a hydroxyl
group in the para position of the benzene ring.
Hydroxyamphetamine may be synthesized from
the oxime of />-methoxyphenyl acetone, or by
interaction of p-nitrobenzyl chloride and a salt
of nitroethane, or by interaction of anisaldehyde
and nitroethane (Hoover and Hass, /. Org. Chem.,
1947, 12, 501). The hydrobromide is obtained
by neutralization of the base with hydrobromic
acid.

Description. — ''Hydroxyamphetamine Hydro-
bromide occurs as a white, crystalline powder.
Its solutions are slightly acid to litmus, having a
pH of about 5. One Gm. of Hydroxyamphetamine
Hydrobromide dissolves in about 1 ml. of water
and in about 2.5 ml. of alcohol. It is slightly sol-
uble in chloroform and almost insoluble in ether.
Hvdroxvamphetamine Hvdrobromide melts be-
tween 1S9° and 192°." U.S.P.

Standards and Tests. — Identification. — (1)
A purple color is produced on adding 0.5 ml. of
ferric chloride T.S. to a solution of 10 mg. of
hydroxyamphetamine hydrobromide in 10 ml. of
water. (2) An intense blue color forms on add-
ing 2 mg. of hydroxyamphetamine hydrobromide
to a solution of 500 mg. of ammonium molybdate
in 10 ml. of sulfuric acid (similar amino com-
pounds such as amphetamine and methamphet-
amine. which lack a phenolic hydroxyl. do not
give this reaction). (3) Hydroxyamphetamine
base separated from the salt melts between 127°
and 129°. (4) A pale yellow precipitate, slightly

soluble in ammonia T.S., is produced on adding
silver nitrate T.S. to a solution of 10 mg. of
hydroxyamphetamine hydrobromide in 10 ml. of
water, acidified with 1 ml. of diluted nitric acid.
Loss on drying. — Not over 0.5 per cent, when
dried at 105° for 2 hours. Residue on ignition. —
Not over 0.1 per cent. Nitrogen content. — Not
less than 5.9 per cent and not more than 6.2 per
cent of N. when determined by the Kjeldahl
method. Bromide content. — Not less than 33.6
per cent and not more than 35.2 per cent of Br,
when determined by the Volhard method. U.S.P.

Uses. — The introduction of the p-hydroxyl
group on the aromatic nucleus of amphetamine
markedly alters its pharmacodynamic properties
(for general discussion see monograph on Sym-
pathomimetic Amines, in Part II). Thus, hydrox-
yamphetamine is 2- to 4-fold more active as a
pressor agent, is relatively inactive when admin-
istered orally, does not have as long a duration
of action and is devoid of central nervous system
stimulation. By comparison, amphetamine is a
less potent pressor agent, is active when admin-
istered orally, has a prolonged duration of action
and is a useful euphoriant (Bever. Physiol. Rev.,
1946, 26, 169). Axelrod (/. 'Pharmacol, 1954.
110, 315) reported that whereas d-amphetamine
is slowly excreted and metabolized at a rate of
about 8 per cent per hour, the overall clearance
of hydroxyamphetamine from the blood was at a
rate of 40 per cent per hour. About 30 per cent
of the intravenously administered drug was ex-
creted as such and an additional 30 per cent was
eliminated in a conjugated form.

Hydroxyamphetamine has been employed as
the hydrobromide for use as a nasal decongestant
and as a mydriatic agent. According to Powell and
Hyde (/. Kansas Med. Soc, 1938, 39, 525) the
agent is mydriatic, not cycloplegic; thus, there
is no loss of accommodation or alteration of
intraocular tension (see also Gettes. Arch. Ophth.,
1950. 43, 446). Griffith (U. S. Nav. M. Bull,
1945, 44, 284) found hydroxyamphetamine to
be useful in the prevention or treatment of
bradycardia induced by a hyperirritable carotid
sinus. Patients with heart block and Adams-
Stokes syndrome were relieved of syncopal at-
tacks by administration of 10 mg. every 3 hours
orally (Green and Bennett. Am. Heart J., 1945,
30, 415). In 45 patients with established attacks
of paroxysmal auricular tachycardia, the attacks
were terminated in 30 minutes to 20 hours by
administering 10 mg. of hydroxyamphetamine
every 1 to 3 hours or 20 mg. every hour for 3
doses. Ordinarily one is not concerned about seri-
ous toxicity of such agents except as arise from
cardiovascular symptomatology or excessive ef-
fects such as headache, palpitation, substernal
discomfort, sweating, nausea and vomiting.

Administration. — For external use. 1 or 2
drops of the 1 per cent solution made isotonic
with boric acid is applied to the conjunctival sac
as a mydriatic. In the nose the 1 per cent solution
made isotonic with sodium chloride is used as a
vasoconstrictor in the form of a spray, drops or
on a tampon ; 2 to 5 drops are applied 4 or 5 times
daily. For irrigation of the paranasal sinuses, a
0.25 per cent solution in sterile isotonic solution

Part I

Hyoscyamine Sulfate 673

of sodium chloride is used. A 1 per cent solution
containing 5 per cent of microcrystalline sulfa-
thiazole and thimerosal as a preservative has been
widely used in the nose. Orally, 20 to 60 mg.
(approximately ^ to 1 grain) is used 1 to 4 times
daily for postural hypotension, carotid sinus syn-
drome and heart block.

Storage. — Preserve "in well-closed, light-
resistant containers." U.S.P.

HYOSCYAMINE HYDROBROMIDE.

N.F.

/-Hyoscyaminium Bromide

CnEfesNOs.HBr

"Hyoscyamine Hydrobromide is the hydrobro-
mide of an alkaloid usually obtained from Hyo-
scyamus species or other plants of the Fam.
Solanacece. Caution. — Hyoscyamine Hydrobro-
mide is extremely poisonous." N.F.

Hyoscyamine is one of the naturally occurring
alkaloids of hyoscyamus and related plants of
the Solanacece; it is the levorotatory component
of the racemic mixture known as atropine, the
latter being prepared from hyoscyamine by race-
mization. A method of obtaining hyoscyamine
from hyoscyamus is described under Atropine;
for another procedure see The Technology and
Chemistry of Alkaloids, by Hamerslag, 1950.
The hydrobromide is obtained from the alkaloid
by interaction with hydrobromic acid.

Description. — "Hyoscyamine Hydrobromide
occurs as white, odorless, crystals or as a crystal-
line powder. Its solutions, freshly prepared, are
neutral to litmus. It is affected by light. Hyoscya-
mine Hydrobromide is freely soluble in water.
One Gm. is soluble in about 2.5 ml. of alcohol,
and in about 1.7 ml. of chloroform. It is very
slightly soluble in ether. Hyoscyamine Hydrobro-
mide melts between 149° and 153°." N.F.

Standards and Tests. — Identification. — (1),
(2) The tests described under Atropine are em-
ployed, hyoscyamine yielding in test (2) reddish-
brown scales, which may be accompanied by
reddish-brown needles. (3) A 1 in 20 aqueous
solution yields a yellowish precipitate, insoluble
in nitric acid, with silver nitrate T.S. Loss on
drying. — Not over 1 per cent, when dried at 105°
for 2 hours. Specific rotation. — Not less than
—20°, when determined in a solution in water
containing 500 mg. of dried hyoscyamine hydro-
bromide in each 10 ml. Residue on ignition. — The
residue from 100 mg. is negligible. Other alka-
loids.— The test is essentially similar to the cor-
responding test under Atropine. N.F.

Uses. — The physiological effects of hyoscya-
mine are qualitatively the same as those of its
racemic derivative atropine, although there are
some quantitative differences. Cushny (/. Phar-
macol., 1903, 30, 177) found hyoscyamine (the
levorotatory or naturally occurring isomer) to be
relatively more active in its paralyzing effect on
nerve endings and less active in its stimulant ac-
tion upon the central nervous system than is
atropine; the peripheral activity of hyoscyamine
is estimated as about twice that of atropine. The
sedative and hypnotic action of hyoscyamine is
weaker than that of scopolamine.

Hyoscyamine and its salts have been variously
employed for therapeutic purposes. In the treat-
ment of delirium tremens and mania they have
been used for sedative effect. In parkinsonism
they relieve tremor, rigidity and excessive saliva-
tion. It is claimed also that they relieve the pain
of neuralgia, and prevent seasickness.

Under the trade-marked name Rabellon (Sharp
& Dohme) there is supplied a tablet containing
0.4507 mg. of hyoscyamine hydrobromide, 0.0372
mg. of atropine sulfate, and 0.0119 mg. of scopol-
amine hydrobromide which is intended for use in
treating parkinsonism; the initial dosage is 2
tablets 4 times daily, which may be increased by
1 tablet every third day if indicated. Older ar-
teriosclerotic patients may obtain symptomatic
relief of muscular rigidity with 1 tablet 2 or 3
times daily without risk of precipitating glaucoma
(Neal and Dillenberg, N. Y. State J. Med., 1940,
40, 1300;. This combination of alkaloids approxi-
mates the composition of an extract of Bulgarian
belladonna which was at one time believed to be
superior to other belladonna preparations for
management of parkinsonism (Hill, Lancet, 1938,
2, 1048).

The usual dose range of hyoscyamine hydro-
bromide is 0.25 to 1 mg. (approximately Vno to
Yqo grain), administered orally or hypodermically;
doses of up to 6 mg. are reported to have been
given in mania.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

HYOSCYAMINE SULFATE.

/-Hyoscyaminium Sulfate

(Ci7H23N03)2.H2S04.2H20

N.F.

"Hyoscyamine Sulfate is the sulfate of an alka-
loid usually obtained from Hyoscyamus species
or other plants of the Fam. Solanacece. Caution. —
Hyoscyamine Sulfate is extremely poisonous."
N.F.

Description. — "Hyoscyamine Sulfate occurs
as white, odorless crystals or as a crystalline
powder. It is deliquescent. It is affected by light.
Its solutions are acid to litmus. One Gm. of Hyo-
scyamine Sulfate dissolves in about 0.5 ml. of
water and in about 5 ml. of alcohol. It is practi-
cally insoluble in ether. Hyoscyamine Sulfate,
previously dried at 105° for 4 hours, melts be-
tween 204° and 210°." N.F.

Standards and Tests. — Identification. — (1),
(2) These tests are identical with corresponding
tests for Hyoscyamine Hydrobromide. (3) A
1 in 20 solution responds to the test for sulfate.
Loss on drying. — Not over 5 per cent, when dried
at 105° for 4 hours. Specific rotation. — As for
Hyoscyamine Hydrobromide. Readily carboniz-
able substances. — A solution of 200 mg. in 5 ml.
of sulfuric acid has no more color than matching
fluid A. Residue on ignition. — Not over 0.2 per
cent. Other alkaloids. — This test is the same as
the corresponding one described under Hyoscy-
amine Hydrobromide. N.F.

The uses and dose of hyoscyamine sulfate are
the same as for Hyoscyamine Hydrobromide.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

674 Hyoscyamus

Part I

HYOSCYAMUS. N.F., B.P. (I.P.)

Henbane, [Hyoscyamus]

"Hyoscyamus is the dried leaf, with or with-
out the stem and flowering or fruiting top, of
Hyoscyamus niger Linne (Fam. Solanacecz). Hyo-
scyamus yields not less than 0.040 per cent of
the alkaloids of Hyoscyamus." N.F. The B.P.
defines the same drug, but requires not less than
0.050 per cent of alkaloids, calculated as hyo-
scyamine. The I.P. title for the identical drug is
Hyoscyamus Herb; an alkaloid content of not
less than 0.050 per cent is required.

The I.P. also recognizes, in a separate mono-
graph, Hyoscyamus Muticus Herb {Hyoscyami
Mutici Herba), known as Egyptian Henbane,
which consists of the dried leaves and flowering
tops of Hyoscyamus muticus L.; an alkaloid con-
tent of not less than 0.5 per cent, calculated as
hyoscyamine, is required.

I.P. Hyoscyamus Herb; Hyoscyami Herba. Hyoscyamus
Leaves; Black Henbar/e; Poison Tobacco; Henbell. Herba
Hyoscyami; Folia Jusquiami. Fr. Jusquiame noire; Feuilles
de jusquiame. Ger. Bilsenkrautblatter; Hiihnertod; Saii-
kraut; Schlafkraut; Tollkraut. It. Giusquiamo; Josciamo.
Sp. Hoja de belefio; Beleno.

There are about eleven species of the genus
Hyoscyamus known; these are distributed from
the Canary Islands over Europe and northern
Africa to Asia.

Hyoscyamus niger, or henbane, occurs in two
varieties representing annual and biennial plants.
They possess a long, tapering, whitish, fleshy,
branching root, not unlike that of parsley, for
which it has been eaten by mistake, with poison-
ous effects. The stem is erect, branching, usually
from one to four feet high, and thickly furnished
with leaves. These are alternate, oblong-ovate,
deeply sinuated with pointed segments, undulated,
soft to the touch, and clasping at their base.
The upper leaves are generally entire. Both the
stem and leaves are hairy, viscid, and of a sea-
green color. The flowers form long, one-sided,
leafy spikes, which terminate the branches, and
hang downward. They are composed of an urn-
shaped calyx with five pointed lobes, a bell-
shaped corolla, wath five unequal, obtuse seg-
ments at the border, five stamens inserted into
the tube of the corolla, and a pistil with a blunt,
round stigma. The corolla is of an obscure yel-
low color, beautifully variegated with purple
veins. The fruit is a two-celled pyxis, invested
with the persistent calyx, and contains numerous
small seeds, which are discharged by the hori-
zontal separation of the lid near the top of the
fruit. The whole plant has a rank, offensive odor.

H. niger is susceptible of considerable diversity
of character, causing varieties which have by
some been considered as distinct species. Thus,
the plant is sometimes annual, the stem simple,
smaller, and less downy than in the biennial plant,
the leaves shorter and less hairy and viscid, and
the flowers often yellow without the purple
streaks.

The plant is found in the northern and eastern
sections of the United States, occupying waste
grounds in the older settlements, particularly
cemeteries, old gardens, and the foundations of
ruined houses. It is not, however, a native of

this country, having been introduced from Eu-
rope. In Great Britain, and on the continent of
Europe, it grows abundantly along the roads,
around villages, amidst rubbish, and in unculti-
vated places. The annual plant flowers in July
or August, the biennial in May or June.

The seeds are very small, roundish, compressed,
somewhat kidney-shaped, a little wrinkled, of a
gray or yellowish-gray color, of the odor of the
plant, and of an oleaginous, bitterish taste. From
experiments made by Hirtz upon the relative
medicinal power of extracts from the seeds and
from the leaves, he inferred that the former had
ten times the strength of the latter. Henbane
leaves yield, by destructive distillation, a very
poisonous empyreumatic oil.

Since 1941 the plant has been produced in the
United States on an increasing commercial scale.
For information on the cultivation of hyoscyamus
see Newcomb and Haynes {Am. J. Pharm., 1916,
88, 1) and Crooks and Sievers {Medicinal Plants,
U. S. Dept. Agr. Bur. PI. Ind., June, 1941, 11).

Total imports of hyoscyamus into the United
States in 1952 amounted to 117,014 pounds, sup-
plies coming from Egypt, Belgium, Hungary,
and West Germany. It is probable that much of
the Egyptian drug is derived from H. muticus L.
which grows abundantly in that country; the drug
from this source is readily recognized by the
presence of the characteristic branching non-
glandular hairs which are found on both the
stems and the leaves (see Am. J. Pharm., 1908,
p. 361). It yields a larger proportion of total
alkaloids than the official species and is now being
imported for alkaloid extraction. The I.P. recog-
nizes this drug in a separate monograph, requir-
ing it to contain not less than 0.5 per cent of
alkaloids.

H. albus L., so named from the whiteness of
its flowers, is used in France indiscriminately
with the former species, with which it appears
to be identical in medicinal properties. Hyoscya-
mus reticularis L., according to Konowalowa and
Magidson {Arch. Pharm., 1928, 266, 449), con-
tains only a small amount of hyoscyamine, but
about 1 per cent of a liquid base, tetramethyldi-
aminobutane.

Description. — "Unground Hyoscyamus con-
sists of leaves, stems, and flowering and fruiting
tops and occurs usually much wrinkled, matted,
and broken. The leaves are ovate or ovate-
lanceolate, inequilateral, with petioles up to one-
third the length of the lamina, or sessile; the
apex is acute, the margin either irregularly den-
tate or pinnatifid with acute triangular lobes;
hairy, densely so on the lower surface. The upper
surface is dark green, the lower surface is light
gray green. The stems are from 2 to 7 mm. in
thickness, cylindrical or somewhat compressed,
longitudinally wrinkled, hairy, gray green. The
flowers are nearly sessile, with an urn-shaped,
hairy, unequally 5-toothed calyx, and a campanu-
late. slightly zygomorphic corolla, yellowish with
purplish veins. The fruit is a 2-locular pyxis en-
closed in the persistent calyx. The odor is dis-
tinctive and the taste is bitter and acrid." N.P.
For histology see N.F. X.

"Powdered Hyoscyamus is grayish green to

Part I

Hyoscyamus Extract 675

dark green. It shows uniseriate hairs; non-glandu-
lar hairs unicellular to 1-celled, the distal cell
frequently spherical and glandular in cultivated
drug; glandular hairs with 1- to 4-celled stalk
and a unicellular or multicellular head. Calcium
oxalate crystals occur in single or twin mono-
clinic prisms or in rosette aggregates from 10 to
25\x in diameter, and in sphenoidal microcrystals
from 6 to 12\i in length. Sclerenchyma fibers at-
taining a length of 1 mm. and a width of 30m.,
some with wavy walls and ends variously forked,
are present. Nearly smooth pollen grains occur
with 3 radiating furrows having a pore in the
median part of each furrow, which when dry or
in alcohol are distinctly elliptical and approxi-
mately 35 by 50n but in water spherical and
about 40^ in diameter. The epidermal cells of
the seed coat have radial and inner greatly thick-
ened walls which are incrusted with granular
crystals of silicic acid." N.F.

The B.P. description of this drug differs from
that of the N.F. in stating that the petioles are
up to 30 centimeters long. Leaf-stalks of this
length are rarely found except in the first year
plants; the N.F. description is based on leaves
of the second year.

Standards and Tests. — Hyoscyamus stems.
— The amount does not exceed 25 per cent, and
none are over 7 mm. in diameter. Acid-insoluble
ash. — Not over 12 per cent. N.F.

Assay. — The assay is performed as directed
for Belladonna Leaf, using 25 Gm. of hyoscyamus.
Each ml. of 0.02 N acid represents 5.788 mg. of
hyoscyamus alkaloids. N.F.

The B.P. assay differs from that of the N.F.
in several respects. Hyoscyamus, in fine powder,
is extracted with a mixture of four parts of
ether and one part of alcohol, the solution being
alkalinized with ammonia water. After complete
extraction of the alkaloids, the concentrated per-
colate is shaken out first with 0.5 N hydrochloric
acid, then with a mixture of 0.1 N hydrochloric
acid and alcohol until complete extraction is
effected. The acid liquids are extracted with
chloroform to remove impurities; this extraction
is rejected. The aqueous solution is then alkalin-
ized with ammonia water and extracted with
chloroform; the chloroform extract, after wash-
ing with water, is evaporated. The residue is dis-
solved in a measured amount of 0.02 N hydro-
chloric acid and titrated with 0.02 N sodium
hydroxide, using methyl red as indicator. Each
ml. of 0.02 N hydrochloric acid is equivalent to
5.788 mg. of alkaloids, calculated as hyoscyamine.
The I. P. assay is practically identical with that
of the B.P. except that it permits an alternative
method of completing the assay, which is iden-
tical with the alternative method permitted by
the LP. for Belladonna Leaf (and is described in
this volume under that title).

Constituents. — Ladenburg in 1880 demon-
strated the presence in hyoscyamus of two alka-
loids which he called hyoscyamine and hyoscine.
The latter is now considered to be identical with
the alkaloid scopolamine (see Scopolamine Hy-
drobromide). Klan (/. A. Ph. A., 1931, 20, 1164)
found that the relative proportion of the two
alkaloids varies greatly with the age of the plant;

when the leaves first appear the alkaloid is
mostly scopolamine but as they grow older the
hyoscyamine gradually predominates; there is an
analogous difference in the root, the young root-
lets showing a larger proportion of scopolamine
and the old ones of hyoscyamine. He also found
traces of tropine and scopoline — decomposition
products of the alkaloids — in withering parts of
the plant. Further information concerning the
alkaloids is provided in separate monographs for
each.

Uses. — The therapeutic effects of hyoscyamus
are very similar to those of belladonna since the
principal active ingredient of both is hyoscya-
mine, but hyoscyamus must be given in consid-
erably larger doses since it contains much less
alkaloid. The action of hyoscyamus, however, is
more or less modified by the presence of scopola-
mine, which imparts a central narcotic effect (see
under Scopolamine Hydrobromide). As the pro-
portion of the two alkaloids may vary consider-
ably in different specimens of the plant it would
appear to be more rational, when a combined
effect of the alkaloids is desired, to add scopola-
mine in the proper proportion to a preparation
of belladonna rather than to depend upon an
uncertain proportion in hyoscyamus.

The most important use of hyoscyamus is to
provide relief of painful spasmodic conditions of
unstriped muscle, as in lead colic and irritable
bladder. It is also employed to allay nervous irri-
tation, as in various forms of hysteria or irritable
cough; it is considered inferior to scopolamine
for these purposes.

Externally, cataplasms or fomentations of
fresh hyoscyamus leaves have been used to allay
pain though it is not certain to what degree these
may have been effective, [v]

The usual dose of hyoscyamus is 200 mg. (ap-
proximately 3 grains), with a range of 120 to
300 mg.

Storage. — Preserve "against attack by in-
sects." N.F.

HYOSCYAMUS EXTRACT. N.F. (B.P.)

Henbane Extract, [Extractum Hyoscyami]

"Hyoscyamus Extract yields, from each 100
Gm., not less than 135 mg. and not more than
175 mg. of the alkaloids of hyoscyamus." N.F.
The B.P. Extract of Hyoscyamus contains 0.3 per
cent of the total alkaloids of hyoscyamus, calcu-
lated as hyoscyamine (limits 0.27 to 0.33).

B.P. Dry Extract of Hyoscyamus; Extractum Hyoscy-
ami Siccum. Fr. Extrait de jusquiame. Get. Bilsen-
krautextrakt. It. Estratto di giusquiamo. Sp. Extracto
de beleno.

As with belladonna extract, two forms of this
extract are official — the Pilular Extract and the
Powdered Extract.

Pilular Hyoscyamus Extract. — Prepare the
extract by percolating 1000 Gm. of hyoscyamus,
in moderately coarse powder, using a menstruum
of 3 volumes of alcohol and 1 volume of water.
Macerate the drug during 16 hours, then percolate
at a moderate rate. Evaporate the percolate to a
pilular consistence under reduced pressure at a
temperature not over 60°, and adjust the residue,

676 Hyoscyamus Extract

Part I

by addition of liquid glucose, so that the finished
extract contains 155 mg. of hyoscyamus alka-
loids in 100 Gm. of extract. N.F.

Powdered Hyoscyamus Extract. — Prepare
the extract by percolating 1000 Gm. of hyos-
cyamus, in moderately coarse powder, using alco-
hol as the menstruum. Macerate the drug during
16 hours, then percolate slowly. Evaporate the
percolate to a soft extract under reduced pressure
at a temperature not over 60°, add 50 Gm. of dry
starch, and continue evaporation until a dry prod-
uct results. Powder the residue and adjust it to
contain, by the addition of sufficient starch, 155
mg. of hyoscyamus alkaloids in 100 Gm. of ex-
tract. The extract may be deprived of fat by
treating either the soft extract first obtained, or
the dry and powdered extract, as directed under
Extracts. N.F.

The B.P. directs percolation of the moderately
coarse powder of hyoscyamus leaf with 70 per
cent alcohol. The percolate is tested for the
amount of alkaloids and also for the proportion
of total solids; nearly the whole of an amount of
powdered hyoscyamus of known alkaloidal con-
tent, which will produce an extract containing
0.3 per cent of alkaloids, is added and the mixture
evaporated at a temperture not exceeding 60°
and dried in a current of air at 80°. The dry resi-
due is then powdered, the remainder of the hyos-
cyamus added, and the whole mixed and passed
through a No. 22 sieve. The B.P. extract of hyos-
cyamus is about double the strength of the N.F.
extract.

The usual dose is 50 mg. (approximately :yi
grain), with a range of 30 to 130 mg. (approxi-
mately Yi to 2 grains).

Storage. — Preserve "in tight, light-resistant
containers, preferably at a temperature not above
30°." N.F.

HYOSCYAMUS TINCTURE.
N.F. (B.P., LP.)

Henbane Tincture, [Tinctura Hyoscyami]

"Hyoscyamus Tincture yields, from each 100
ml., not less than 3.4 mg. and not more than 4.6
mg. of the alkaloids of hyoscyamus." N.F. The
B.P. Tincture of Hyoscyamus contains 0.005 per
cent w/v of the alkaloids of hyoscyamus, calcu-
lated as hyoscyamine (limits 0.0045 to 0.0055).
The LP. rubric is the same.

B.P. Tincture of Hyoscyamus. Fr. Teinture de jus-
quiame. Ger. Bilsenkrauttinktur. It. Tintura di gius-
quiamo. Sp. Tintura de beleno.

Prepare the tincture, by Process P, as modified
for assayed tinctures (see under Tinctures), from
100 Gm. of hyoscyamus, in moderately coarse
powder, using a menstruum of 3 volumes of alco-
hol and 1 volume of water. Adjust the volume of
the product so as to contain 4 mg. of the alkaloids
of hyoscyamus in 100 ml. of tincture. N.F.

The B.P. tincture is prepared by diluting 10
per cent by volume of liquid extract of hyos-
cyamus with 70 per cent alcohol. It contains more
alkaloid than the N.F. tincture.

Assay. — A 250-ml. portion of tincture is con-
centrated to about 25 ml. and assayed by the

method summarized under Belladonna Tincture.
Each ml. of 0.02 N sulfuric acid represents 5.788
mg. of the alkaloids of hyoscyamus. N.F.

Alcohol Content. — From 65 to 70 per cent,
by volume, of C2H5OH. U.S.P.

The usual dose is 2 ml. (approximately 30
minims) ; the B.P. gives a range of 2 to 4 ml.

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to direct sunlight
and to excessive heat." N.F.

COMPOUND HYPOPHOSPHITES
SYRUP. N.F.

[Syrupus Hypophosphitum Compositus]

Ger. Hypophosphitsirup. It. Sciroppo di ipofosfiti com-
posto. Sp. Jarabe de hipofosfitos. compuesto.

Mix 2.2 Gm. of ferric hypophosphite and 2.2
Gm. of manganese hypophosphite with 3.7 Gm.
of sodium citrate, add 30 ml. of purified water and
warm the mixture until solution results. Dissolve
35 Gm. of calcium hypophosphite, 17.5 Gm. of
potassium hypophosphite and 17.5 Gm. of sodium
hypophosphite in 400 ml. of purified water con-
taining 2 ml. of hypophosphorous acid; then dis-
solve 1.1 Gm. of quinine and 0.1 Gm. of strych-
nine in 30 ml. of purified water containing 3 ml.
of hypophosphorous acid and add 300 ml. of
glycerin; mix the solutions, and dissolve 250 Gm.
of dextrose in the product. Add enough purified
water to make 1000 ml., and strain. N.F.

Although not infrequently prescribed, the quan-
tities of active ingredients are so small that this
syrup can hardly be expected to have any useful
physiological effect.

The N.F. gives the average dose as 8 ml. (ap-
proximately 2 fluidrachms).

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." N.F.

HYPOPHOSPHOROUS ACID.

[Acidum Hypophosphorosum]

N.F.

"Hypophosphorous Acid contains not less than
30 per cent and not more than 32 per cent of
HPH2O2." N.F.

Fr. Acide hypophosphoreux. Ger. Unterphosphorigesaure.
Sp. Acido Hipofosforoso (31 per cent).

Hypophosphorous acid may be prepared by
several different processes. In one of these barium
hypophosphite interacts with dilute sulfuric acid;
the barium sulfate is precipitated and the hypo-
phosphorous acid is obtained by evaporating the
liquid phase. In a second method calcium hypo-
phosphate reacts with oxalic acid; in this case
calcium oxalate is precipitated, the hypophos-
phorous acid again being found in the liquid por-
tion. A third method involves interaction between
potassium hypophosphite and tartaric acid in
hydroalcoholic solution; potassium bitartrate pre-
cipitates on cooling the mixture, with hypophos-
phorous acid remaining in solution.

Description. — "Hypophosphorous Acid is a
colorless or slightly yellow, odorless liquid. It is
acid to litmus paper even when highly diluted. Its
specific gravity is about 1.13." N.F.

Absolute hypophosphorous acid is a colorless,

Part I

Ichthammol

677

syrupy liquid which, at about 17.5°, becomes a
white, crystalline solid melting at 26.5°.

Standards and Tests. — Identification. — Hy-
pophosphorous acid responds to tests for hypo-
phosphite. Arsenic. — The limit is 1.5 parts per
million. Barium. — No turbidity is produced when
30 ml. of a dilution of hypophosphorous acid with
3 volumes of water is neutralized with ammonia
T.S., filtered, a portion of the filtrate acidulated
with hydrochloric acid and potassium sulfate T.S.
added. Oxalate. — A portion of the filtrate in the
preceding test exhibits no turbidity on addition of
calcium chloride T.S. Heavy metals. — The limit is
20 parts per million. U.S.P.

Assay. — About 7 ml., accurately weighed, is
titrated, as a monobasic acid, with 1 N sodium
hydroxide, using methyl red T.S. as indicator.
Each ml. of 1 IV sodium hydroxide represents
66.00 mg. of HPH2O2. N.F.

Incompatibilities. — Hypophosphorous acid is
incompatible with many substances because of its
powerful reducing properties. It reduces bismuth,
mercuric, and mercurous compounds to the metal-
lic state. Ferric and cupric compounds are reduced
to ferrous and cuprous. Permanganates are
changed to manganous compounds; arsenates are
reduced to arsenites and sometimes to metallic
arsenic. When triturated with some oxidizing
agents, like potassium chlorate, it may cause an
explosion.

Uses. — Hypophosphorous acid and its salts
were once believed to have a "tonic" effect upon
the nervous system, but it has been demonstrated
that hypophosphite ion passes through the system
unchanged. The acid is officially recognized be-
cause of its use as a stabilizing reducing agent in
several official preparations.

The acid has been administered in doses of
from 0.2 to 0.3 ml. (approximately 3 to 5 minims).

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Ferrous Iodide Syrup; Compound
Hypophosphites Syrup, N.F.

ICHTHAMMOL. N.F., B.P.

Ichthosulfonate, [Ichthammol]

"Ichthammol is obtained by the destructive
distillation of certain bituminous schists, sulfo-
nating the distillate, and neutralizing the product
with ammonia. Ichthammol yields not less than
2.5 per cent of ammonia, and not less than 10
per cent of total sulfur." N.F. The B.P. require-
ments for ichthammol are not less than 10.5 per
cent (w/w) of organically combined sulfur, cal-
culated to the substance dried at 105°, and not
more than one-fourth of the total sulfur in the
form of sulfates.

Sulfonated Bitumen; Ammonium Sulfoichthyolate. Ich-
thymall (Mallinckrodt) ; Ichthyol {Schering) ; Ammonium
Sulf qichthyolicum ; Bitumen Sulfonatum; Ammonium Ich-
thyolicum; Ammonii Sulfoichthyolas. Fr. Ichthyolsulfonate
d'ammonium; Ichthyolammonium. Ger. Ichthyolsulfonsaures
Ammonium; It. Solfoittiolato di ammonio. Sp. Ictiol ;
Ictiosulfonato amonico.

There has long been used in medicine a group
of tarry preparations obtained by sulfonating bi-
tuminous shale. The original preparation of this

type was prepared from the distillate of a deposit
found in the Tyrol. When treated with sulfuric
acid this distillate gave a compound known as
ichthyol- sulfonic acid which was neutralized be-
fore being used, generally with ammonia; salts
of sodium, lithium, calcium, zinc and mercury
have also been prepared and used.

Description. — "Ichthammol is a reddish
brown to brownish black, viscous fluid, with a
strong, characteristic, empyreumatic odor. Ich-
thammol is miscible with water and with glycerin,
and with fixed oils and fats. It is partially miscible
with alcohol and with ether." N.F.

Standards and Tests. — Identification. — (1)
A dark, resinous mass, insoluble in ether, sepa-
rates on adding hydrochloric acid to a 1 in 10
aqueous solution of ichthammol. (2) Ammonia
is evolved on boiling an aqueous solution of ich-
thammol with sodium hydroxide T.S. Loss on
drying. — Not over 50 per cent, when dried at
105° for 6 hours. Residue on ignition. — Not over
0.5 per cent. Limit for ammonium sulfate. — After
washing out interfering substances with a mixture
of alcohol and ether the ammonium sulfate in
the insoluble residue is dissolved in water and
the sulfate precipitated as barium sulfate, which
is finally weighed. Not more than 8 per cent of
ammonium sulfate is permitted. N.F.

Assay. — For ammonia. — A 5-Gm. portion of
ichthammol is mixed with water, an excess of
sodium hydroxide T.S. added, and the ammonia
distilled into a measured excess of 0.5 A'' sulfuric
acid; the excess of acid is titrated with 0.5 IV
sodium hydroxide. Each ml. of 0.5 N sulfuric
acid represents 8.516 mg. of NH3. Assay for total
sulfur. — Oxidation of the sulfur in from 500 mg.
to 800 mg. of ichthammol is effected by warming
with potassium chlorate and nitric acid; the sul-
fate is precipitated as barium sulfate, which is
finally weighed. Each Gm. of barium sulfate
represents 137.4 mg. of S. N.F.

In the B.P. assay for organically combined
sulfur the sample is mixed with sodium carbonate,
using some chloroform to produce a uniform dis-
persion, then heated with cupric nitrate to oxi-
dize sulfur to sulfate, which is finally precipi-
tated as barium sulfate. From the percentage of
total sulfur thus obtained, the percentage of sul-
fur in the form of sulfates is subtracted. The
assay for sulfur in the form of sulfates specifies
addition of a solution of cupric chloride to an
aqueous solution of ichthammol to precipitate
the resinous matter from the latter; in a one-
half aliquot portion of the filtrate the sulfate is
precipitated with barium chloride.

Incompatibilities. — Acids and many metal-
lic salts precipitate ichthammol from solutions;
alkaloids and their salts form less soluble deriva-
tives. Alkalies liberate ammonia. Overheating
causes separation of ichthammol from a supposi-
tory mass.

Uses. — Ichthammol was formerly attributed
with an almost magic "alterative" action upon
the skin and was extensively used; its popularity
has waned in recent decades. Such therapeutic
value as it possesses appears to be ascribable to
a combination of properties. It is feebly irritant,

678

Ichthammol

Part I

as a result of which it acts as a local stimulant
and tends to improve peripheral circulation. It
is feebly antiseptic, and appears to penetrate the
skin rather readily. Mild analgesic action has
been claimed for it.

Ichthyol, undiluted, kills staphylococci in 5
minutes but does not destroy the typhoid bacillus
even after an hour; in 1:2000 concentration it
inhibits the growth of streptococci but a concen-
tration of 5 per cent is required to prevent
growth of staphylococci (Abel, Zentralbl. Bakt.,
1893, 14, 413). In a concentration of 66 per
cent ichthammol sterilized rich cultures of B.
subtilis, B. parathyphus (A, B, and C), B. typhus,
B. oedematiens, and B. perjringens in 3 to 24
hours (Nelis and Lafontaine, Compt. rend. soc.
biol, 1948, 142, 1086).

Ichthammol has been advocated and used in
a variety of cutaneous diseases. It is of most
value in subacute and chronic eczematous derma-
titis, where it is customarily used in 1 to 5 per
cent strength in a zinc oxide ointment or paste
base. By virtue of its being soluble in water it
may be incorporated in lotions, in concentrations
up to 10 per cent, for similar use. Some value
as topical medication in prurigo, lichen planus,
herpes simplex, psoriasis, and some pyogenic in-
fections has been claimed. In higher concentra-
tions, as 10 or 20 per cent ichthammol ointment,
it has long been favored for use in the early
phases of furuncle and carbuncle formation. The
mildly analgesic and antiseptic properties of ich-
thammol are utilized in hemorrhoidal and vaginal
suppositories. Its mildly irritant effect has been
used to some advantage in painful rheumatoid
conditions, bursitis, synovitis, sprains, etc. A 5 or
10 per cent ointment has been used for refractory
ulcerative blepharitis.

In addition to its being used in ointment form,
ichthammol is employed in various lotion formu-
lations; one containing 7.5 Gm. of ichthammol.
12 Gm. of calamine, 120 Gm. of Unseed oil, and
120 Gm. of lime water is recommended for acute
dermatitis due to streptococci (Smith, Pract.,
1944, 152, 297; Fergusson, ibid., 1947, 159, 59).
Glycerin solutions containing 5 to 20 per cent of
ichthammol have been used on the skin, in the
external auditory canal, the vagina, etc.

Ichthammol has also been occasionally pre-
scribed internally as an expectorant. Hypogly-
cemic action has been attributed to it by Schmitz
(Bed. klin. Wchnschr., 1929, 2371).

The usual dose of ichthammol is 200 mg. (ap-
proximately 3 grains), with a range of 120 to
300 mg.

Storage. — Preserve "in well-closed con-
tainers." N.F.

ICHTHAMMOL OINTMENT.

Unguentum Ichthammolis

N.F.

Unguentum Bitumis Sulfonati; Pomatum cum Ichthyolo
Compositum. Fe. Pommade a l'ichthyolsulfonate d'am-
monium ; Pate ichthyolee.

Thoroughly mix 100 Gm. of ichthammol with
100 Gm. of wool fat, and then with 800 Gm. of
petrolatum. N.F.

Storage. — Preserve "in tight containers and
avoid prolonged exposure to temperatures above
30°." N.F.

INOSITOL. N.F.

1,2,3, 5/4, 6-Hexahydroxycyclohexane, /-Inositol,
aww Inositol

"Inositol, dried at 105° for 4 hours, yields not
less than 97 per cent of C6H12O6." N.F.

Myoinositol. Bios I; Dambose; Inosin; Inosite; Phaseo-
mannitol; Meat Sugar; Muscle Sugar.

Inositol was discovered in 1850, by Scherer,
who isolated it from animal muscle tissue and
named it from the Greek word inos, meaning
muscle. It has been found in various forms in
many plant and animal tissues. In plants inositol
generally occurs as a hexaphosphate ester known
as phytic acid, which forms complex salts with
potassium, calcium, magnesium, iron, manganese
and other metals. Seeds and cereal grains are
particularly rich in inositol hexaphosphate. Inosi-
tol occurs in plants also as the polyhydroxy alco-
hol component of certain phospholipids called
lipositols; thus, the soybean phosphatides con-
tain a lipositol.

Inositol may be regarded as a cyclic derivative
of D-glucose in which the aldehyde group of the
latter has been converted to a secondary alcohol
group, with linkage being effected between car-
bon atoms 1 and 6. Altogether there are nine
hexahydroxycyclohexanes, known collectively as
the inositols; the official inositol is the only
isomer which has important biological activity.

While inositol occurs in many natural tissues,
it is obtained commercially in the steep water
in which corn has been soaked prior to manufac-
ture of starch (for a summary of the process see
Chemical Engineering, July 1951, p. 200).

Description. — "Inositol occurs as fine white
crystals or as a white, crystalline powder. It is
odorless, has a sweet taste, and is stable in air. Its
solutions are neutral to litmus. It is optically
inactive. One Gm. of Inositol dissolves in 6 ml.
of water. It is slightly soluble in alcohol and is
insoluble in ether and in chloroform. Inositol
melts between 224° and 227°." N.F.

Standards and Tests. — Identification. — (1)
On boiling a solution containing inositol and lead
subacetate T.S. the mixture becomes translucent
and gelatinizes. (2), (3) Rhodizonic acid, ob-
tained by nitric acid oxidation of inositol, yields
a violet strontium salt and a rose red calcium
salt. (4) Hexaacetylinositol obtained in the assay
melts between 212° and 216°. Loss on drying. —
Not over 0.5 per cent, when dried at 105° for 4
hours. Residue on ignition. — Not over 0.1 per
cent. Chloride. — The limit is 50 parts per mil-

Part I

Inositol

679

lion. Sulfate. — The limit is 60 parts per million.
Calcium. — No precipitate is obtained at once
on addition of ammonium oxalate T.S. to a solu-
tion of inositol. Iron. — The limit is 5 parts per
million. Heavy metals. — The limit is 25 parts per
million. N.F.

Assay. — About 250 mg. of dried inositol is
converted to hexaacetylinositol by heating with
acetic anhydride in the presence of some sulfuric
acid; the derivative is precipitated with water
and, after hydrolyzing the excess acetic anhydride
by boiling, the hexaacetyl compound is extracted
with chloroform, the solvent evaporated, the resi-
due of the compound dried at 105° for 1 hour,
and finally weighed. The gravimetric factor for
converting the weight of the hexaacetyl com-
pound to inositol is 0.4167. N.F.

Uses. — Inositol is of biochemical interest be-
cause it is a constituent of many tissues of the
human body ; medicinally it is of interest because
of the possibility that it may have useful lipo-
tropic activity.

In humans inositol is found in the brain, stom-
ach, kidney, spleen, liver and other tissues; while
it is esterified with phosphoric acid it generally
contains less than the 6 phosphate ester radicals
associated with each molecule of it when present
in plant tissues. The intake of inositol in food
by a person on a diet of 2500 Calories per day is
approximately 1 Gm. daily, which is estimated
to be the probable human requirement (Williams,
J. A.M. A., 1942, 119, 1). Inositol is a product of
hydrolysis of phosphatides in the brain and spinal
cord (Folch and Woolley, /. Biol. Chem., 1942,
142, 963). It is to be noted that inositol and
choline form different types of phospholipids in
the body; thus, inositol has been isolated from
P-cephalins, while choline is found in lecithins
and sphingomyelins (McHenry and Patterson,
Physiol. Rev., 1944, 24, 128).

Inositol is commonly considered to be a mem-
ber of the vitamin B complex; it is essential for
growth of yeasts, being identical with the bios I
factor (Eastcott, /. Physiol. Chem., 1928, 32,
1094; Burkholder et al., J. Bad., 1944, 48, 386;
Woolley, /. Biol. Chem., 1941, 140, 453; and
others), and also promotes the growth of several
bacterial species.

Various beneficial effects of inositol in many
different animals have been reported, including
those of serving as an antialopecia factor in cer-
tain species of mice and of enhancing growth of
some animals (for a review of such reports see
Weidlein's The Biochemistry of Inositol, 1951,
Mellon Institute Bibliographic Series, Bulletin
No. 6). Some of these beneficial effects could
not be confirmed, and it would appear that in
many instances effects attributed to inositol in-
volved a dependence also on the presence of
other factors, such as pantothenic acid and para-
aminobenzoic acid.

Definite symptoms of inositol deficiency have
not been observed in man; the presence of the
substance in many foods and the possibility that
man may synthesize inositol make it difficult to
produce such a deficiency.

Lipotropic Action. — Gavin and McHenry (/.

Biol. Chem., 1941, 139, 485; 141, 619) discov-
ered that inositol has lipotropic action on fatty
livers in rats; such an action was confirmed by
Best et al. {Science, 1946, 103, 12; Biochem. J.,
1946, 40, 368) and others. In clinical studies on
patients with fatty livers administration of inosi-
tol reduced liver fat levels quickly (Abels et al.,
Proc. S. Exp. Biol. Med., 1943, 54, 157). Dietary
fat, which appears to be necessary for choline to
function, has been found to reduce the effective-
ness of inositol (Best et al., J. Biol. Chem., 1950,
186, 317). A synergistic lipotropic action of
inositol and choline has been reported by several
investigators, including Best and his associates
{loc. cit.).

Though the liver is the possible site of forma-
tion of inositol-containing phospholipids little is
known of the method of their formation or their
role in fat metabolism. From the absence of any
methyl group in inositol it is apparent that it
cannot in any way serve as a methyl donor, a
role suggested for choline.

Cholesterol Metabolism. — Inositol is appar-
ently concerned with the metabolism of choles-
terol; it has been observed to reduce the choles-
teryl ester content of animal livers infiltrated
with excessive fat and cholesterol (Best et al.,
loc. cit.; Ridout et al., Biochem. J., 1946, 40,
494; Beveridge and Lucas, /. Biol. Chem., 1945,
157, 311; and others). In hypercholesterolemic
humans, inositol administered at a dosage level
of 2 Gm. a day for 6 to 10 weeks reduced both
blood cholesterol and cholesteryl esters by ap-
proximately 20 per cent (Herrmann, Exp. Med.
& Surg., 1947, 5, 149). It has been hypothesized
that such an effect may be the result of forma-
tion of inositol-containing phospholipids which
inhibit formation of lipid-cholesterol macromole-
cules.

Cirrhosis. — While the usual progressive course
of liver cirrhosis was not altered in 36 patients
receiving inositol, 7 of 10 given inositol with a
high-protein diet experienced a definite subjective
and clinical improvement (Echaurren and Jor-
quera, Rev. Medica de Chile, 1943, 71, 755, re-
ported through J.A.M.A., 1944, 124, 66). A low-
fat and low- cholesterol intake, accompanied by
inositol administration, lowered blood-lipid levels
in a patient with xanthomatous biliary cirrhosis
(Gephardt, Ann. Int. Med., 1947, 26, 764). In a
case of cirrhosis and ascites of dietary origin,
administration of inositol was beneficial and
Broun {Postgrad. Med., 1948, 4, 203) concluded
that use of choline, inositol and other lipotropic
substances probably permits successful treatment
of cirrhosis at a lower level of protein intake
than would otherwise be feasible. Inositol ap-
pears to have no favorable action, however, in
cirrhosis resulting from carbon tetrachloride
poisoning.

The dose of inositol has varied widely; the
usual dosage has been 1 to 3 Gm. daily in di-
vided doses but the N.F. gives the usual dose as
2 Gm.

Storage. — Preserve "in well-closed con-
tainers." N.F.

680

Inositol Tablets

Part I

INOSITOL TABLETS. N.F.

"Inositol Tablets contain not less than 93 per
cent and not more than 107 per cent of the labeled
amount of C6H12O6." N.F.

Usual Sizes. — 250 and 500 mg. (approxi-
mately 4 and iy2 grains).

INSULIN INJECTION. U.S.P.
(B.P, LP.)

Insulin, Insulin Hydrochloride, [Injectio Insulini]

"Insulin Injection is a sterile, acidified solu-
tion of the active principle of the pancreas which
affects the metabolism of glucose. Insulin Injec-
tion possesses a potency of not less than 95 per
cent and not more than 105 per cent of the po-
tency stated on the label, expressed in U.S.P.
Insulin Units. Insulin Injection contains 40, 80,
100, or 500 U.S.P. Insulin Units in each ml."
U.S.P. The B.P. and LP. define Injection of
Insulin as a sterile solution of the specific anti-
diabetic principle of the mammalian pancreas
containing, according to the B.P., 20, 40, or 80
Units per ml., or, according to the LP., 20, 40,
80, or 100 International Units per ml.

B.P., I. P. Injection of Insulin. Iletin {Lilly'). Solutum
Insulini. Fr. Solute injectable d'insuline. Sp. Inyeccion
de Insulina.

In addition to producing digestive enzymes,
the pancreas is concerned with the elaboration of
one and possibly two hormones regulating me-
tabolism of carbohydrates. These hormonal se-
cretions arise from minute nests of cells located
in the body and tail of the pancreas, these being
approximately 0.3 mm. in diameter and separated
from the pancreatic acini by a delicate envelope
of connective tissue provided with a rich supply
of blood; these structures are known as the islets
of Langerhans. In some animals, notably in cer-
tain species of fish, the islets are entirely sep-
arate from the pancreas. The product of the beta
cells of the islets, which is insulin, is essential
for utilization of glucose; the rate of formation
of the hormone varies directly with the level of
blood sugar. In the condition known as diabetes
mellitus, there is evidence that a deficiency of
insulin is involved in its pathogenesis, giving rise
to an elevation of blood sugar and to the appear-
ance of glucose in urine when the renal threshold
is exceeded. This is known as the underproduction
theory of diabetes and is supported by the low
levels of insulin present in the pancreas of dia-
betic humans as well as the reduced levels of
insulin found in the serum of diabetic patients
(in some cases no insulin is present). Abnormali-
ties in other endocrine glands (pituitary, adrenal
and thyroid), and possibly hepatic dysfunction,
may rarely be encountered as a cause of diabetes;
even in these instances insulin deficiency is prob-
ably responsible for appearance of diabetes. The
overproduction of glucose is a theory of the
pathogenesis of diabetes mellitus (see presenta-
tion of evidence in Carbohydrate Metabolism,
Soskin and Levine, 2nd edition) which has not
met with general acceptance. Although cortisone
(q.v.) has marked action on carbohydrate metab-
olism, studies indicate that only a few cases of

hyperadrenocorticism have diabetes mellitus;
moreover, the functional activity of the adrenal
cortex in diabetes mellitus seems to be depressed
if it is abnormal at all. If adrenal steroids are
involved in the pathogenesis of diabetes mellitus,
present information indicates an interference with
utilization of carbohydrate rather than overpro-
duction of glucose. The overproduction theory
cannot, however, be discarded on the basis of
available information.

The second substance, which also may be a
hormone, isolated from the islets is thought to
arise from the alpha cells and has been designated
the hyperglycemic-glycogenolytic factor, also
known as glucagon and HGF. Direct proof that
the substance is an actual hormone remains to be
provided. The presence of HGF in insulin prep-
arations was suspected from the observation that
prior to their hypoglycemic effect most commer-
cial insulin preparations produced an initial rise
of blood sugar on injection. Certain Danish in-
sulins (Novo brand) do not contain this con-
taminant. Following its isolation, Sutherland
found that the action of HGF was that of activa-
tion of hepatic phosphorylase, resulting in the
hydrolysis of glycogen to glucose and giving rise
to a transient elevation of blood sugar (Recent
Progress in Hormone Research, 1950, Academic
Press; also /. Biol. Chem., 1949, 180, 825).
Glucagon may be a modifying agent in patients
with diabetes (Pincus and Rutman, Arch. Int.
Med., 1953, 92, 666).

In the treatment of diabetes, oral administra-
tion of various extracts of pancreas has been at-
tempted without success; insulin, being a protein
hormone, is rapidly destroyed by the action of
the proteolytic enzymes of the pancreas, espe-
cially by chymotrypsin. The problem of separat-
ing insulin in a form suitable for administration
by injection was solved by the classical researches
of Banting and Best (/. Lab. Clin. Med., 1922, 7,
251).

Manufacture. — The commercial production
of insulin has undergone many improvements
since the hormone was first introduced for thera-
peutic use. While details of manufacturing proc-
esses vary to some degree, the process described
by the B.P. is typical. Finely divided pancreas
(which may be beef or pork), either fresh or
frozen from the time of removal from the animal,
is extracted with alcohol acidified with a suitable
mineral acid. The extract, separated from the
marc, is concentrated under reduced pressure
and. after removal of separated fat, crude insulin
is salted out as the hydrochloride or precipitated
as the picrate, which latter is subsequently con-
verted to the hydrochloride. From an aqueous
solution of the hydrochloride insulin is precipi-
tated by adjusting the pH to 5.2 and allowing the
liquid to stand. The precipitate is purified by
crystallization from suitably buffered aqueous
solutions containing zinc chloride; crystallization
is repeated until regular cubic crystals are ob-
tained, having an activity equivalent to not less
than 22 units per mg., calculated with reference
to anhydrous material. The pure crystals are dis-
solved in distilled water containing 1.45 to 1.75
per cent w/v of glycerin sufficient hydrochloric

Part I

Insulin Injection 681

acid to adjust the pH to not less than 3 and not
more than 3.5, and sufficient of a suitable bac-
teriostatic agent to prevent growth of micro-
organisms, are added. The solution is sterilized
by filtration through a bacteria-proof filter, as-
sayed biologically, and its strength adjusted to
the desired potency.

Zinc-Insulins. — In 1934, Scott (Biochem. J.,
1934, 28, 1592) discovered that by adding a
small amount of a zinc salt to a solution of
amorphous insulin it is possible to obtain it in
crystalline form, of a higher degree of purity
than the product obtained when zinc is omitted.
The potency of the zinc-insulin crystals, as they
are known, varies between 22 and 24 Interna-
tional Units per milligram, the Permanent Com-
mission on Biological Standardization of the
League of Nations assigning to an international
standard preparation of such crystals an activity
of 22 International Units per milligram; by con-
trast, the old International standard preparation
of amorphous insulin had an activity of 8 Inter-
national Units per milligram. The considerably
greater purity of zinc-insulin crystals resulted in
a substantial reduction of instances of hypersen-
sitive response by patients who had received
amorphous insulin.

In the course of a study seeking to elucidate
the nature of the interaction between insulin and
zinc, Hallas-M0ller et at. {Science, 1952, 116,
394) made certain observations which have led
to what appear to be the most significant im-
provement in the preparation of insulin injections
since Scott's finding led to the preparation of
injections from zinc-insulin crystals. One of
Hallas-M0ller's observations was that in certain
aqueous media it is possible to prepare both
amorphous and crystalline forms of zinc-insulin,
these varying in zinc content according to the
concentration of insulin and of zinc employed,
and also on the pH of the medium in which the
particles are suspended. A second observation was
that as the zinc content of the crystals is in-
creased up to a certain point the solubility of
the crystals is reduced and hypoglycemic action
is prolonged. The third observation was that the
larger the crystal size, the longer the duration of
the hypoglycemic effect, with amorphous particles
acting for only a short period.

These effects were observed principally in solu-
tions of sodium acetate buffered over a wide
range of pH values; when sodium phosphate was
used (as in the preparation of protamine zinc
insulin and NPH or isophane insulin) the effects
of zinc were neutralized, apparently as a result of
an affinity between zinc and phosphate. Citrate
buffers likewise neutralize the effects of zinc. In
acetate buffers zinc insulin is completely insoluble
in the range of pH 5.0 to 8.0, while in phosphate
buffers the range of complete insolubility is about
pH 5.0 to 6.0, which is substantially the same
range in which zinc-free insulin is precipitated.

Based on these recent observations, the Novo
Laboratories of Denmark introduced three new
preparations of insulin, as follows: (1) one con-
taining relatively large crystals of zinc-insulin,
which have prolonged action (more than 30
hours), and designated Ultralente insulin; (2) a

preparation containing fine, amorphous particles
of zinc-insulin having a short duration of action
(12 to 14 hours), called Semilente insulin; (3) a
mixture of 3 parts of the amorphous insulin and
7 parts of the crystalline insulin, the mixture
having an intermediate duration of action (about
24 hours), known as Lente insulin. These insulin
preparations are now available in the United
States. The preparations contain thrice-crystal-
lized insulin, are combined with zinc in the pro-
portion of 2 mg. per 1000 units of insulin (which
is several times the content of zinc in zinc-
insulin crystals used in preparing the official in-
sulin injection), and are suspended in a saline and
acetate buffer medium having a pH of 7.2 (the
pH of U.S. P. insulin injection is between 2.5 and
3.5). Each of the three varieties may be mixed
with either of the others to produce stable mix-
tures; they should not be mixed with insulin
preparations containing phosphate. It is claimed
that 90 per cent of diabetics requiring insulin
can be successfully treated with a single daily
injection of the appropriate form of one of the
new insulins; the absence of foreign protein in
these insulins materially reduces the chance of
local skin sensitization.

Description. — "Insulin Injection containing
in each ml. not more than 100 U.S. P. Units is a
colorless or almost colorless liquid, and that con-
taining 500 Units may be straw-colored. It is
substantially free from turbidity and from insolu-
ble matter. Insulin Injection contains 0.1 to 0.25
per cent (w/v) of either phenol or cresol. It
contains 1.4 to 1.8 per cent (w/v) of glycerin."
U.S.P.

Standards and Tests. — Identification. — (1)
Into each of six rabbits, weighing from 1.8 to 2.2
Kg. each and from which food has been withheld
for 18 to 24 hours, sufficient insulin injection to
cause convulsions in at least three animals is in-
jected subcutaneously. The convulsions are re-
lieved when 5 ml. of 50 per cent dextrose solution
is injected intravenously, and 4 or more of the
animals remain alive for at least 3 days. (2)
When the pH of insulin injection is adjusted to
between 5.1 and 5.3 a precipitate forms, which
dissolves on subsequent adjustment of the pH
to between 2.5 and 3.5. At a pH between 8.0 and
8.5 insulin injection, adjusted to contain not
more than 100 Units per ml., shows only a slight
haze. pH. — Between 2.5 and 3.5. Nitrogen con-
tent.— When determined on a portion of insulin
injection representing not less than 200 U.S. P.
Insulin Units the content of total nitrogen, esti-
mated by semi-micro Kjeldahl method, does not
exceed 0.65 mg. for each 100 Units of the injec-
tion prepared from zinc-insulin crystals, and not
more than 0.85 mg. when prepared from other
than such crystals. Zinc. — Injection prepared
from zinc-insulin crystals contains not less than
0.1 mg. and not more than 0.4 mg. of zinc for
each 1000 U.S. P. Insulin Units, while that pre-
pared from other than zinc-insulin crystals con-
tains not more than 0.4 mg. of zinc. Residue on
ignition. — The residue, when determined in a
portion of injection representing not less than 500
Units, is not over 1.0 mg. per 1000 Units. U.S. P.

Assay. — A number of biological methods of

682 Insulin Injection

Part I

assaying insulin injection have been employed.
The U.S. P. assay is based on the observation of
the hypoglycemic effect on rabbits; quantitative
results are obtained by comparing the effect pro-
duced by dilutions of the insulin injection under
test with that of dilutions of a standard solution
prepared from Zinc-Insulin Crystals Reference
Standard. Blood-sugar determinations are made
on samples of blood withdrawn at intervals of
1 and lYz hours after injection. The chemical
procedure employed for the determination in-
volves deproteinization of the blood sample with
zinc hydroxide, reduction of a measured excess
of alkaline cupric iodide T.S. by the blood-sugar,
and estimation of the excess of cupric ion which
remains after the reaction by titrating the iodine
which is liberated upon acidification with 0.005 N
sodium thiosulfate. A blank titration is performed
on the reagents and the difference in volumes of
thiosulfate required for the two titrations is cal-
culated to the content of blood-sugar, in mg. per
100 ml. U.S. P. The B.P. describes two suggested
methods of assay, one of which is essentially
similar to that of the U.S. P. in measuring the
hypoglycemia produced in rabbits, the other de-
pending on the incidence of convulsions or death
in mice. The LP. directs the assay to be per-
formed by the law of the country concerned.

An in vitro assay of insulin based on fibril pre-
cipitation has been described (Forster, /. Pharm.
Pharmacol., 1951, 3, 897); each mg. of insulin
fibrils is equivalent to 25 units of insulin by this
method. Assays of the insulin content of human
serum may be performed by the Bornstein
method (Australian J. Exp. Biol. M. Set., 1950,
28, 93) in which the alloxan-diabetic, adrenalec-
tomized, hypophysectomized rat is used as a
sensitive test animal.

Constitution of Insulin. — Insulin was first
isolated in crystalline form by Abel in 1926.
Scott (loc. cit.) found that addition of small
quantities of zinc salts made it possible to obtain
an almost completely crystalline product. Abel's
crystalline insulin, as well as commercial prepara-
tions of insulin, all contain zinc. Although it was
thought at first that the action of crystalline zinc
insulin was slower in onset and of longer duration
after subcutaneous injection in humans, further
study has shown no significant difference and
insulin injection derived from crystals or the
older method may be used interchangeably
(Ricketts and Wilder, J. A.M. A., 1939, 113,
1310). It now appears that zinc is an essential
constituent of insulin, although it is not known
in what manner it is linked in the insulin mole-
cule. At least three other metals have the same
effect in aiding crystallization of insulin; for this
reason it is desirable to designate the crystalline
product obtained in the presence of zinc as zinc-
insulin. Of the four metals which possess the
property of inducing crystallization of insulin
three (zinc, cobalt and nickel) have been re-
ported to be natural constituents of the pancreas
(cadmium is the fourth). It is not unlikely that
zinc may be involved in controlling the liberation
and activity of insulin in the body.

The non-metallic portion of the insulin mole-

cule is a complex protein built up of many dif-
ferent amino acids by peptide linkages. With the
notable exceptions of tryptophan, methionine and
hydroxyproline, nearly all the amino acids have
been identified in two types of peptide chains, an
acidic fraction A and a basic fraction B. These
chains have been subjected to acid and proteo-
lytic enzyme hydrolysis to form smaller peptide
groups in which the specific amino acid composi-
tion has been determined, thus establishing the
precise structure of the complete protein mole-
cule. This represents a major achievement in
protein chemistry (Sanger, Biochetn. J., 1949,
44, 126; ibid., 1952, 52, 111.) Insulin has been
found to have four terminal free amino acid
groups, two from glycine and two from phenyl-
alanine. The results of studies using modified
insulin derivatives suggest that the carboxyl and
phenolic hydroxyl groups are essential for bio-
logic activity.

Recent evidence indicates that, instead of a
molecular weight of 36,000 or 48,000 as previ-
ously supposed, the monomeric form of insulin
has a molecular weight of 12,000, or possibly
6000. This would account for its rapid diffusion
in tissues. The basic molecular weight of 12,000
provides for two chains of polypeptides with two
pairs of sulfur linkages derived from cysteine to
join them. It is believed that insulin crystallized
in the presence of zinc contains three atoms of
the element per molecule of insulin. However,
recent evidence has shown that more than 2.0
per cent zinc may be contained in insulin crystals
prepared under specific conditions and that this
element has a remarkable influence upon the solu-
bility of the preparation (Hallas-M0ller, Science,
1952, 116, 394).

Uses. — The great value of insulin in medicine
is in the treatment of that common metabolic
disorder known as diabetes mellitus. Insulin has
completely revolutionized the treatment of this
disease.

Action. — The action of insulin has been dem-
onstrated to be that of facilitating the rate of
conversion of glucose to glucose-6-phosphate. In
the phosphorylated form, glucose can rapidly
undergo a series of degradative reactions known
as glycolysis. In this way, a portion of ingested
carbohydrate is disposed of and provides energy
for cellular metabolism and function. The ulti-
mate products of oxidative degradation of glucose
through the tricarboxylic acid cycle are CO2 and
H2O, and the high-energy phosphate bonds re-
quired for cellular activity. Other important path-
ways for the disposal of glucose-6-phosphate are
those of conversion into glycogen in liver and
muscle, and the formation of fat within the liver
and fat depots of the body. Here again, the action
of insulin in permitting the phosphorylation of
glucose by the cells is the indispensable initiating
step. Insulin has also been shown to increase the
rate of protein biosynthesis from amino acids,
probably by making available the energy neces-
sary for these reactions from glucose utilization.
In the absence of insulin, glucose is no longer
phosphorylated and oxidized. In these conditions,
the body mobilizes fat which undergoes P-oxida-

Part

Insulin Injection 683

tion within the liver to form acetate fragments.
Oxidation of these substances is achieved by the
same final common pathway as the carbohydrate-
derived substrates to provide energy. However,
when the rate of production of keto-acids, formed
by condensation of the acetate fragments, ex-
ceeds the rate of oxidation, ketonemia, and ulti-
mately acidosis, supervene.

The mode of action of insulin in effecting the
formation of glucose-6-phosphate has been dis-
puted. The enzyme hexokinase, located within
the cells, catalyzes phosphorylation of glucose.
This enzyme is inhibited by certain pituitary and
adrenal steroid hormones and is released from
this inhibition by insulin, according to Cori.
Others have suggested that insulin is active at
the cell membrane in altering the surface perme-
ability, permitting glucose to enter the cell rap-
idly, whereupon it is phosphorylated by hexo-
kinase.

In the treatment of diabetes, insulin will usu-
ally effect a rapid lowering of the blood sugar,
replenish hepatic glycogen, increase the rate of
utilization of glucose for energy formation, di-
minish the rate of ketone body formation and
restore lipogenesis and protein formation. It has
been found clinically that after a few weeks'
treatment with insulin the dose employed may be
very greatly reduced; in other words, there is a
partial recovery of normal pancreatic power just
as has been observed from the dietetic treatment
alone. Banting, Campbell and Fletcher {Brit.
M. J., 1923, 1, 8) and others have shown that
even in diabetic coma it may bring about not
merely a reduction in the excessive dextrose in
the blood but also a restoration of the normal
alkalinity of the body and consequent recovery
in apparently moribund cases of diabetic acidosis.
Diabetic patients who can be controlled by diet
regulation alone need not be subjected to the
risks, expense and nuisance of insulin injections
unless certain complications exist. In the manage-
ment of various infections, either local or sys-
temic, occurring in diabetic patients, the use of
insulin to regulate the diabetes is very important.

For good therapeutic effects, it is necessary to
give insulin by injection either subcutaneously or
intravenously. Various attempts have been made
to give it by other routes, but while some of
them (percutaneous, rectal, etc.) have given
feeble insulin action, none of them is clinically
reliable. The protein molecule is too large to
penetrate with any readiness either the skin or
mucous membrane; it is not to be expected that
insulin would be absorbed from any portion of the
alimentary canal without decomposition by the
digestive enzymes (Campbell and Morgan, /.
Pharmacol, 1933, 49, 450).

Diabetes Mellitus. — The dose of insulin
varies greatly according to the excess of dextrose
in the blood. The amount of sugar in the blood
of the diabetic depends not merely on the sever-
ity of the disease but also on the intake of carbo-
hydrate and calories. Both the dose and the diet
must be controlled. Initially the diet is prescribed
according to the ideal weight, activity and age of
the patient with, for an adult, about 1 Gm. of

protein per kilogram of body weight, 100 to 200
Gm. of carbohydrate and 50 to 100 Gm. of fat
or more daily to obtain sufficient calories.

In the treatment of mild or moderately severe
diabetes without significant complications a depot
form of insulin, such as isophane insulin (NPH),
is recommended; an initial dose of 10 to 20 units
is given. Subsequent adjustments of the dose are
made on the basis of the content of glucose in
urine and the fasting and/or postprandial blood
sugar level. Thus, if urine glucose remains
strongly positive, the dose of insulin may be in-
creased by 4 units every third day until the glu-
cose content is reduced. Larger adjustments of
the insulin dose may be made when the blood
sugar level remains elevated. If the urine sugar
becomes persistently negative, the dose of in-
sulin is gradually reduced. A decline of blood
sugar to normal (80 to 120 mg. per 100 ml.) is
also an indication for reduction of insulin dosage.
In the presence of complications of medical or
surgical nature, and in diabetic acidosis, more
rapidly acting forms of insulin, such as unmodi-
fied or regular insulin, are employed. Urine speci-
mens obtained every 4 or 6 hours are tested by
the Clinitest, Galatest, or Benedict's reagent tech-
nics for glucose content. Insulin administration
is dependent upon the degree of glycosuria: thus,
4+, 20 units; 3+, 15 units; 2+, 10 units; 1 + ,
5 units. If acetone is strongly positive in the
urine the rate of insulin administration is doubled,
and the frequency of testing may be increased to
every 2 or 3 hours until acetonuria is diminished
as glucoSe metabolism increases. In the treat-
ment of diabetic coma or severe acidosis, which
may represent a fatal condition, the immediate
administration of 80 to 100 units of regular in-
sulin is recommended. If the blood sugar is over
600 mg. per 100 ml. an additional 100 units of
regular insulin is given. In the presence of periph-
eral vascular collapse, about half of the insulin
is given intravenously and the remainder intra-
muscularly. Otherwise all insulin injections are
given subcutaneously. In the routine treatment
of diabetes the depot insulins are usually given
20 to 30 minutes before breakfast; regular in-
sulin is given 15 to 20 minutes before each meal.
For comparison of the action of the several modi-
fications of insulin, see under Isophane Insulin
(NPH Insulin).

Miscellaneous Uses. — In recent years the
production of insulin shock has been used to a
considerable extent in treating schizophrenia and
other psychiatric disturbances. Although there is
considerable evidence that it frequently produces
beneficial effects, the treatment is not without
danger and should be undertaken only by those
with special experience in giving such treatments.
For information concerning methods and results
of this treatment see Katzenelbogen et al. {Arch.
Neurol. Psychiat., 1938, 39, 1). Hyaluronidase
is reported to have increased the speed and cer-
tainty of coma induction (Straccia, Am. J.
Psychiat., 1952, 108, 702). Sub-coma insulin
shock therapy for various psychiatric disorders
has been recommended for home treatment by
Cohen {New Eng. J. Med., 1949, 240, 669).

684 Insulin Injection

Part I

Satisfactory results have been reported in the
treatment of delirium tremens (Tillim, Am. J.
Psychiat., 1953, 50, 697), and of the withdrawal
symptoms of morphine addiction. Favorable re-
sults were also reported in the treatment of se-
vere anxiety states (Martin, /. Nerv. Ment. Dis.,

1949, 109, 347). In this connection it is note-
worthy that light insulin coma had previously
been advocated for a mild sedation effect. Insulin
therapy has been advocated for treatment of
hyperemesis gravidarum (Bice, Northwest Med.,
1941, 40, 270). and in the diagnosis of adrenal
tumors. The effect of insulin-induced hypogly-
cemia upon gastric secretions is the basis of a
test for postoperative evaluation of vagotomy
procedures (Thornton, J.A.M.A., 1946, 130,
764). Significant improvement of rheumatoid
arthritis has been reported following repeated
insulin-induced hypoglycemia (Gordon, ibid.,
1951, 145, 842); Kersley. Brit. M. J., 1950, 2,
855); in this connection, insulin has been found
to potentiate the action of cortisone. Thrombo-
angiitis obliterans was found by Franco (Lancet,

1950, 2, 655) to be improved by insulin shock
therapy. Insulin has been employed with varying
results in increasing appetite in undernutrition.
It is significant that slow-acting insulin, adminis-
tered in gradually increasing doses, has been
found to induce somatic growth, including
growth of the skeleton, in hypophysectomized
rats, while untreated control animals grew not
at all (Salter and Best, Brit. M. J., 1953,2,383). E

Toxicology. — The reduction in blood sugar
effected by injection of insulin may g^e rise to
serious symptoms; if the dose is large enough
the patient may die. In rodents, the toxic effects
are manifested chiefly by convulsions, collapse
and, when the dose is large enough, death by
respiratory failure. These symptoms may be im-
mediately abolished by intravenous injection of
dextrose.

In humans, insulin reactions have two phases:
the first is the hypoglycemia-epinephrine phase
characterized by tremors, headache, sweating,
hunger, pallor, tachycardia; the second is the
central nervous system phase in which prostra-
tion, abnormal behavior, diplopia, unconscious-
ness and ultimately death occur. Patients should
be instructed to carry identification cards and
some form of sugar or fruit for their protection.
Epinephrine may afford rapid but transient relief.
In elderly diabetics or in those with heart dis-
ease, it is very important to avoid hypoglycemia.

Local reactions to insulin injection, manifested
as redness, swelling or itching, occur in about 20
per cent of patients within 2 weeks after starting
therapy. These reactions subside spontaneously
in most patients; antihistaminic ointments may
be helpful if discomfort persists. Generalized al-
lergic reactions, such as urticaria, arthralgia and
dyspnea, are rare in insulin therapy. Changing
the brand of insulin to an all-beef preparation
may be effective, or a desensitization schedule
may be attempted using 3 dilutions of insulin —
1:1000, 1:100. and 1:10 — giving 0.1 ml. of the
weakest solution first and increasing by 0.1 ml.
every half hour until 1 ml. is given, then repeat-

ing this dosage schedule with the 1:100 and
finally with the 1:10 dilution. Other methods for
combating insulin allergy include use of recrystal-
lized insulin or of denatured insulin prepared by
immersing crystalline insulin in boiling water for
30 minutes, which treatment inactivates allergenic
proteins.

Lipoatrophy or insulin dystrophy is another
form of cutaneous reaction to insulin therapy.
Between 30 and 50 per cent of patients receiving
insulin will manifest some degree of atrophy and/
or induration of subcutaneous tissues at the site
of insulin injections. The cause of subcutaneous
fat loss is not known; it has been found that the
tissue may return to normal whether or not in-
sulin injections are continued at the site of the
lesion.

Zinc Insulin Suspensions. — The finding
that a long-acting crystalline zinc insulin and a
short-acting amorphous zinc insulin may be
readily prepared and used either separately or in
admixture to provide a series of prepaartions
having a wide range of time-activity characteris-
tics has been discussed in some detail earlier in
this monograph (see under Zinc Insulins). Three
types of preparations are available commercially:
the short-acting Setnilente insulin, consisting of
amorphous zinc insulin ; the long-acting Ultralente
insulin, consisting of crystalline zinc insulin; a
mixture of 3 parts of the amorphous form and 7
parts of the crystalline variety known as Lente
insulin. According to Venning {Lancet, 1954, 1,
480) the duration of action of Lente insulin is
approximately the same as that of globin zinc
insulin; Ultralente insulin has a duration of ac-
tion similar to that of protamine zinc insulin,
while Semilente insulin acts less rapidly than
soluble (regular) insulin. Venning found the ac-
tion of the zinc insulin suspensions to be more
even and less erratic than that of other prepara-
tions of insulin; the dose required to achieve
satisfactory control may often be higher than
the dose of insulin previously used. Also, there
is a natural variation from patient to patient of
the duration of action of Lente insulin. The pre-
liminary impression that the hypoglycemic reac-
tions are less severe than with soluble insulin was
not entirely confirmed by further observations.
Obviously, more experimentation will be required
before the exact role of these zinc insulin suspen-
sions is determined. Lente insulin is available in
the United States under the name Lente Iletin
(Lilly). For other reports on the use of these
insulins see Gerritzen, Brit. M. J., 1953, 2, 1030;
Lawrence and Oakley, ibid., 1953, 1, 242; Murray
and Wilson, ibid., 1953, 2, 1023; Nabarro and
Stowers, ibid., 1953, 2, 1027; Oakley, ibid., 1953.
2, 1021. This form of insulin has been accepted
by N.N.R.

Other Insulin Modifications. — Besides the
several official insulin modifications and the zinc
insulin suspensions discussed above many other
attempts have been made to produce a depot
insulin which will permit control of blood sugar
postprandially as well as overnight, so that one
injection daily will suffice to maintain normal
metabolism in diabetes.

Part I

Insulin Injection, Globin Zinc 685

Jenkinson and Milne (Brit. M. J., 1938, 1,
380) employed a mixture of insulin and tannic
acid with some success; Broom and Bavin {Quart.
J. P., 1937, 10, 334) found a combination of
insulin, tannic acid and zinc to be better. An
alum-precipitated insulin was proposed by Rosen-
thal et al. (Am. J. Med. Sc, 1939, 198, 98), while
Feinblatt (/. Lab. Clin. Med., 1939, 24, 337)
employed successfully a compound of insulin and
methenamine. Histone zinc insulin, prepared by
adding to zinc insulin the protein histone, derived
from thymus, has been studied by Gray and
Sansum (Ann. Int. Med., 1937, 11, 274), and by
Bailey and Marble (J. A.M. A., 1942, 118, 683).
Pectin insulin, introduced in Great Britain under
the name Decurvon, contains 4 to 5 per cent of
pectin with insulin in a medium adjusted to a pH
between 4.0 and 4.4; it is claimed to be absorbed
slowly because of the high viscosity of the solu-
tion rather than because of compound formation
of the insulin (see Brahn, Lancet, 1940, 1, 1078).
A depot effect was noted following use of an in-
soluble streptomycin insulinate, prepared by mix-
ing insulin with streptomycin sulfate solution
(Barnard and Saperstein, /. A. Ph. A., 1951, 40,
55). None of these preparations has demonstrated
any advantages over those which are officially
recognized. Di-insulin, a mixture of insulin with
phenyl-ureido-insulin, introduced in Denmark,
exerts a rapid and prolonged action; because of
irregularities in blood sugar response it has not
received wide trial in the United States.

Dose. — The usual dose of insulin is determined
according to the needs of the patient (see dis-
cussion above). The dose range is generally from
5 to 100 U.S. P. units; the maximum safe dose is
100 units. Insulin is usually injected subcutane-
ously but may be given intravenously or intra-
muscularly.

The American Diabetic Association has made
recommendations concerning the syringes to be
used in the injection of insulin. Instead of dual
calibrations, syringes should have single calibra-
tions corresponding to the concentration of in-
sulin being used by the patient; the plunger is
colored red for U40 insulin and green for U80
insulin.

Labeling. — "The label of the Insulin Injection
container and the outside label of each retail pack-
age states the potency in U.S. P. Insulin Units in
each ml. The outside labeling of each retail pack-
ages states also an expiration date which is not
later than 2 years after the date of its removal
from the manufacturer's place of storage, the
temperature of which is above 0° but does not
exceed 15°. Insulin Injection prepared from zinc-
insulin crystals which contain not less than 22
U.S. P. Insulin Units in each mg., on the anhy-
drous basis, may be labeled 'Insulin made from
Zinc-Insulin Crystals.' " U.S.P.

Storage. — "Preserve Insulin Injection in a
refrigerator, protected from freezing. Dispense it
in a satisfactory, unopened, multiple-dose con-
tainer in which it was placed by the manufacturer.
The container for Insulin Injection, 40, 80, or
100 U.S.P. Units in each ml., is of approximately
10-ml. capacity and contains not less than 10 ml.

of the Injection, and the container for Insulin
Injection, 500 U.S.P. Units in each ml., is of
approximately 20-ml. capacity and contains not
less than 20 ml. of the Injection." U.S.P.

GLOBIN ZINC INSULIN INJECTION.
U.S.P. (B.P.)

Globin Insulin with Zinc, Globin Zinc Insulin, [Injectio
Zinco Insulini Globini]

"Globin Zinc Insulin Injection is a sterile solu-
tion of insulin modified by the addition of zinc
chloride and globin. The globin used is obtained
from globin hydrochloride prepared from beef
blood and conforms to the regulations of the fed-
eral Food and Drug Administration concerning
certification of batches of drugs composed wholly
or partly of insulin. In the preparation of Globin
Zinc Insulin Injection, the amount of insulin used
is sufficient to provide either 40 or 80 U.S.P. In-
sulin Units for each ml. of the Injection. Note. —
Globin Zinc Insulin Injection differs in its action
from that of other insulin injections in this Phar-
macopeia in both time of onset and duration."
U.S.P.

The B.P. Injection of Globin Zinc Insulin is
defined as a sterile preparation of the specific
antidiabetic principle of the mammalian pancreas
with a suitable globin and zinc chloride, contain-
ing 40 or 80 units per ml.

B.P. Injection of Globin Zinc Insulin.

Description. — "Globin Zinc Insulin Injection
is an almost colorless liquid, substantially free
from turbidity and insoluble matter. Globin Zinc
Insulin Injection contains from 1.3 to 1.7 per
cent (w/v) of glycerin, and either from 0.15 to
0.20 per cent (w/v) of cresol or from 0.20 to 0.26
per cent (w/v) of phenol. It contains from 0.25
to 0.35 mg. of zinc for each 100 U.S.P. Insulin
Units. It also contains from 3.6 to 4.0 mg. of
globin (calculated as 6.0 times the nitrogen con-
tent of the globin) for each 100 U.S.P. Insulin
Units." U.S.P.

Standards and Tests. — Identification. — (1)
On adjusting globin zinc insulin injection to a pH
between 4.5 and 5.5 a precipitate forms; when the
pH of one portion of such a mixture is adjusted
to between 2.5 and 3.5 and that of another to
more than 11.0, the precipitate dissolves in each
case. (2) This test is the same as identification
test (1) under Insulin Injection. pH. — Between
3.4 and 3.8, determined with a glass electrode.
Sterility. — The injection meets the requirements
of the Sterility Test for Liquids. Total nitrogen.
— Not over 1.50 mg. for each 100 U.S.P. Insulin
Units. Zinc. — The content is between 0.25 and
0.35 mg. for each 100 U.S.P. Insulin Units.
Biological reaction. — This test, which is essentially
an assay, is similar in principle, in most of its
details, and in the interpretation of the data, to
the corresponding test under Protamine Zinc In-
sidin Injection. U.S.P.

Uses. — Globin zinc insulin injection has the
same action as unmodified insulin except that the
maximum effect occurs 8 to 16 hours after injec-
tion. This insulin was developed to fill the need
for an insulin intermediate in action between

686 Insulin Injection, Globin Zinc

Part I

short-acting, unmodified insulin and long, slow-
acting protamine zinc insulin. (For comparison of
action see discussion of Isophane Insulin Injection.

Unmodified insulin has such a brief action in
diabetic patients that repeated doses are neces-
during the day to control post-prandial hy-
perglycemia. Protamine zinc insulin is so slow
and prolonged in action that a single morning
dose sufficient to result in a normal fasting blood
sugar will not prevent hyperglycemia after meals.
Mixtures of these two types of insulin in various
proportions or multiple doses of one or both have
been used to overcome this difficulty. XPH In-
sulin is currently being used in place of these
ures.

Comparing equal doses of protamine zinc in-
sulin and globin zinc insulin in uncomplicated
moderately severe diabetes Roberts and Yater
Med., 1947, 26, 41) found better con-
trol of blood sugar during the day and at night
with the latter insulin in 70 of 97 cases. Rabino-
witch et al. (Can. Med. Assoc. J., 1947, 56, 595)
studied globin zinc insulin in refractory cases and
in cases with a medical or surgical complication
which tended to interfere with the action of in-
sulin. They reported that most effective control
was obtained by using a single morning dose of
globin zinc insulin and an evening dose of prota-
mine zinc insulin. They achieved almost equally
good results using unmodified insulin at 8-hour
intervals but the objection to this schedule was
that it required one additional hypodermic injec-
tion each day. In 67 patients maintained on globin
zinc insulin alone Shippe and Shippe ( West Yirg.
J., 1949, 45, 79) found the action similar to
a 2 :1 mixture of crystalline and protamine insulin.
They also reported good results using mixtures of
globin insulin and crystalline insulin in 1:2. 1:1.
and 2 : 1 ratios. Hypoglycemic reactions observed
occurred between 4 and S p.m.

st of 126 hypoglycemic reactions reported
by patients taking a single dose of globin zinc
insulin before breakfast occurred 2y2 to 5 hours
later OVauchope. Brit. M. J., 194S. 2, 191). Al-
though globin insulin has been found superior to
protamine zinc insulin in the post-prandial regu-
lation of the blood sugar, the duration of action
is not adequate for 24-hour control in all cases.
For this reason, the total daily insulin require-
ment, if greater than 30 or 40 units, is given as
two doses: J_; before breakfast and J 3 before
supper. If the requirement is less than 30 units
per day, a single dose given l/2 hour before break-
fast is usually satisfactory. Because of the peak
intensity of action occurring about S hours after
the injection, a mid-aftemoon feeding is advo-
cated for most patients using globin insulin. A
small bedtime feeding should be arranged for
virtually all patients receiving insulin in any
form.

Dose. — The usual dose is given hypodermically
according to the needs of the patient. The range
of dose is 10 to SO U.S. P. units'

Labeling. — 'The label of the Globin Zinc
Insulin Injection container and the outside label
of each retail package must state the potency in
units per ml. This refers to the number of U.S. P.
Insulin Units added in preparing the Injection.

The outside labeling of each retail package states
also an expiration date which is not more than
IS months after the immediate container was
filled." L.S.P.

Storage. — "Preserve Globin Zinc Insulin In-
jection at a temperature above 0° but not exceed-
ing 15°. Avoid freezing. Dispense it in a satisfac-
tory, unopened, multiple-dose container in which
it was placed by the manufacturer, which con-
tainer is of approximately 10-ml. capacity and
shall contain not less than 10 ml. of the Injec-
tion." U.S.P.

ISOPHANE INSULIN INJECTION.
U.S.P.

Isophane Insulin, NPH Insulin

"Isophane Insulin Injection is a sterile suspen-
sion, in a buffered water medium, of insulin made
from zinc-insulin crystals modified by the addi-
tion of protamine in a manner such that the solid
phase of the suspension consists of crystals com-
posed of insulin, protamine, and zinc. The
protamine is prepared from the sperm or from
the mature testes of fish belonging to the genus
Oncorhynchus Suckley, or Salmo Linne (Fam.
Salmonidee), and conforms to the regulations of
the federal Food and Drug Administration con-
cerning certification of drugs composed wholly or
partly of insulin. In preparing Isophane Insulin
Injection, sufficient insulin is used to provide
either 40 or 80 U.S.P. Insulin Units for each ml.
of the Injection. Note. — Isophane Insulin Injec-
tion differs in its action from that of other insulin
injections in this Pharmacopeia in both time of
onset and duration." U.S.P.

The addition of protamine to zinc insulin, in
the proportion required to produce the official
protamine zinc insulin, yields a product having a
more prolonged, though less intense, action than
that of regular insulin. In the official product the
proportion of protamine to insulin may be as high
as 1.5 mg. of the former to 100 units of the
latter. Such a preparation contains approximately
three times the amount of protamine required to
combine with the insulin. The proportion may.
however, be progressively decreased to yield
products having time-activity characteristics rang-
ing from the short profound action of unmodified
insulin to the long, slow effect of protamine zinc
insulin.

Prior to the development of XPH insulin, it
was the practice to make preparations of inter-
mediate time-activity characteristics by extempo-
raneous aclmixture of unmodified insulin and
protamine zinc insulin. The most useful of these
mixtures, for many patients, proved to be the 2:1
mixture of regular insulin and protamine zinc
insulin. In this mixture protamine is present to
the extent of about 0.5 mg. per 100 units of
insulin, which is the combining proportion, or
so-called isophane ratio, of protamine and insulin.

The development of XPH insulin embodies this
concept of having an isophane ratio of protamine
and insulin in a single preparation. The designa-
tion XPH is derived as follows: X refers to the
preparation being neutral (pH 7.2); P stands
for protamine, of which about 0.5 mg. per 100

Part I

Insulin Injection, Isophane 687

units of insulin is present (the designation NPH-
50 has been used to indicate substantially the
same product) ; H refers to Hagedorn, in whose
laboratory the preparation was developed. NPH
insulin is, essentially, a modification of protamine
zinc insulin which contains less protamine and
less zinc than the latter; also, the interaction
product is crystalline, rather than amorphous, as
is the case with protamine zinc insulin.

Description. — "Isophane Insulin Injection is
a white suspension of rod-shaped crystals approx-
imately 30 m- in length and is free from large
aggregates of crystals following moderate agita-
tion. Isophane Insulin Injection contains either
(1) 1.4 to 1.8 per cent (w/v) of glycerin, 0.15
to 0.17 per cent (w/v) of metacresol, and 0.06 to
0.07 per cent (w/v) of phenol, or (2) 0.42 to 0.45
per cent (w/v) of sodium chloride, 0.7 to 0.9 per
cent (w/v) of glycerin, and 0.18 to 0.22 per cent
(w/v) of metacresol. Isophane Insulin Injection
contains 0.15 to 0.25 per cent (w/v) of dibasic
sodium phosphate. It contains also 0.016 to 0.04
mg. of zinc and 0.3 to 0.6 mg. of protamine for
each 100 U.S. P. Insulin Units. When examined
microscopically, the insoluble matter in Isophane
Insulin Injection is crystalline, and contains not
more than traces of amorphous material." U.S.P.

Standards and Tests. — Identification. — (1)
On acidifying isophane insulin injection to a pH
between 2.5 and 3.5 the suspended solid dissolves,
producing a clear, colorless liquid. (2) This test
is identical with identification test (1) under
Insulin Injection. pH. — It is between 7.1 and 7.4.
Sterility. — The product meets the requirements
of the official sterility tests. Nitrogen content. —
Not over 0.85 mg. for each 100 U.S.P. Insulin
Units. Biological activity of the supernatant liq-
uid.— Not over 1 U.S.P. Insulin Unit per ml. for
an injection containing 40 U.S.P. Units per ml.,
and not over 1.5 Units per ml. for an injection
containing 80 U.S.P. Units per ml. Zinc. — The
content is between 0.016 mg. and 0.04 mg. for
each 100 U.S.P. Units. U.S.P.

Uses. — Isophane or NPH insulin has the same
action as unmodified insulin except for its time-
activity range with respect to blood sugar regula-
tion. In this respect it occupies a position inter-
mediate between that of protamine zinc insulin
and of globin zinc insulin. The onset of activity

zinc insulin and regular insulin. Kirkpatrick
(Proc. Mayo, 1949, 24, 365) found NPH insulin
superior to previously available insulins in his
patients and predicted that protamine zinc insulin
would be replaced by it. In the stable diabetic pa-
tient, almost any depot insulin will provide satis-
factory control. In the unstable diabetic, however,
more careful timing of insulin activity is essential
for maintenance of metabolic hemostasis. Such
careful regulation may be achieved by use of mix-
tures of regular insulin and protamine zinc in-
sulin, especially in a 2:1 ratio or, more con-
veniently, by NPH insulin (Izzo, /. Clin. Inv.,
1950, 29, 1514).

The treatment of diabetes during complications
such as pregnancy, surgery, or infection requires
an insulin capable of contributing an early action
as well as a prolonged blood-sugar-lowering effect.
Shuman (Am. J. Med. Sci., 1951, 222, 179) de-
scribed the use of NPH insulin in diabetic con-
trol during these complications. Occasionally the
prompt action of NPH is inadequate for control
of the postprandial blood sugar and gylcosuria.
In these instances, Shuman recommends addition
of small amounts of regular insulin directly to
the syringe containing NPH insulin. Since NPH
is an isophane mixture of protamine, zinc and
insulin, the added regular insulin will not be com-
bined with protamine to a significant degree. The
amount of regular insulin added depends upon
the total daily insulin requirements and the
degree of post-prandial glycosuria. The proper
dosage can be reached by testing the urine sugar
at 11:00 a.m. and increasing the regular insulin
component by two units each third day as long
as 1 to 2 per cent glycosuria is present at that
time. The initial dose of regular insulin used may
be about 10 per cent of the NPH dose being
given. Prior to adding the regular insulin, a re-
duction of the breakfast carbohydrate ration by
15 to 20 per cent may be advocated, adding this
to supper or bedtime feeding when NPH insulin
is more active. When the daily insulin require-
ments are greater than 80 to 100 units, the total
dose may be divided and given three-fourths be-
fore breakfast and one-fourth before supper,
although a single pre-breakfast dose of 160 units
has been found to afford control of the blood
sugar in several cases. NPH insulin is never used

TIME OF ACTION OF VARIOUS INSULIN PREPARATIONS

Soluble Unmodified

and Crystalline

Zinc Insulin

Globin Insulin

Isophane
Insulin

Protamine
Zinc Insulin

Onset

Peak Action
Duration

1 hour

2 to 3 hours
6 to 8 hours

1 to 2 hours

6 to 12 hours

18 to 24 hours

1 to 2 hours
10 to 20 hours
20 to 32 hours

4 to 6 hours
16 to 24 hours
24 to 48 hours

of isophane insulin occurs within 2 hours after
subcutaneous injection, the peak blood-sugar-
lowering action occurs within 10 to 12 hours, and
the duration of action is 28 to 30 hours. Gabriele
and Marble employed this new insulin in 1949
in 94 boys at a summer diabetic camp (Am. J.
Digest. Dis., 1949, 16, 197) and discovered that
it provided better control of hyperglycemia and
glycosuria than did combinations of protamine

intravenously. Subcutaneous injection, 20 minutes
before breakfast, is advised. It is not recom-
mended for the treatment of diabetic coma. Used
in conjunction with dietary regulation and exer-
cise, it is of value in the control of all diabetics,
and especially those with severe, labile diabetes.
Its time-activity curve makes it a suitable agent
for the control of diabetic patients who are under-
going surgery and anesthesia, although frequently

688 Insulin Injection, Isophane

Part I

small doses of regular insulin are employed to
supplement its action during the immediate post-
operative phase.

Hypoglycemic reactions occurring with NPH
insulin are similar to those described under
protamine zinc and unmodified insulins. Patients
should be cautioned never to omit feedings,
especially lunch, as the peak action of this agent
occurs in the late afternoon. The precautions
enumerated in the previous discussions must be
followed in the use of this preparation. Local
allergic reactions have been observed as fre-
quently as with other insulins.

Dose. — The range of dose, which is based on
the needs of the patient, is from 10 to 80 U.S. P.
units, administered subcutaneously.

Labeling. — 'The label of the Isophane In-
sulin Injection container states that the Injec-
tion is to be shaken carefully before use. The
label of the Injection container and the outside
label of each retail package state the potency in
Units per ml. This refers to the number of U.S. P.
Insulin Units added in preparing the Injection.
The outside labeling of each retail package states
also an expiration date which is not later than
IS months after the immediate container was
filled." U.S.P.

Storage. — Preserve "in a refrigerator, pro-
tected from freezing. Dispense it in the unopened,
multiple-dose container in which it was placed by
the manufacturer, which container is of approxi-
matelv 10-ml. capacity and contains not less than
10 ml. of the Injection." U.S.P.

PROTAMINE ZINC INSULIN INJEC-
TION. U.S.P. (B.P.) (LP.)

Protamine Zinc Insulin, [Injectio Zinco Insulini
Protaminati]

''Protamine Zinc Insulin Injection is a sterile
suspension, in a buffered water medium, of insulin
modified by the addition of zinc chloride and
protamine. The protamine is prepared from the
sperm or from the mature testes of fish belonging
to the genus Oncorhynckus Suckley, or Salmo
Linne (Fam. Salmonidce). and conforms to the
regulations of the Food and Drug Administration
concerning certification of batches of drugs com-
posed wholly or partly of insulin. In the prepara-
tion of Protamine Zinc Insulin Injection the
amount of insulin used is sufficient to provide
either 40 or SO U.S.P. Insulin Units for each ml.
of the Injection. Note. — Protamine Zinc Insulin
Injection differs in its action from that of other
insulin injections in this Pharmacopeia in both
time of onset and duration." U.S.P.

The B.P. defines Injection of Protamine Zinc
Insulin as a sterile suspension of the specific anti-
diabetic principle of the mammalian pancreas with
a suitable protamine and zinc chloride, containing
40 or SO units per ml.

The LP. recognizes the same preparation under
the title Injection of Insulin Zinc Protaminate.

B.P. Injection of Protamine Zinc Insulin. Injectio
Insulini Protaminati cum Zinco. LP. Injection of In-
sulin Zinc Protaminate; Injectio Insulini Zinci Prota-
minati. Protamine Zinc Insulin (Sharp & Dohme, Squibb) ;
Protamine, Zinc and Iletin (Lilly). Sp. Inyeccion de In-
su'.ina y Protamina en Zinc.

In the attempt to develop an insulin compound
which acts more gradually and over a longer
period of time than does insulin itself Hagedorn
et al. (J.A.M.A., 1936, 106, 177) showed that
when a solution of protamine, a basic protein of
simple composition derived from the sperm or
from mature testes of certain fishes (see definition
above ) . in a sodium phosphate buffer is added to
insulin an insoluble compound forms at pH 7.2
which exerts a prolonged hypoglycemic action.
Subsequently it was found that the addition of
zinc to this mixture produced a still greater re-
tardation of action and, also, markedly stabilized
the combination of insulin and protamine.

The reaction of this suspension is highly impor-
tant; the adjustment to a pH of approximately
7.2 corresponds to the isoelectric point of prota-
mine zinc insulin at which it exhibits its maximum
degree of insolubility. At any pH above or below
this point the solubility is increased and. of course,
the intensity and duration of hypoglycemic action
are affected.

Description. — "Protamine Zinc Insulin Injec-
tion is a white, or almost white suspension and is
free from large particles, following moderate agi-
tation. Protamine Zinc Insulin Injection contains
from 1.4 to l.S per cent (w v) of glycerin, and
either from 0.1S to 0.22 per cent :>f cresol

or from 0.22 to 0.28 per cent i w v) of phenol. It
contains from 0.15 to 0.25 per cent (w/v) of
XasHPO-i. It contains from 0.20 to 0.25 mg. of
zinc and from 1.0 to 1.5 mg. of protamine for each
100 U.S.P. Units of Insulin." US.P.

Standards and Tests. — Identification. — (1)
On acidifying protamine zinc insulin to a pH be-
tween 2.5 and 3.5. the precipitate dissolves, pro-
ducing a clear, colorless liquid. (2) This test is
the same as identification test ( 1 > under Insulin
Injection. Reaction. — The pH is between 7.1 and
7.4. when measured using a glass electrode. Nitro-
gen content. — When determined on a portion of
injection representing not less than 200 U.S.P. In-
sulin L'nits the content of total nitrogen, estimated
by the semimicro Kjeldahl method, does not ex-
ceed 1.25 mg. for each 100 U.S.P. Units. Zinc. —
The zinc content is between 0.20 mg. and 0.25 mg.
for each 100 U.S.P. Insulin Units. Biological Re-
action.— This test serves in the place of an assay
and is in many respects similar to the assay
provided under Insulin Injection. The underlying
principle of the test is that there shall be sub-
stantially no difference in the average degree of
hypoglycemic action of identical doses of a stand-
ard preparation of protamine zinc insulin (con-
taining 40 or 80 units, as the case may be) and
of the injection being tested. The hypoglycemic
action is measured in rabbits, employing the
chemical method utilized in the assay of Insulin
Injection (which see). U.S.P.

The B.P. requires that the clear supernatant
liquid separated from the injection does not con-
tain more than 3.75 per cent of the original activ-
ity, when tested by the B.P. biological assay of
insulin (on rabbits). The injection is also required
to comply with a test for retardation of insulin
effect : this test is similar to the rabbit assay with
the principal specification that when the average
blood-sugar percentage of rabbits being injected

Part I

Insulin Injection, Protamine Zinc 689

with a standard preparation of regular insulin
has just returned to the initial level, that of rab-
bits receiving the same dosage of the protamine
preparation shall be not more than 80 per cent of
the corresponding initial value. The I. P. limits the
concentration of insulin in the clear supernatant
liquid to 4.0 per cent of the original activity.

Assay. — The U.S. P. test serving as an assay is
described above, under Standards and Tests. The
B.P. assay is performed on rabbits, being the
same as that required for Injection of Insulin;
solution of the protamine zinc insulin is first
effected by adding 0.3 ml. of 0.01 N hydrochloric
acid per ml. of injection.

Uses. — Protamine Zinc Insulin Injection has
the same action as unmodified insulin (q.v.) ex-
cept that its maximum action occurs between 12
and 24 hours after injection (for comparison of
action of insulins see Isophane Insulin Injection.
Ricketts (Am. J. Med. Sc, 1941, 201, 51) and
others have found that many patients can be kept
in satisfactory condition with one dose daily. Its
special indication is in those patients requiring
multiple doses of unmodified insulin daily and
in those with frequent attacks of hypoglycemia
under such treatment. Tolstoi (Am. I. Digest.
Dis., 1943, 10, 247), in fact, has used a dose
of 15 to 20 units daily, without rigid control
of the diet, for several years with satisfaction.
However, because of the failure of this prep-
aration to control the blood sugar during the
day following the ingestion of food and because
of nocturnal hypoglycemic reactions, other depot
forms of insulin, such as NPH and globin insulins,
have been more widely employed recently. In the
treatment of diabetic coma, protamine zinc in-
sulin or other depot preparations should not be
used. To change a patient regulated with unmodi-
fied insulin to protamine zinc insulin, the dose the
first morning should be about two-thirds of the
previous total daily dose. Because of its slow
action, glycosuria is common at first but the dose
should not be changed for 3 to 5 days, when the
full effect of this slow-acting insulin has been
reached. Unmodified insulin may be used in addi-
tion during the first few days but this practice in-
creases the danger of hypoglycemic reactions. The
carbohydrate content of the first meal (breakfast)
may require limitation to avoid hyperglycemia be-
fore the dose of protamine zinc insulin becomes
active; the carbohydrate ingested at night may
need to be increased to avoid nocturnal hypo-
glycemia.

Hypoglycemic reactions develop slowly with
protamine zinc insulin and may not be recognized
until unconsciousness develops. The manifesta-
tions are the same as with unmodified insulin but
are milder at first ; a rapid fall of the blood sugar
level seems to stimulate the compensatory mech-
anisms, such as the secretion of epinephrine, more
actively and many of the symptoms are compen-
satory in nature. The symptoms include: fatigue,
slight weakness, headache, nervousness, irrita-
bility, tremors, sweating, hunger. Likewise, be-
cause of the continued absorption of the modified
insulin, the reaction is prolonged. Although sugar
relieves the symptoms rapidly, the manifestations
may recur in about an hour. The administration

of both rapidly-absorbed carbohydrate (sugar)
and slowly-absorbed carbohydrate (bread) is ad-
vocated, or the sugar should be repeated after
1 hour. If the patient is unconscious, intravenous
administration of 25 to 50 ml. of 50 per cent
dextrose is necessary.

In the milder cases of diabetes mellitus, prota-
mine zinc insulin in a single dose daily controls
the metabolic abnormality well because of the
rather extraordinary constancy of its action (Rick-
etts, loc cit.). Because a single dose of protamine
zinc insulin does not adequately control many
cases without an additional daily injection of some
form of insulin, much effort has been expended to
devise an adequate single dose preparation (see
discussion of other modifications under Insidin
Injection). Except for globin zinc insulin and NPH
insulin, none of these has attained any wide use.
It was found that unmodified and protamine zinc
insulin could be mixed in the syringe at the time
of injection by intelligent patients and thus avoid
the necessity of two hypodermic injections (Peck,
Ann. Int. Med., 1943, 18, 177). Although this is
a complicated procedure, it has worked well (for
technic see Wilder, A Primer for Diabetic Pa-
tients, 7th ed., W. B. Saunders, 1941). Since there
is an excess of protamine in most available com-
mercial preparations of protamine zinc insulin,
about half of the unmodified insulin, which is
added in the proportions commonly employed, is
converted into the insoluble form of insulin.
Hence, if the action of 10 units of unmodified and
30 units of protamine zinc insulin is desired, 20
units of unmodified and 20 units of protamine
zinc insulin should be mixed in the syringe. Peck
and Schecter (Proc. A. Diabetes A., 1944, 4, 59)
studied these mixtures carefully and Abrahamson
(Am. J. Digest. Dis., 1945, 12, 385) devised a
nomogram to determine the proportions to employ
to achieve the desired effect. A 2 : 1 mixture of
unmodified and protamine zinc insulin is said to
be the most generally useful; a few cases required
3:2 and 1:1 proportions. Fierro and Sevringhaus
(Ann. Int. Med., 1945, 22, 667) confirmed the
value of a 3:1 mixture in the management with
a single dose daily of diabetics requiring more
than 40 units of insulin daily. The use of NPH
insulin has largely replaced insulin mixtures since
this preparation has a prompt phase of hypo-
glycemic action previously contributed by the
regular component of the mixture.

Dose. — The usual dose is given hypodermically
according to the needs of the patient. The range
of dose is from 10 to 80 U.S. P. units.

Labeling. — "The label of the Protamine Zinc
Insulin Injection container states that the Injec-
tion is to be shaken carefully before use. The
label of the Injection container and the outside
label of each retail package state the potency
in units per ml. This potency refers to the num-
ber of U.S. P. Insulin Units added in preparing the
Injection. The outside labeling of each retail
package states also an expiration date which is not
later than 24 months after the immediate con-
tainer was filled." U.S.P.

Storage. — "Preserve Protamine Zinc Insulin
Injection at a temperature above 0° but not ex-
ceeding 15°, avoiding freezing. Dispense it in a

690 Insulin Injection, Protamine Zinc

Part I

satisfactory, unopened, multiple-dose container in
which it was placed by the manufacturer, which
container is of approximately 10-ml. capacity and
contains not less than 10 ml. of the Injection."
US.P.

IODINE. U.S.P., B.P., LP.

[Iodum]

"Iodine contains not less than 99.8 per cent of
I." c7.5.P. The B.P. and I.P. require not less
than 99.5 per cent of I.

Jodum; Iodinium; Iodum Bisublimatum. Ft. lode
bisublime. Ger. Jod. It. Jodio. Sp. Yodo.

Iodine, a non-metallic element discovered in
1812 by the French chemist Courtois while work-
ing with the ash of sea-weed, was in IS 14 named
by Gay-Lussac after the Greek word meaning
violet, in recognition of the color of its vapor.
Iodine, in combined form, is a constituent of sea
water and of certain algae, particularly the kelps
and rockweeds, which have the power of remov-
ing it from water and storing it in their tissues.
Saks of the element occur also in oil-field brines,
as well as in Chile saltpeter, in which latter it
exists as sodium iodate and from which source
most of the world's supply of iodine comes.

From dried sea-weeds the iodine may be ex-
tracted in a variety of ways. Usually the weeds
are burned and the ash, which contains from 0.2
to 2 per cent of iodine, is lixiviated with hot
water, the solution run off and concentrated to
separate some of the undesired saline matter, and
the mother liquor treated with sulfuric acid to
liberate hydriodic acid from which elemental
iodine is released by treatment with manganese
dioxide. The iodine is distilled out of the mixture
and purified by sublimation.

In the process of extracting iodine from Chile
saltpeter, which contains about 0.15 per cent of
iodine, the mother liquor remaining after crystal-
lization of sodium nitrate is treated with sodium
bisulfite, which reduces the iodate to elemental
iodine, in which form it is separated and purified
by sublimation.

Iodine may be recovered from oil-field brines
by treatment of the latter with sodium nitrite and
sulfuric acid, liberating iodine which is adsorbed
on activated carbon. The carbon is filtered off. the
iodine leached out with alkali, the solution con-
centrated, then chlorinated to liberate iodine
which is distilled out of the liquor and condensed
in a ceramic condenser. Another method of treat-
ing the brines consists in precipitation of iodide as
silver iodide, reaction of this substance with steel
scrap to precipitate silver while leaving an equiva-
lent amount of ferrous iodide in solution from
which elemental iodine is liberated with chlorine.

Most of the iodine produced in this country is
extracted in California from the brines of wells
and from sea water, which latter may be treated
in much the same way as the former. Consider-
ably more iodine is imported, however, than is
produced here.

Iodine resembles chlorine and bromine in its
chemical properties, but is somewhat less active.
It forms salts with most of the elements. The
oxides IO2, or I2O4, and I2O5 are well character-

ized. The important acids of iodine include
hydriodic, hypoiodous, iodic and periodic; each of
these forms a corresponding series of salts. Iodine
forms with chlorine and bromine the compounds
IC1 and I Br, respectively. Both of these are de-
composed by water. Iodine dissolves easily in
aqueous solutions of alkali iodides to form
triiodides. such as KI3.

Description. — "Iodine occurs in the form of
heavy, grayish black plates or granules, having
a metallic luster and a characteristic odor. One
Gm. of Iodine dissolves in about 2950 ml. of
water, in 13 ml. of alcohol, in about 80 ml. of
glycerin, and in about 4 ml. of carbon disulfide.
It is freely soluble in chloroform, in carbon tetra-
chloride, and in ether, and is soluble in solutions
of iodides." U.S. P.

Standards and Tests. — Identification. — (1)
Solutions (1 in 1000) in chloroform, carbon tetra-
chloride or carbon disulfide have a violet color.
Addition of starch T.S. to a saturated solu-
tion of iodine produces a blue color which disap-
pears on boiling but. unless boiled for a long
time, reappears on cooling. Residue on evapora-
tion.— Not over 0.05 per cent, when volatilized
on a steam bath. Chloride or bromide. — A satu-
rated solution in water, decolorized with sulfurous
acid, produces no greater turbidity with silver
nitrate T. S., following preliminary precipitation
of silver iodide in an ammoniacal solution, than
is produced in a control containing 0.1 ml. of
0.02 A hydrochloric acid. U.S.P.

The B.P. and I.P. include a test for limit of
cyanogen which specifies that no blue color shall
be produced on addition of ferrous sulfate and
alkali to a saturated solution of iodine decolorized
with zinc, the mixture being heated and finally
acidified with hydrochloric acid.

Assay. — About 500 mg. of iodine is dissolved
in potassium iodide solution, acidified with diluted
hydrochloric acid, and titrated with 0.1 -V sodium
thiosulfate, using starch T.S. as indicator. Each
ml. of 0.1 N sodium thiosulfate represents 12.69
me. of I. U.S.P.

Bargu and Starling (Pharm. /., 1914. 92, 146^
called attention to the fact that more than 60
compounds besides starch have the property of
showing a blue color with iodine.

Iodine Deficiency. — Iodine is found in plant
foods grown on iodine-containing soil and in
animal foods derived from animals fed on such
iodine-containing plants. In many inland regions
of the world the iodine has been largely leached
out of the soil and the content of this element in
food is low. In these regions goiter is common.
Iodine deficiency results in colloid goiter, in
which there is an increase in colloid in the follicles
and which is deficient in iodine; however, afflicted
individuals still have enough hormone production
to maintain normal metabolism and symptoms
arise from the mechanical pressure of the mass in
the neck. Repeated periods of iodine deficiency
result in alternating hyperplasia and atrophy of
the thyroid and eventually result in toxic nodular
goiter. The hyperplasia arises from overactivity
of the thyrotropic hormone (TSH) of the
anterior lobe of the hypophysis. Iodine deficiency
and the resulting deficiency of thyroid hormone

Part I

Iodine

691

result in excessive TSH production. The minimal
daily requirement of iodine in the diet is not
definitely established, although 150 to 300 micro-
grams daily for an adult has been used as an
estimate. It is certain that 2 to 3 micrograms per
Kg. of body weight is adequate. In the United
States 0.01 per cent of potassium iodide has been
added to table salt (Kimball, J.A.M.A., 1946,
130, 80) and the incidence of goiter has decreased
tremendously during the last three decades
(Marine and Kimball, ibid., 1920, 75, 674). In
coastal regions of the world sea-food provides
sufficient iodine for most individuals.

The subject of thyroid function has been ex-
tensively reviewed by Rosenberg and Astwood,
and by Werner (Glandular Physiology and
Therapy, American Medical Association, Lippin-
cott, Philadelphia, 1954, pp. 258 and 309). In
brief, current information indicates that iodide
ion absorbed from food circulates in the blood
and is concentrated to an amazing degree in the
thyroid gland. Intracellularly in thyroid, the
iodide, under the influence of peroxidase-like
enzymes, forms iodinated tyrosine in protein
combination, i.e., it is not present as the free
amino acid. Oxidative condensation of iodinated
tyrosines forms the thyroxyl groups of thyro-
globulin, which is stored in the acinar colloid of
the gland. Proteolysis of thyroglobulin releases
thyroxin, tyrosine and iodide. The thyroxin enters
the blood stream to circulate to tissues, while the
iodide and tyrosine are utilized in the thyroid
gland to form new thyroglobulin.

Iodine Metabolism. — Of the 20 to 50 mg. of
iodine in the human body 60 to 80 per cent is
found in the thyroid gland (Riggs, Pharmacol.
Rev., 1952, 4, 284). The intake of iodine varies
greatly, from 150 to 200 micrograms daily in
coastal areas of the world to 50 micrograms or
less in inland regions. Iodide is readily absorbed
from the gastrointestinal tract and the skin (Nyiri
and Jannitti, /. Pharmacol., 1932, 45, 85) and
excreted largely in the urine; on an intake of 150
micrograms daily about 144 micrograms appears
in the urine (mostly in inorganic form) while 6
micrograms is found in the feces (mostly in
organic combination). Most of the iodine in
tissues is in organic form. The amount of in-
organic iodine, except following large doses of
iodide, does not exceed 1 microgram per 100 ml.
of blood. Inorganic iodine is found in the extra-
cellular fluids and does not normally exceed 75
micrograms in the entire body. In addition to
excretion into the urine, it is secreted into the
gastric juice and saliva in concentrations about
30 times that in blood plasma. Traces are also
present in tears, sweat, milk, spinal fluid and
serous effusions. Renal excretion and thyroid
storage of iodine accounts for 90 per cent of a
dose of the isotope iodine-131 (Keating and
Albert, Rec. Progr. Hormone Res., 1949, 4, 429;
Pochin, Lancet, 1950, 2, 41, 84). In myxedema-
tous patients or after administration of anti-
thyroid drugs, most of a tracer dose of iodine
appears in the urine, whereas in cases of hyper-
thyroidism more of the isotope enters the thyroid
rather than the urine. The rates of accumulation
are proportional to the plasma concentration. The

renal clearance of iodide is about 32 ml. of
plasma per minute while that of the thyroid is
16 ml. per minute (Berson et al., J. Clin. Inv.,
1952, 31, 141; Myant et al., Clin. Sc, 1949,
8, 109). The iodine-accumulating activity of the
thyroid comprises two processes: iodide-concen-
trating and organic-binding mechanisms (for
further discussion see under Thyroid, in Part I).

In the blood, iodine circulates chiefly as
thyroxin, which is loosely bound to serum albumin
(Rosenberg, /. Clin. Inv., 1951, 30, 1; Laidlaw,
Nature, 1949, 164, 927). Thyroxin iodine may be
separated from inorganic iodine by precipitation
of the serum proteins; this is the serum-precipi-
table or plasma protein-bound iodine. Total
serum iodine includes inorganic iodide and varies
with the iodine content of the diet and use of
medicinal iodine. The level of protein-bound
iodine is correlated in general with the basal
metabolic rate of the individual (Lowenstein
et al., J. Clin. Endocrinol, 1944, 4, 268). The
concentration increases in hyperthyroidism and
decreases in myxedema (Mann et al., J. Clin. Inv.,
1942, 21, 773) and after treatment of hyper-
thyroidism by surgical resection of the thyroid or
administration of propylthiouracil or iodide
(Winkler et al., ibid., 1946, 25, 404; Lowenstein
et al., J. Clin. Endocrinol., 1945, 5, 181). Nor-
mally about 4 to 8 micrograms of protein-bound
iodine per 100 ml. of blood is found. Certain
discrepancies appear between protein-bound
iodine concentrations and the clinical status of
the patient, apparently because of the variable
presence of non-thyroxin organic iodine com-
pounds which are also attached to the serum
proteins (Rapport and Curtis, ibid., 1950, 10,
735). For example, following the use of iodized
oil, iodoalphionic acid and other roentgen con-
trast media high levels of serum-precipitable
iodine are found for many months (Salter et al.,
ibid., 1949, 9, 1080). Furthermore, large doses
of iodides may result in increase in protein-
bound iodine due to formation of other iodinated
proteins than thyroxin (Riggs et al., J. Clin. Inv.,
1945, 24, 722). However, thyroxin can be ex-
tracted from serum separately from other organic
iodine compounds by butanol and these studies
indicate that thyroxin is the circulating form of
the thyroid hormone and that almost all of the
protein-bound iodine in the absence of artefacts
mentioned above consists of thyroxin (Trevorrow,
/. Biol. Chem., 1939, 127, 737; Mann et al.,
J. Clin. Inv., 1951, 30, 531); by butanol extrac-
tion in normal individuals the level is found to
be 3 to 7 micrograms per 100 ml.

When ingestion of iodide is increased an in-
creased concentration of iodide and of thyroxin
is found in the thyroid gland while protein-bound
iodine increases in the blood (Taurog and
Chaikoff, /. Biol. Chem., 1946, 165, 217) but
when the plasma-iodide concentration reaches 6
to 12 micrograms per 100 ml. the binding of
iodine in the thyroid decreases (Wolff and
Chaikoff, ibid., 1948, 174, 555) and less thyroxin
and di-iodotyrosine are found in the thyroid
(Endocrinology, 1948, 43, 174). In patients with
hyperthyroidism binding of iodine in the thyroid
gland ceases at a lower concentration of blood

692

Iodine

Part I

iodine, i.e., at about 5 micrograms per 100 ml.
(Stanley, /. Clin. Endocrinol., 1949, 9, 941;
Childs et al., J. Clin. Inv., 1950, 29, 726). The
iodine concentration in the acinar cell of the
thyroid, rather than that in the blood, probably
determines the response. After a few days of
inhibition binding occurs again (Wolff et al.,
Endocrinology, 1949, 45, 504). The administra-
tion of thiocyanate prevents the inhibition of
binding caused by high blood-iodine levels
(Raben, ibid., 296). The inhibitory action of high
levels of iodine in the blood may be important
in preventing manifestations of hyperthyroidism
in association with a variable dietary intake of
iodine. A high level of iodide inhibits the usual
increase in metabolic rate and the glandular
hyperplasia of the thyroid gland which is usually
caused by administration of thyrotropin (Ander-
son and Evans, Am. J. Physiol., 1937, 120, 597;
Cutting and Robson, /. Pharmacol., 1939, 66,
389), although the usual release of previously
isotope-labeled thyroxin from the thyroid occurs
(Wolff, Endocrinology, 1951, 48, 284). A de-
ficiency of iodine increases goitrogenic action of
antithyroid drugs while a high iodine intake tends
to counteract the goitrogenic action of thiouracil-
type drugs but not of sulfonamide-type anti-
thyroid agents (Mackenzie, ibid., 1947, 40, 137).
The decrease in vascularity of the thyroid gland
caused by iodide during the action of the
thiouracil-type of drug is utilized clinically dur-
ing the 1 to 2 weeks just before surgical resec-
tion to minimize hemorrhage during the operation
(McGinty, Ann. N. Y. Acad. Sc, 1949, 50, 403).
In hyperthyroidism, iodine therapy causes regres-
sion of the histologic signs of stimulation of the
thyroid; iodine causes lower acinar cells, larger
follicles, increased colloid and less hyperemia. It
has been suggested that iodide inactivates thyro-
tropin (Albert et al, J. Biol. Chem., 1946, 166,
637; Wright and Trikojus, Med. J. Australia,
1946, 2, 541), or inhibits the action of thyro-
tropin on the thyroid gland (Rawson, Ann. N. Y.
Acad. Sc, 1949, 50, 491), or inhibits a pro-
teolytic enzyme in the thyroid which usually re-
leases thyroxin from the gland (DeRobertis and
Nowinski, Science, 1946, 103, 421). Goiter in
the newborn has been associated with large doses
of iodide during pregnancy but goiter has not
been observed following iodide therapy in adults.
Therapeutic Uses. — Iodine was first em-
ployed therapeutically in 1819, by Coindet of
Geneva, in the treatment of goiter. In current
clinical practice, mild and uncomplicated cases
of hyperthyroidism are prepared for surgical
resection of the thyroid by iodide therapy during
1 to 2 weeks in the hospital. Severe cases of
hyperthyroidism or those who appear to be bad
surgical risks are managed, usually at home, with
an antithyroid drug such as propylthiouracil until
the basal metabolic rate returns to normal and
then iodide therapy is added for about a week
prior to surgery in the hospital (Bartels, New
Eng. J. Med., 1948, 238, 6). The iodine and the
antithyroid drug may be continued for 1 to 2
weeks following operation according to the
severity of the situation and the clinical course.
Sodium Radio-Iodide (I131) Solution (q.v.) is

also injected in cases of hyperthyroidism to cause
regression of the hyperplastic thyroid by internal
irradiation as an alternative method of treatment
to surgical resection. Iodine, along with bed rest,
sedation, and a high-caloric, high-protein and
vitamin diet, is very important in the preoperative
preparation of patients with thyrotoxicosis (either
Graves' disease or exophthalmic goiter and toxic
nodular goiter) for thyroidectomy. Iodine is com-
monly administered in the form of Lugol's solu-
tion in doses of 0.3 ml. (approximately 5 minims)
3 times daily. The patient must be watched
closely, both clinically and by determinations of
basal metabolic rate. On the average, maximum
improvement is attained after about 10 days of
this regimen and it is important to operate at
that point. If thyroidectomy is delayed the thyro-
toxicosis returns in several weeks despite con-
tinued iodine therapy. The patient becomes so-
called iodine-fast and the operative risk is so
great that it has been the practice to postpone
surgery rather indefinitely and attempt to weather
the storm with isolation of the patient, heavy
sedation and forced nutrition without iodine
therapy. After about 2 months the patient will
again respond to iodine therapy and is a fit candi-
date for thyroidectomy. The so-called thyroid
crisis, observed either immediately after thyroid-
ectomy or unassociated with surgery, is one of
the most dangerous and dramatic complications
of hyperthyroidism. For this larger doses of
iodine are given— such as 1 ml. of Lugol's solu-
tion 4 times daily or 1 Gm. of sodium iodide
intravenously every 6 hours for 3 to 6 doses;
the restlessness is controlled with 15 to 30 mg.
of morphine sulfate hypodermically, every 4
hours if necessary. At least 100 Gm. of dextrose
is given intravenously and from 2000 to 4000 ml.
of isotonic sodium chloride solution, as well as
large doses of thiamine, niacin, and riboflavin, are
given parenterally daily. Patients with non-toxic
enlargements of the thyroid, or even those with
mild hyperthyroidism, respond well to iodine
therapy and, where necessary, it seems safe to
prescribe iodine over rather prolonged periods of
time. In severe cases of hyperthyroidism the pro-
longed use of iodine courts disaster. The develop-
ment of thiouracil and similar compounds (see
Methimazole, Methylthiouracil, and Propylthio-
uracil, in Part I) has advanced the treatment of
hyperthyroidism greatly but iodine continues to
be important in this condition.

Classical Uses. — For many years potassium
iodide and other iodide salts have been employed
in the management of a great variety of chronic
conditions. Many empirical and often ill-defined
concepts developed. When injected into the blood
stream the iodides have practically no effect on
circulation. The common belief that iodides dilate
arterioles is without reasonable foundation
(Capps, J.A.M.A., 1912, 59, 1350). The only im-
portant physiological effect of iodine is its in-
fluence upon metabolism through the thyroid and
related endocrine glands. According to Chistoni
{Arch, internat. pharmacodyn. therap., 1911, 21,
339), the elimination of uric acid and other purine
bases is increased disproportionately by iodides.
Grabfield and Prentiss (/. Pharmacol, 1925, 25,

Part I

Iodine

693

411) found that iodides caused a marked increase
of nitrogen in the urine, which they interpreted
to mean an increased catabolism. There were
differences in the effects of various salts. Iodide
appears to have some influence upon glands —
beyond its action as a salt — not only increasing
the quantity but changing the character of their
secretions, especially diminishing excessive vis-
cidity. In morbid states attended with fibrinous
exudation iodides have a similar effect on the
exudate. There was a belief that iodide would
even cause absorption of organized fibrous tissue;
this, however, is not well substantiated. In
syphilis and tuberculosis there is often a very
rapid breaking down of characteristic local
lesions. This effect seems to be due to an in-
creased autolysis but the mechanism is unknown.

In syphilis iodides are without direct curative
action, that is, they have no effect upon the
growth of the specific microorganism (Raiziss
and Severac, /. Chemother., 1929, 5, 1). Because,
however, of their power of causing the break-
down of syphilitic lesions they were formerly
considered of utmost importance in the tertiary
stage, not merely because they lessen the extent
of the sequelae of the luetic affection, but because
they drive the spirochetes from their lurking
places into the general circulation where they
may be reached by direct-acting antitreponemal
drugs.

The effect of iodides in tuberculosis is analo-
gous to that in syphilis, but whether this action
in hastening breakdown of lesions will be bene-
ficial or otherwise to the tuberculous patient de-
pends upon the location and character of the
infection. Thus, in phthisis, prior to streptomycin
and other effective chemotherapeutic agents, the
most favorable result was the walling off and ulti-
mate calcification of the local lesion. Iodides, by
softening the infected area, were capable of not
only delaying the whole process but also of
disseminating the microorganisms throughout the
lung. On the other hand, in lymphadenitis they
hasten suppuration and may lead to extrusion of
the bacilli. In a somewhat similar way iodides
may be useful in bone tuberculosis. In leprosy
they apparently have a somewhat similar type of
action, although less marked. They have also a
potent effect in actinomycosis and even appear to
have a direct curative effect (see under Potassium
Iodide and, for other pulmonary fungus infec-
tions, Kunstadter et al., Am. J. Med. Sc, 1946,
211, 583, and Friedman and Signorelli, Ann. Int.
Med., 1946, 24, 385, and J.A.M.A., 1946, 130,
545). _

In inflammations of either the serous or mucous
membranes attended with fibrinous exudates or
viscid secretions — as pleurisy, pericarditis, or
bronchitis — iodides are often used because of
their liquefying action. In bronchial asthma, while
they have no direct influence upon the paroxysms,
by their effect in increasing and liquefying the
bronchial secretions they have proved to be
among the most frequently serviceable drugs we
possess. Iodides are of similar value in liquefying
tenacious sputum in chronic bronchitis. They are
contraindicated in acute bronchial infections be-
cause they add to the hyperemia. In chronic in-

flammatory conditions accompanied with forma-
tion of fibroid connective tissue — as in interstitial
nephritis, arteriosclerosis, and fibroid degenera-
tions of the nervous centers — they were widely
employed, not, however, because they were of
pro#en utility, but in a kind of despairing hope
that they may have produced some amelioration
of the condition. In degenerative changes occur-
ring as the result of syphilis, however, such as
locomotor ataxia, they often appear to have some
beneficial effect. Iodides are frequently employed
in chronic rheumatism; whether their beneficial
effect is due to an influence on metabolism or to
a softening of fibrinous exudate is uncertain.

Potassium iodide, by virtue of its iodide com-
ponent forming a freely-soluble complex with
mercuric and lead ions, has been used in treat-
ment of lead poisoning and in mercurial cachexia
to hasten elimination of the heavy metal; such
treatment, however, by mobilizing deposits of the
poisonius metal may cause exacerbation of
symptoms.

For the various internal effects of iodide it is
the rule to administer an iodide as being less
likely to disturb digestion but solutions of the
element itself, such as the official strong iodine
solution, are widely prescribed.

Elemental Iodine. — Elemental iodine has two
important therapeutic properties which its salts
do not share; these are its local irritant and
germicidal effects. As a counterirritant it is used
especially in various forms of arthritis, notably
those due to trauma, but it is also effective in
bronchitis and glandular enlargement. Its action
in these conditions may be supplemented by
systemic effects following absorption through the
skin. Iodine has also been employed for its local
irritant effect as an injection for treatment of
local effusions, such as hydrocele and ganglion,
although surgical repair is usually required.

Antiseptic Uses. — Elemental iodine is one of
the most potent and useful of germicides. Ac-
cording to Gershenfeld and Miller (/. A. Ph. A.,
1932, 21, 894) the phenol coefficient varies be-
tween 180 and 237, depending on the character
of the solvent and the species of bacteria. Nye
(J.A.M.A., 1937, 108, 280) found that in the
presence of blood serum a 1 in 2000 solution was
bactericidal to staphylococci and surpassed all
the mercurials tested. Using dilutions of Iodine
Solution, N.F., Gershenfeld et al. (Mil. Surg.,
1954, 114, 172) found that free iodine concen-
trations as low as 0.0625 per cent were bacteri-
cidal for human tubercle bacilli in cultures and
that suspensions of Mycobacterium tuberculosis
var. hominis exposed to 0.5 or even 0.05 per cent
concentration of free iodine for 5 minutes failed
to infect guinea pigs. Albumin decreased the
bactericidal action. Most antiseptics are ineffec-
tive against tubercle bacilli. Simons (J.A.M.A.,
1928, 91, 704) found that to kill anthrax spores
much stronger solutions are required; the
formerly official 7 per cent tincture of iodine re-
quired 2 hours for such action. Gershenfeld (/. .4.
Ph. A., 1955, 44, 77) found that a concentration
of 0.375 mg. of free iodine per ml. prevented
within 1 minute the appearance of cytopathogenic
effects in monkey kidney cells due to Types I

694

Iodine

Part I

and II poliomyelitis virus; the same report re-
views the effectiveness of iodine as a virucidal
agent.

Disinfection of Drinking Water. — In a study
of the efficacy of elemental iodine as a disin-
fectant for drinking water, Chang and Mfcrris
(Ind. Eng. Chem., 1953, 45, 1009) determined
the concentration required to kill the cysts of
Endamoeba histolytica, which is probably the
primary consideration in evaluating iodine to be
used for this purpose. They found that a dosage
of 8 parts per million of iodine completely de-
stroyed 30 cysts per ml. within 10 minutes in
most natural waters, exceptions being waters with
iodine demands greater than 4 p.p.m, and those at
a temperature near 0° C. For waters with high
iodine demand, such as those that are highly
colored, more iodine should be used; waters at
low temperatures are satisfactorily disinfected by
increasing the time of treatment to 20 minutes.
The 8 p.p.m. dosage also reduced a count of 1
million enteric bacteria per ml. to less than 5 per
100 ml. within 10 minutes, and the treatment
was effective against leptospira, schistosomes, and
viruses. Certain soluble polyiodides, prepared in
tablet form, may be added to water to attain
this 8 p.p.m. concentration of elemental iodine.
These polyiodides include: (1) tetramethylam-
monium iodide, (CH3)4Nl3, which dissolves in
water to the extent of 0.25 Gm. per liter; (2)
tetraglycine hydroperiodide, (NH2CH2COOH)4-
HI. 1^412, known by the trivial name globaline,
soluble to the extent of 380 Gm. per liter; (3)
potassium tetraglycine triiodide, (NH2CH2-
COOH)4Kl3, also called potadine, very soluble
in water; (4) aluminum hexaurea sulfate tri-
iodide, Al[CO(NH2)2]eS04l3, also known as
hexadine-S, soluble to the extent of 590 Gm. per
liter; (5) aluminum hexaurea dinitrate triiodide,
Al[CO(NH2)2]6(N03)2l3, or hexadine-N, dis-
solving to the extent of 390 Gm. per liter. Morris
et al. (ibid., 1953, 45, 1013) concluded that
while any of these compounds may be used to
prepare tablets for emergency disinfection of
water, tetraglycine hydroperiodide appeared to
have the best storage properties; the formulation
they found satisfactory contains 20 mg. of tetra-
glycine hydroperiodide, 90 mg. of disodium di-
hydrogen pyrophosphate, and 5 mg. of talc. When
dissolved in a quart of water each tablet provides
a concentration of 8 p.p.m. of elemental iodine.
A tablet containing triglycine hydroperiodide,
liberating 7.5 p.p.m. of elemental iodine under
the conditions of usage has been included in the
soldier's canteen for emergency purification of
water (J.A.M.A., 1946, 132, 930). The taste and
odor of water thus purified are less objectionable
than when purified by chlorine-yielding com-
pounds.

Topical Use. — An important advantage of
iodine when used as an antiseptic is its compara-
tively slight injurious effect on animal tissues.
Several investigators have compared the "toxicity
index" (the concentration injurious to tissue
divided by the antiseptic concentration) of iodine
with various mercury derivatives, phenol, hexyl-
resorcinol, etc., using either leukocytes or chicken
embryo cells as the test tissue, and in practically

every study iodine gave the most favorable re-
sults (Welsh and Hunter, Am. J. Pub. Health,
1940, 30, 129). Shaughnessy and Zichia
(J.A.M.A., 1943, 123, 525) demonstrated efficacy
of iodine tincture in preventing experimental
rabies. Dunham and MacNeal (/. Immunol.,
1944, 49, 129) found 0.1 per cent of iodine to
inactivate the influenza virus in less than 3
minutes.

As a wound disinfectant iodine is one of the
best but it should never be applied in concen-
trations higher than 2 or 3 per cent. Cognizance
of this fact was taken in U.S. P. XIII in reducing
the strength of iodine tincture from 7 to 2 per
cent.

Iodine has been extensively used to sterilize
the skin prior to operation (Ficarra, J. Internat.
Col. Surg., 1951, 16, 115); for this purpose it
may be employed in strengths of 5 to 10 per
cent. The controversy concerning the possibility
of rendering the skin aseptic by application of
iodine has led to considerable experimentation
and polemics. Certain conclusions seem justi-
fiable: (1) In a large proportion of cases the skin
may be rendered aseptic by simple application
of the solution of iodine; (2) in some instances
application of iodine will not sterilize the skin
but may reduce the number of viable organisms;
(3) in view of this latter fact the surgeon is not
justified in neglecting mechanical measures for
obtaining surface disinfection. Various solvents
have been suggested for preparing iodine solu-
tions for such use; Macdonald and Peck (Lancet,
Sept. 1, 1928) concluded that the best solvent —
giving consideration to germicidal power, irritant
action, penetrating properties, etc. — is isopropyl
alcohol.

Iodine is of value in the treatment of fungus
infections of the skin, such as ringworm, favus,
etc. In these conditions it may be applied either
as an ointment or tincture. Stricklcr (Urol.
Cutan. Rev., 1947, 51, 264) reported on the
superiority of a special iodine ointment for treat-
ment of tinea capitis infestations. Collins and
Hughes (/. Laryng. Otol., 1944, 59, 81) used a
powder containing iodine and boric acid for
effective treatment of chonic suppurative otitis
media caused by coliform or diphtheroid organ-
isms. Prior to the advent of penicillin beneficial
results were obtained in erysipelas by painting
of the affected part with stronger tincture of
iodine (Lammerhirt, Berl. klin. Wchnschr., 1921,
58, 1389). Nascent iodine, as in Heliogen tablets
(containing potassium iodide, chloramine-T and
excipient), has been advocated as a mouth wash
and cleansing solution on skin wounds (Am. J.
Surg., 1952, 78, 446). A compound of polyvinyl-
pyorrolidone and iodine has been applied with
benefit to a variety of skin lesions without pro-
ducing irritation; it has also been administered
orally or intravenously in a variety of systemic
infections (Shelanski, Drug Trade News, 1951,
26, 36). S

Toxicology. — Iodine is a frequent cause of
poisoning, the symptoms of which are pain in the
epigastrium, followed by nausea and vomiting;
the vomitus may be brown, or blue if there has
been any starch in the stomach, and later may

Part I

Iodine Solution

695

become bloody. Purging, excessive thirst, abdom-
inal cramps, and circulatory failure may follow
in severe cases. The treatment should be prompt
administration of a chemical antidote, the most
efficient being sodium thiosulfate; the observa-
tions of Myers and Ferguson (Proc. S. Exp.
Biol. Med., 1928, 25, 784) indicated that the
thiosulfate was capable of following iodine into
the blood stream and should be useful if there
are symptoms of constitutional absorption. It is,
however, not likely to be quickly available in an
emergency; in this case a couple of tablespoonfuls
of cornstarch stirred up with water — or in its
absence, bread or other starchy material — forms
a useful substitute. The subsequent treatment
will be that of any toxic gastroenteritis.

When given continuously over long periods of
time, even in medicinal doses, iodine or one of
its salts may give rise to more or less serious
disturbances known as iodism. This is usually
characterized by pain or heaviness in the region
of the frontal sinuses, with or without coryza;
in some instances soreness of the mucous mem-
brane of the mouth and throat, or a mild ptyal-
ism, or a papular eruption is the prominent
symptom. Various skin lesions of all degrees of
severity have followed internal use of iodides in
sensitive persons. Absorption of mammae and
wasting of testicles have been reported as caused
by long-continued use of iodine, but such results
are extremely rare.

Dose. — The usual internal dose is 0.3 ml. (ap-
proximately 5 minims) of Strong Iodine Solution,
well diluted, which represents about 15 mg. of
iodine and 30 mg. of potassium iodide.

Storage. — Preserve "in tight containers."
U.S.P.

IODINE AMPULS. N.F.

Iodine Swabs, [Ampullae Iodi]

"Iodine Ampuls contain, in each 100 ml., not
less than 1.8 Gm. and not more than 2.2 Gm. of I
and not less than 2.1 Gm. and not more than 2.6
Gm. of Nal. Note. — Iodine Ampuls must contain
Iodine Tincture, U.S.P. Prepare the solution, fill
the cleansed ampuls, and seal them." N.F.

Alcohol Content. — From 44 to 50 per cent,
by volume, of C2H5OH. N.F.

These ampuls are supplied in cartridge-like
devices which permit breaking of the thin, taper-
ing portion of the ampul and absorption of the
iodine tincture in cotton or other absorbent ma-
terial which serves also as an applicator for the
tincture.

IODINE OINTMENT. N.F.

Ungentum Iodi

"Iodine Ointment contains not less than 6.5
per cent and not more than 7.5 per cent of I."
N.F.

Fr. Pommade a l'iodure de potassium iod6e. Ger.
Jodsalbe. It. Unguento con joduro di potassio e jodio;
Poraata jodo-jodurata. Sp. Pomada de yodo yodurada;
Unguento de yodo.

Dissolve 40 Gm. of iodine and 40 Gm. of potas-
sium iodide in 120 Gm. of glycerin, preferably
in a glass mortar, and thoroughly mix this solu-

tion with a mixture of 40 Gm. of yellow wax, 40
Gm. of wool fat, and 720 Gm. of petrolatum,
previously melted together and cooled until con-
gealed. Contact with metallic utensils or con-
tainers should be avoided during manufacture
and storage of this ointment. N.F.

Assay. — About 1 Gm. of the ointment is
heated with potassium carbonate at a tempera-
ture of 650° to 675° whereby the iodine is
reduced to potassium iodide. The halide is ex-
tracted with hot distilled water, the solution
slightly acidified with nitric acid, and sufficient
of a dilute potassium permanganate solution
added to liberate enough iodine to give the solu-
tion a faint yellow color. Starch T.S. is added
and the mixture titrated with 0.1 N silver nitrate
until the blue color is discharged and a canary
yellow precipitate remains (disappearance of the
blue color is due to depletion of iodide ions).
Each ml. of 0.1 N silver nitrate represents 12.69
mg. of I. N.F.

Uses. — Iodine ointment is antiseptic and
mildly counterirritant. Wetzel and Sollmann
(/. Pharmacol., 1920, 15, 168) reported that
iodine may be absorbed after application of the
ointment but the quantity which enters the sys-
tem through the intact skin is small. The oint-
ment has been popularly employed as a local
resolvent and counterirritant in various forms of
arthritis, lymphadenitis, and other local tume-
factions. The experiments of Sollmann (J. A.M. A.,
1919, 73, 899) show that results are obtained
only after application for several days has caused
considerable irritation of the skin.

Storage. — Preserve "in tight containers and
avoid prolonged exposure to temperatures above
30°." N.F.

IODINE SOLUTION.

Liquor Iodi

N.F.

"Iodine Solution contains, in each 100 ml., not
less than 1.8 Gm. and not more than 2.2 Gm. of I,
and not less than 2.1 Gm. and not more than 2.6
Gm. of Nal." N.F.

Dissolve 20 Gm. of iodine and 24 Gm. of so-
dium iodide in 50 ml. of purified water, then add
enough purified water to make 1000 ml. N.F.

This solution is identical with the currently
official formula for Iodine Tincture (U.S.P.) in
content of iodine and of sodium iodide but differs
from the latter preparation in the solvent em-
ployed; the solution is made with purified water,
the tincture with diluted alcohol.

Description. — "Iodine Solution is a transpar-
ent liquid, having a reddish brown color and the
odor of iodine." N.F.

Test. — Identification. — A deep blue color re-
sults when a drop of iodine solution is added to
a mixture of 1 ml. of starch T.S. and 9 ml. of
distilled water. N.F.

Assay. — A 5 -ml. portion of solution, diluted
with distilled water, is titrated with 0.1 iV potas-
sium arsenite, which reduces elemental iodine to
iodide, using starch T.S. as indicator. Each ml.
of 0.1 iV potassium arsenite represents 12.69 mg.
of I. To this solution hydrochloric acid and chloro-
form are added, and the mixture is titrated with

696

Iodine Solution

Part I

0.05 M potassium iodate until the purple color of
iodine disappears from the chloroform layer,
signifying that the iodide, which is first oxidized
to elemental iodine, has been finally oxidized to
the plus one valence characteristic of iodine mono-
chloride (see under Potassium Iodide for further
discussion). The difference between the number
of ml. of 0.05 M potassium iodate used and the
number of ml. of 0.1 iV potassium arsenite added,
multiplied by 14.99, represents the number of
mg. of Nal in 5 ml. of iodine solution. In this
assay 1 ml. of 0.1 N potassium arsenite is equiva-
lent to 1 ml. of 0.05 M (or 0.2 N) potassium
iodate by virtue of the fact that potassium ar-
senite reduces an atom of iodine by only one
valence unit (to iodide) while potassium iodate
oxidizes an iodide ion by two valence units (to
the plus one valence of iodine monochloride).
N.F.

Uses. — The experiments of Karns (/. A. Ph.
A., 1932, 21, 779), of Karns, Cretcher and Beal
(/. A. Ph. A., 1932', 21, 783), and of LaWall and
Tice (J. A. Ph. A., 1932, 21, 122) led to the in-
troduction of two useful iodine-containing anti-
septics, currently official under the titles Iodine
Solution and Iodine Tincture, respectively. Both
contain the same concentration of iodine and so-
dium iodide, but the former utilizes purified
water, and the latter diluted alcohol, as the sol-
vent. The aqueous preparation would appear to
have the greater penetrating power but the hy-
droalcoholic preparation has the apparent advan-
tage of more rapid evaporation of solvent. The
experiments of Gershenfeld and Miller (/. A.
Ph. A., 1932, 21, 894) demonstrated that both
iodine preparations possess bactericidal efficiency
superior to many proprietary preparations em-
ployed as wound disinfectants.

The concentration of sodium iodide is that
corresponding to a solution isotonic with human
blood serum. Sodium iodide is preferable to potas-
sium iodide as the source of halide ions because
the former, a normal physiological constituent, is
less likely to disturb the equilibrium in the tissues.
The concentration of alcohol in the tincture — ap-
proximately 47 per cent — provides a sufficient
degree of penetration and evaporation without
exhibiting the dehydrating or blood-cell coagu-
lating effects of higher concentrations of alcohol.
For application to wounds some physicians dilute
these preparations to contain 0.5 or 1 per cent of
iodine; for irrigations a dilution containing 0.1 per
cent of iodine is commonly employed. S

Storage. — Preserve "in tight, light-resistant
containers, preferably at a temperature not above
35°." N.F.

STRONG IODINE SOLUTION.

U.S.P. (B.P., LP.)

Compound Iodine Solution, Lugol's Solution,
Solutio Iodi Aquosa, Liquor Iodi Fortis

"Strong Iodine Solution contains, in each 100
ml., not less than 4.5 Gm. and not more than 5.5
Gm. of iodine (I), and not less than 9.5 Gm. and
not more than 10.5 Gm. of KI." U.S.P.

Both the B.P. and the LP. recognize this same
solution as Aqueous Solution of Iodine; the B.P.
Strong Solution of Iodine, on the other hand, is

an alcoholic solution containing 10 per cent w/v
of iodine. The latter is described under Strong
Iodine Tincture.

B.P. Aqueous Solution of Iodine; Liquor Iodi Aquosus.
LP. Solutio Iodi Aquosa. Solutum Iodo-iodatum Forte.
Fr. Solute iodo-iodure fort; Solute dit de Lugol. Get.
Lugolsche Losung. Sp. Solucidn de Yodo Fuerte.

Dissolve 50 Gm. of iodine and 100 Gm. of
potassium iodide in 100 ml. of purified water,
then add enough purified water to make 1000 ml.
U.S.P.

Description. — "Strong Iodine Solution is a
transparent liquid having a deep brown color and
the odor of iodine." U.S.P.

Tests. — Identification. — (1) A deep blue color
is produced when a drop of strong iodine solution
is added to 1 ml. of starch T.S. previously diluted
with 10 ml. of distilled water. (2) The residue
remaining after the evaporation of a few ml. of
solution to dryness, followed by gentle ignition
to volatilize elemental iodine, responds to tests
for potassium and for iodide. U.S.P.

Assay.— The assays for iodine and for potas-
sium iodide are performed in the same manner
as directed for iodine and for sodium iodide under
Iodine Solution. The factor for calculating to mg.
of KI is 16.60. U.S.P.

The B.P. assays for iodine and for potassium
iodide on separate portions of a 1 to 4 aqueous
dilution of the solution. To determine iodine, 20
ml. of the diluted solution is titrated with 0.1 A7
sodium thiosulfate. The assay for potassium
iodide involves titration of 10 ml. of the diluted
solution with 0.05 M potassium iodate in the
presence of hydrochloric acid and chloroform;
from the volume of potassium iodate required is
subtracted one quarter of the quantity of 0.1 N
sodium thiosulfate required in the assay for
iodine. Each ml. of the difference is equivalent to
16.60 mg. of potassium iodide. The LP. assays
are essentially the same as those of the B.P. ex-
cept that in the assay for potassium iodide there
is added potassium cyanide prior to titration
with potassium iodate; thereby there is produced
iodine monocyanide instead of iodine monochlo-
ride. This allows the concentration of hydrochloric
acid in the titrated solution to be reduced to a
point where starch may be employed as the indi-
cator, the chloroform being omitted.

Uses. — Doctor Lugol, to whose investigations
— carried on about 1830— is due chiefly the intro-
duction of iodine as a drug, used solutions of vary-
ing strength according to the purpose for which
they were employed. His iodine lotion, used as a
wash in scrofulous ophthalmia, in ozena, etc., con-
tained two grains of iodine and four of potassium
iodide in a pint of water. His rubefacient iodine
solution was prepared by dissolving half an ounce
of iodine and an ounce of potassium iodide in six
fluidounces of water. Lugol's caustic iodine solu-
tion, containing an ounce each of iodine and po-
tassium iodide, dissolved in two fluidounces of
water, was used to destroy soft and fungous
granulations, and in lupus. The official solution is
used chiefly internally as a means of obtaining the
therapeutic effects of iodine. It is also an efficient
antidote to most alkaloidal poisons. E

The usual dose of the U.S.P. solution is 0.3 ml.

Part I

Iodine Tincture, Strong 697

(approximately 5 minims), three times a day,
given in at least four tablespoonfuls of water or
milk, so as to avoid irritation of the stomach.
The range of dose is 0.1 to 1 ml.; not more than
3 ml. should be given in 24 hours.

Storage. — Preserve "in tight containers, pref-
erably at a temperature not above 35°." U.S.P.

Off. Prep. — Phenolated Iodine Solution, N.F.

PHENOLATED IODINE SOLUTION.

N.F.

Boulton's Solution, French Mixture, Carbolized Iodine
Solution, Liquor Iodi Phenolatus

Mix 6 ml. of liquefied phenol and 15 ml. of
strong iodine solution with 165 ml. of glycerin,
and add enough water to make the product meas-
ure 1000 ml. Expose this liquid, in a strong, tightly
stoppered, glass container, to sunlight, or heat it
at a temperature not exceeding 70°, until it has
become colorless or faintly yellow. N.F.

The mechanism of the reaction involved in pre-
paring this solution is not known with certainty.
Some believe that a compound of phenol and
iodine results, others that the iodine is converted
to hydrogen iodide.

Description. — "Phenolated Iodine Solution is
a colorless or light yellow liquid, with the char-
acteristic odor and taste of phenol. The specific
gravity of Phenolated Iodine Solution is about
1.047." N.F.

Standards and Tests. — Identification. — A red
precipitate forms on adding mercury bichloride
T.S. to phenolated iodine solution. Free iodine. —
The solution does not turn blue with starch T.S.
Residue on ignition. — The residue from 10 ml. is
negligible. N.F.

Uses. — This solution has for many years been
employed, to a limited extent, as an antiseptic
mouth wash. Tests of its antibacterial powers
apparently have not been published. If an iodo-
phenol is formed one would expect considerable
antiseptic potency. It is used undiluted.

Storage. — Preserve "in tight containers." N.F.

IODINE TINCTURE. U.S.P. (B.P.) (LP.)

[Tinctura Iodi]

"Iodine Tincture contains, in each 100 ml., not
less than 1.8 Gm. and not more than 2.2 Gm. of
iodine (I), and not less than 2.1 Gm. and not
more than 2.6 Gm. of sodium iodide (Nal)."
U.S.P. The tincture is prepared by dissolving 20
Gm. of iodine and 24 Gm. of sodium iodide in
enough diluted alcohol to make 1000 ml. U.S.P.

Under the name Weak Solution of Iodine
(Liquor Iodi Mitis), the B.P. recognizes a similar
solution prepared by dissolving 25 Gm. of iodine
and 25 Gm. of potassium iodide in 25 ml. of water
and diluting this solution to 1000 ml. with 90 per
cent alcohol. It is required to contain 2.5 per cent
w/v of iodine (limits, 2.45 to 2.55), and 2.5 per
cent w/v of potassium iodide (limits, 2.45 to
2.55). B.P.

The corresponding I. P. preparation is desig-
nated Ethanolic Solution of Iodine (Solutio Iodi
Spirituosa) and is prepared by dissolving 20 Gm.
of iodine and 25 Gm. of sodium iodide in suffi-
cient 50 per cent alcohol to make 1000 ml. of

solution. The solution is required to contain 2.0
per cent w/v of iodine (limits, 1.95 to 2.05) and
2.5 per cent w/v of sodium iodide (limits, 2.45
to 2.55).

Description. — "Iodine Tincture is a trans-
parent liquid having a reddish brown color and
the odors of iodine and of alcohol." U.S.P.

Alcohol Content. — From 44 to 50 per cent
of C2H5OH. U.S.P.

Uses. — The U.S.P. iodine tincture contains
the same concentrations of iodine and sodium
iodide as Iodine Solution of the N.F.; the two
preparations differ only in the solvent, the N.F.
solution being prepared with purified water while
the U.S.P. preparation contains diluted alcohol.
Both preparations are effective wound antiseptics
(see under Iodine Solution for discussion) and
are much more acceptable for such use than the
preparation formerly known as iodine tincture
(now the Strong Iodine Tincture of the N.F.).

Storage. — Preserve "in tight containers."
U.S.P.

Off. Prep. — Iodine Ampuls, N.F.

STRONG IODINE TINCTURE.

N.F. (B.P.)

Tinctura Iodi Fortis

"Strong Iodine Tincture is an alcohol solution
of iodine and potassium iodide containing, in each
100 ml., not less than 6.8 Gm. and not more than
7.5 Gm. of I, and not less than 4.7 Gm. and not
more than 5.5 Gm. of KI." N.F.

The B.P. Strong Solution of Iodine contains
10.0 per cent w/v of iodine (limits, 9.8 to 10.2)
and 6.0 per cent w/v of potassium iodide (limits
5.8 to 6.2).

B.P. Strong Solution of Iodine; Liquor Iodi Fortis.
Tincture of Iodine, U.S.P. XII. Tinctura Iodi Officinalis
(Fr.); Tinctura Jodi (Ger.) ; Solutio Jodi Spirituosa (It.);
Solutio Iodi Alcoholica (Sp.). Fr. Teinture d'iode. Ger.
Jodtinktur. It. Tintura di jodio. Sp. Solucion de yodo
alcoholica.

Strong iodine tincture may be prepared by dis-
solving 50 Gm. of potassium iodide in 50 ml. of
purified water, agitating with this solution 70 Gm.
of iodine and, when solution is effected, adding
enough alcohol to make 1000 ml. N.F.

The B.P. directs solution of 60 Gm. of po-
tassium iodide and 100 Gm. of iodine in 100 ml.
of distilled water and dilution of this solution
with 90 per cent alcohol to 1000 ml.

The present Strong Iodine Tincture was official
in the U.S.P. XII as Tincture of Iodine; there
was no change of formula with the change in
name. In the N.F. VII there was official Stronger
Tincture of Iodine, popularly called Churchill's
Tincture of Iodine, prepared from 165 Gm. of
iodine, 35 Gm. of potassium iodide, 250 ml. of
water, and alcohol to make 1000 ml. This prep-
aration, formerly occasionally used as an escha-
rotic, should not be confused with the almost
identically named preparation of the present N.F.
and never dispensed when strong iodine tincture
is requested.

Description. — "Strong Iodine Tincture is a
transparent liquid having a reddish brown color
and the odor of iodine and of alcohol. It is
affected by light." N.F.

698 Iodine Tincture, Strong

Part I

Alcohol Content. — From 83 to 88 per cent
by volume, of C2H5OH. N.F.

Beal et al. (J. A. Ph. A., 1947, 36, 203) found
all official iodine preparations (Iodine Tincture,
Strong Iodine Tincture, Iodine Solution, and
Strong Iodine Solution) to be stable when stored
in all-glass containers, whether these are of clear,
amber or blue glass. A survey of household
samples of strong iodine tincture showed that
these have a tendency to be somewhat stronger,
presumably through evaporation of alcohol as a
result of improper closure (see also Roberts,
Am. I. Pharm., 1932, 104, 635).

Strong iodine tincture was formerly prepared
simply by dissolving iodine in alcohol. Such a
solution, however, is not stable, a considerable
proportion of the iodine being converted to hydro-
gen iodide. Potassium iodide effectively stabilizes
the solution against such change, and also reduces
the vapor pressure of iodine; both effects are the
result of the reaction of iodide ion with iodine
to form triodide. '

Uses. — Strong iodine tincture is not intended
to be used as a wound disinfectant; it is far too
concentrated a preparation for this purpose. It is
a powerful local irritant, acting somewhat slowly
but with great persistence. If applied too freely it
will produce an acute dermatitis with desquama-
tion of the cuticle. It is a favorite remedy as a
counterirritant in inflammations of the joint, espe-
cially when of a more or less chronic type ; thus it
is widely employed in sprains after the stage of
acute inflammation has subsided, in chronic rheu-
matism, arthritis deformans, gout, chilblains,
myalgias, and the like. In scrofulous glands and
chronic rheumatic conditions it has been applied
with the idea of obtaining constitutional action
of iodine from its absorption through the skin as
well as its local counterirritant effect. While it is
true that, if evaporation is guarded against, per-
ceptible amounts of iodine may be absorbed fol-
lowing application of the tincture to the skin, as
ordinarily employed the extent of systemic ab-
sorption is insignificant. The irritant action of
strong iodine tincture has also been utilized for
obliteration of serous cavities, as in the radical
cure of hydrocele or ovarian dropsies.

Although this tincture is too powerful to be
used as a germicide on raw surfaces it is a valu-
able disinfectant for the skin where there are no
living tissue cells for it to kill. It is widely used by
surgeons for sterilizing the skin before operation
(see under Iodine). Dermatologists have found it
serviceable in the treatment of various parasitic
skin diseases, whether due to fungi or to bacteria.
It has also been employed as a local remedy in the
treatment of erysipelas, but its application re-
quires some caution and it is better to surround
the inflamed surface with a border of the tincture,
embracing a portion of both the sound and dis-
eased skin with the idea of preventing the progress
of the inflammation, than to attempt cure by
covering the whole surface affected.

For internal use, Lugol's solution (Strong Iodine
Solution) is a preferable preparation though the
strong iodine tincture has been sometimes thus
used. S

Dose, 0.06 to 0.3 ml. (approximately 1 to 5
minims).

Storage. — Preserve "in tight, light-resistant
containers, preferably at a temperature not above
25°." N.F.

IODIZED OIL. U.S.P. (B.P.)

[Oleum Iodatum]

"Iodized Oil is an iodine addition product of
vegetable oil or oils containing not less than 38
per cent and not more than 42 per cent of
organically combined iodine (I). It is sterile."
U.S.P.

The B.P. title for the same product is Injection
of Iodised Oil; it is defined as the iodine addition
product of poppy-seed oil and is required to con-
tain not less than 39.0 per cent and not more than
41.0 per cent of combined iodine.

B.P. Injection of Iodised Oil; Oleum Iodisatum.
Sp. Aceite Yodado. Lipiodol (Fotigera).

The B.P. states that iodized oil may be pre-
pared by treating poppy-seed oil with hydriodic
acid. Other methods involve interaction of ele-
mental iodine and the oil. The U.S.P. does not
indicate which oil shall be used, thus allowing for
some variation in the viscosity of the product
since oils which are highly unsaturated yield less
viscous products than those which are less un-
saturated. For information concerning certain
related products see Iodized Fats and Oils, in
Part II.

Description. — "Iodized Oil is a thick, viscous,
oily liquid, having an alliaceous odor and an
oleaginous taste. Iodized Oil decomposes on ex-
posure to air and sunlight, becoming dark brown
in color. Mix 1 ml. of Iodized Oil with 10 ml. of
petroleum benzin: a clear solution results." U.S.P.

Standards and Tests. — Identification. — On
heating iodized oil with anhydrous sodium car-
bonate, extracting with hot water, filtering the
mixture and adding to the filtrate, hydrochloric
acid, chloroform and chlorine T.S. the chloroform
layer is colored violet. Acidity. — A red color is
produced when 0.3 ml. of 0.1 N sodium hydroxide
is added to a solution of 1 ml. of iodized oil in
10 ml. of chloroform, using phenolphthalein T.S.
as indicator. Residue on ignition. — Not over 0.1
per cent. U.S.P.

The B.P. identity test directs boiling one drop
of oil with 2 ml. of glacial acetic acid and 100 mg.
of zinc powder for two minutes, adding 5 ml. of
water, shaking, then decanting from any undis-
solved zinc and, finally, adding 1 ml. of hydrogen
peroxide solution, whereupon iodine should be
liberated. Several tests for purity find no coun-
terpart in the U.S.P. Absence of mercury is
established by the failure of a solution of 1 Gm.
of oil in 10 ml. of ether to produce darkening on
adding a drop of ammonium sulfide solution. The
test for the limit of chloro-compounds requires
that not more than 0.5 ml. of 0.1 N sodium thio-
sulfate be required to titrate a solution of 1 Gm.
of oil in 20 ml. of acetone to which 1 Gm. of
sodium iodide has been added, the mixture set
aside in the dark for 30 minutes, and 50 ml. of
water and some starch mucilage added. The limit

Part I

Iodized Oil

699

of free iodine corresponds to a maximum of 0.1
ml. of 0.1 N sodium thiosulfate required for a
solution of 1 Gm. in 5 ml. of chloroform to which
a solution of 1 Gm. of potassium iodide in 20 ml.
of water has been added. The oil is further re-
quired to comply with the official tests for
sterility.

Assay. — About 300 mg. of the oil is assayed
by the procedure described under I ophendylate
Injection. U.S.P.

The B.P. assay specifies that the oil be boiled
with glacial acetic acid and zinc powder under a
reflux condenser to reduce the iodine to iodide
which is titrated with 0.05 N potassium iodate in
the presence of potassium cyanide. Each ml. of
0.05 M potassium iodate is equivalent to 12.69
mg. of combined iodine. This titration is ana-
logous to titration with iodate in the presence of
a high concentration of hydrochloric acid (see
Assay under Potassium Iodide for explanation) ;
instead of IC1 being formed, ICN is produced. In
the presence of HCN it becomes possible to use
starch as indicator. The equivalent weight of
iodine is one-half the atomic weight.

Uses. — Although they have lost favor, fluid
iodized fats have been used as contrast media for
making x-ray pictures, since iodine, whether free
or combined, is radiopaque. For certain purposes,
especially outlining of internal cavities — such as
the bronchi, spinal canal (see Frazier, J.A.M.A.,
1928, 91, 1609), fistulous tracts, paranasal sinuses,
lacrimal ducts, uterus and tubes, otitic brain
abscess (Blonder, J.A.M.A., 1946, 130, 635), etc.
— non-irritant solutions of iodine can be injected
directly into the cavity for x-ray photography.
For this use, 40 per cent iodized oils have been
widely employed because of their lack of irritant
action and low toxicity. A 28 per cent iodized oil
has also been used, as has a 10 per cent solution
with a density less than that of spinal fluid. How-
ever, these preparations are not free from danger.
Therapeutic instillation of iodized oil by nasal
catheter into the bronchial tree in certain types
of asthma was formerly viewed with enthusiasm,
but it is now known that its retention for periods
as long as two years may result in continued
severe asthma and pneumonitis.

Absorption. — When iodine is chemically com-
bined with a fatty acid, the combination is ab-
sorbed from the intestines undecomposed. The
iodized fat, being more soluble in lipoids, is de-
posited in the tissues, especially in nerve tissue,
and there slowly liberates its iodine to exert the
characteristic therapeutic effect of iodides. A con-
siderable number of these iodized fats have been
introduced into medicine as sources of iodine;
the advantages claimed for them are less harmful
action upon the stomach, and a more gradual and
continuous remedial action. They are not popular
at present.

Toxicology. — Archibald and Brown
(J. A.M. A., 1927, 83, 1310) pointed out in some
detail the possible injurious effects of local irrita-
tion from introduction of iodized oil into the
bronchial tree. The presence of exudative lesions
in pulmonary tuberculosis is considered to be a
contraindication to bronchography with iodized
oil. Firth {J. A.M. A., 1933, 100, 110) called at-

tention to the possibility of severe iodism from
the oil escaping into the alimentary canal. Hyde
and Hyde (/. Lab. Clin. Med., 1949, 34, 1516)
found that after instillation of 5 to 20 ml. of 40
per cent Lipiodol for bronchograms in 30 patients,
blood iodine concentration after one week was
over 440 micrograms per 100 ml. It fell to an
average of 200 at one month and to normal levels
of 6 to 8 micrograms per 100 ml. after 17 months.
In some cases the level did not return to normal
for two to four years. Among reactions after
bronchography Mahon (J.A.M.A., 1946, 130,
194) reported asthma and urticaria, and in non-
allergic patients he observed swelling of salivary
glands and papular and pustular skin eruptions.
One death has been reported from asthma with
thick mucus, resulting in massive atelectasis.
Fischer (Schweiz. med. Wchnschr., 1950, 80,
273) warned that danger of injury is very great
in diseased lung tissue, where foreign body granu-
lomas can be demonstrated frequently. As a sub-
stitute for iodized oil, Vogt and Konig (Deutsche
med. Wchnschr., 1949, 74, 1080) used brominated
refined fatty oil in 21 bronchographies; they
stated that the oil is completely coughed up
within 10 minutes and that it does not activate
tuberculosis.

The difficulties in performing diagnostic studies
with iodized oil have been summarized as follows
(Am. Prof. Pharm., 1948, 14, 333) : it is immis-
cible with aqueous material that may be present
in a cavity; embolism is a constant danger; acci-
dental injection into a blood vessel may be fatal;
its viscid character hinders even distribution,
renders its removal difficult, permitting a quantity
to remain which acts as a foreign body, and slows
its absorption. The Council on Pharmacy and
Chemistry of the A.M. A. listed the dangers of
injection of iodized oils into the cavities, and the
conditions under which such measures are justi-
fiable (J. A.M. A., 1932, 99, 1946; see also N.N.R.,
1955, page 367).

Air and oxygen have largely supplanted iodized
oil as a contrast medium for study of lesions in-
volving the central nervous system, because of
the dangers incidental to the latter. Jaeger (Arch.
Neurol. Psychiat., 1950, 64, 715) demonstrated
the irritating effect of iodized oil on the brain and
spinal cord when dispersed as small particles. In
his study an emulsion of iodized oil was injected
into the cerebrospinal fluid system of dogs; it
was clear that no part of the subarachnoid space
escaped the devastating effects. Necropsy dis-
closed extensive adhesions at the site of injection,
attempts at encapsulation of the oil, and the tis-
sues at the base of the brain and in the spinal
canal were matted together with exudate and in-
flammatory granulations. Since blood serum is an
effective emulsifying agent, its presence may bring
about similar results even though the oil itself is
not emulsified when injected. In a case report,
Themel (Zentralbl. Chir., 1952, 77, 1508) dis-
cussed the compression of the cauda equina and
meningeal changes, as well as urinary tract infec-
tion and uremia, which followed injection of
iodized oil for myelography when blood appeared
in the needle at the time of lumbar puncture. He
strongly urged that in such event oil injection be

700

Iodized Oil

Part I

delayed for a considerable period, and that in
every instance of such use efforts be made to
eliminate urinary tract inflammation prior to oil
myelography. In general, subarachnoid injection
of iodized oil is contraindicated unless immedi-
ate surgery is contemplated during which it can
be removed. The danger of oil embolism has been
emphasized in the use of iodized oil for utero-
salpingography. Brown et al. {Am. J. Obst. Gyn.,
1949, 58, 1041) found that aqueous media are
nonirritating to the structures, are promptly ex-
creted and are preferable to oily preparations for
this purpose.

Dose.— The usual dose is 10 ml. (about 2y2
fluidrachms) by special injection, with a range of
0.5 to 20 ml. The maximum safe dose is usually
20 ml. and the total dose in 24 hours should
seldom exceed 20 ml. Orally, 0.5 to 1 Gm. (ap-
proximately iy2 to 15 grains) is used one to
three times daily in capsules.

Storage. — Preserve "in well-filled, tight, light-
resistant containers'" U.S.P.

IODOALPHIONIC ACID. U.S.P. (B.P.)

0-(4-Hydroxy-3,5-diiodophenyl)-tt-phenylpropionic Acid,
[Acidum Iodoalphionicum]

H0"^ VcH2CHC00H

"Iodoalphionic Acid, dried over sulfuric acid
for 4 hours, contains an amount of iodine equiva-
lent to not less than 98 per cent and not more
than 102 per cent of C15H12I2O3." U.S.P. The
B.P. recognizes this compound as Pheniodol, de-
fining it as P-(4-hydroxy-3:5-di-iodophenyl)-a-
phenylpropionic acid, and requiring it to contain
not less than 50.5 per cent and not more than 51.5
per cent of I, calculated with reference to the
substance dried to constant weight at 105°.

B.P. Pheniodol. Priodax (Schering).

This contrast medium employed in cholecys-
tography was introduced into European medicine
some years ago under the name Biselectan. The
substance may be prepared by iodinating (3- (4-
hydroxyphenyl)-a-phenylpropionic acid, the lat-
ter obtained by the interaction of cinnamic acid
and 4-hydroxybenzaldehyde (see U. S. Patent
2,345,384, March 28, 1944; also Baker and Sans-
bury, /. Soc. Chem. Ind., 1943, 62, 191).

Description. — "Iodoalphionic Acid occurs as
white crystals or as a white or faintly yellowish
powder, having a faint characteristic odor and
taste. It is stable in air but is slightly discolored
on prolonged exposure to light. Iodoalphionic Acid
is insoluble in water. It is readily soluble in alco-
hol, soluble in ether, and slightly soluble in ben-
zene and in chloroform. It is soluble in solutions
of alkali carbonates and hydroxides. Iodoalphionic
Acid melts between 160° and 164°, with some
decomposition." U.S.P. The B.P. gives the melting
point as 158° to 162°.

Standards and Tests. — Identification. — (l)
The solution obtained when a mixture of iodo-
alphionic acid and sodium carbonate is ignited
and then leached with hot water responds to tests
for iodide. (2) The ethyl ester of iodoalphionic
acid prepared by the interaction of iodoalphionic
acid, absolute alcohol and acetyl chloride melts
between 84° and 87°. Loss on drying. — Not over
0.5 per cent, when dried over sulfuric acid for
4 hours. Residue on ig?iition. — Xot over 0.3 per
cent. Free iodine. — When iodoalphionic acid is
agitated with a mixture of water and chloroform
the latter liquid remains colorless. Halide ions.
— The halide in a saturated aqueous solution
representing 60 mg. of iodoalphionic acid corre-
sponds to not more than 0.1 ml. of 0.02 N hydro-
chloric acid, when turbidimetrically examined fol-
lowing addition of silver nitrate T.S. Heavy
metals. — The limit is 10 parts per million. U.S.P.

Assay. — About 200 mg. of iodoalphionic acid,
previously dried over sulfuric acid for 4 hours, is
analyzed by the method employed in determining
the iodine content of Iodophthalein Sodium. Each
ml. of 0.05 N silver nitrate represents 12.35 mg.
of C15H12I2O3. U.S.P. The B.P. assay utilizes
nascent hydrogen produced by zinc in sodium hy-
droxide solution to decompose the sample and
reduce the iodine to iodide, which is subsequently
titrated with 0.05 M potassium iodate solution in
the presence of potassium cyanide, using starch
as indicator.

Uses. — Iodoalphionic acid is employed as a
medium for cholecystography. The patient takes
the drug orally during or after a light fat-free
meal in the late afternoon and eats nothing until
the roentgenologic examination is completed the
next morning. The drug is claimed to cause less
nausea, vomiting and diarrhea than tetraiodo-
phenolphthalein, and has the additional advantage
of leaving no radiopaque shadows in the colon to
overlie the gall bladder.

Side effects may include pain on urination,
nausea, vomiting, diarrhea, griping, headache,
sensation of burning in the esophagus, generalized
itching, dryness of the mouth, general weakness
and flatulence. It is excreted primarily through
the kidneys. Transient increase in blood sugar and
non-protein nitrogen have been demonstrated
(Lominack, /. South Carolina M. Assn., 1951, 47,
237). Pseudoalbuminuria will follow ingestion of
Priodax for a day or two, giving positive tests
for albumin with Exton's reagent, Heller's test or
Roberts' reagent, but is differentiated from al-
bumin by its absence when the urine is boiled
and acidified with acetic acid (Holoubek et al.,
J.A.M.A., 1953, 153, 1018). It is not indicative
of renal damage. Iodoalphionic acid is contra-
indicated in acute nephritis, uremia and acute dis-
orders of the intestinal tract.

Nonvisualization of the gall bladder following
ingestion of iodoalphionic acid does not neces-
sarily mean that there is disease of the liver or
biliary tract, but may be caused by such disorders
as active peptic ulcer or small bowel disease, in-
creased intestinal motility, concomitant use of
certain drugs, etc. (Martin and Massimiano, New
Eng. J. Med., 1952, 246, 488). However, non-
visualization ordinarily means that there is ob-

Part I

lodochlorhydroxyquin 701

struction of the hepatic or cystic ducts, cholecys-
titis which diminishes the ability of the gall
bladder to concentrate the dye, or severe liver
disease. The gall bladder may be visualized in
most cases of viral hepatitis, though patients with
a total serum bilirubin level above 5 mg. per cent
or those whose bromsulfalein retention exceeds
15 per cent (45 minutes after intravenous injec-
tion of 5 mg. dye/Kg. of body weight) will re-
quire a double dose of iodoalphionic acid (Read-
inger et al., Am. J. Med., 1950, 8, 611).

Cholecystograms have been obtained in infants
given iodoalphionic acid in the form of powder
suspended in orange juice, dosage being 150 mg.
per Kg. of body weight (Harris and Caffey,
J.A.M.A., 1953, 153, 1333).

The usual adult dose is 3 Gm. (approximately
45 grains) with a range of 1.5 to 12 Gm. The
tablets are swallowed whole, at intervals with sev-
eral glasses of water, the evening before the
roentgen examination.

Storage. — Preserve "in well-closed, light-re-
sistant containers." U.S.P.

IODOALPHIONIC ACID TABLETS.
U.S.P.

"Iodoalphionic Acid Tablets contain not less
than 94 per cent and not more than 106 per cent
of the labeled amount of C15H12I2O3." U.S.P.

Usual Size. — 500 mg.

IODOCHLORHYDROXYQUIN.

S-Chloro-7-iodo-8-quinolinol

U.S.P.

"lodochlorhydroxyquin, dried over sulfuric
acid for 4 hours, contains not less than 40 per
cent and not more than 41.5 per cent of iodine
(I), and not less than 11.9 per cent and not more
than 12.2 per cent of chlorine (CI)." U.S.P.

Vioform (Ciba).

This substance is chemically closely related to,
and used for the same purposes as, chiniofon.
lodochlorhydroxyquin differs from the 7-iodo-8-
hydroxyquinoline-5-sulfonic acid component of
chiniofon only in having a chlorine atom in place
of a sulfonic acid group.

The patent (U. S. 641,491) granted in 1900
for the manufacture of iodochlorhydroxyquin
indicates that it may be prepared by treating an
aqueous solution of an alkali salt of 5-chloro-8-
hydroxyquinoline with potassium iodide and a
hypochlorite, or by iodizing in some other way.
The precipitate of iodochlorhydroxyquin thus
obtained is heated with a dilute hydrochloric acid
solution to remove unreacted chlorohydroxy-
quinoline.

Description. — "Iodochlorhydroxyquin occurs
as a voluminous, spongy, brownish yellow powder,
with a slight characteristic odor. It is affected by
light. It melts with decomposition at about 172°.
Iodochlorhydroxyquin is practically insoluble in

water and in alcohol. It is soluble in hot ethyl
acetate and in hot glacial acetic acid." U.S.P.

Standards and Tests. — Identification. — (1)
When boiled with diluted hydrochloric acid
iodochlorhydroxyquin dissolves slowly, evolving
an odor of iodine. (2) When heated with sulfuric
acid it evolves copious vapors of iodine. (3)
Ignition with sodium carbonate yields chloride
and iodide ions, which are detected by precipita-
tion as the mixed silver halides and separated by
treatment with ammonia solution. Loss on dry-
ing.— Not over 0.5 per cent, when dried over
sulfuric acid for 4 hours. Residue on ignition. —
Not over 0.5 per cent. U.S.P.

Assay. — About 1 Gm. of iodochlorhydroxy-
quin, previously dried over sulfuric acid for 4
hours, is oxidatively decomposed with potassium
permanganate in the presence of sodium hy-
droxide. By use of sodium bisulfite, after acidifica-
tion, the halogens of iodochlorhydroxyquin are
obtained in solution as chloride and iodide; the
solution is diluted to a definite volume. In an
aliquot portion the chloride and iodide are pre-
cipitated as the silver salts with a measured
excess of 0.1 N silver nitrate, the excess of this
solution being determined by titration with 0.1 N
ammonium thiocyanate. In another portion of the
solution the iodide is determined by titration
with 0.05 M potassium iodate (see under Potas-
sium Iodide for explanation). From the volume
of silver nitrate solution required to precipitate
both halides is subtracted the volume of potas-
sium iodate equivalent to the iodide, and the
difference is calculated to the content of CI.
U.S.P.

Uses. — This drug, used today chiefly for amebic
dysentery, was introduced as an almost odor-
less substitute for iodoform as a surgical dusting
powder; lower toxicity and greater antiseptic
power were claimed for it.

Iodochlorhydroxyquin has merited popularity
for local use in ointment form in the treatment
of a wide range of dermatologic disorders; its
value depends on antieczematous, antibacterial,
antifungal, and antipruritic properties, combined
with unusual tolerance and minimal sensitization.
It is indicated in the treatment of virtually every
kind of eczema, whether acute, subacute or
chronic, including allergic or atopic eczema, in-
fantile eczema, nummular eczema, contact and
"housewives" eczema, psoriasis (eczematized, in-
fected and inteitriginous), the common pyo-
dermas (impetigo, sycosis vulgaris, folliculitis,
impetiginized eczema) and other superficially in-
fected dermatoses, seborrheic dermatitis, derma-
tophytoses, and pruritic dermatoses, especially
where surface infection, maceration and irritation
play a role.

It is employed in 3 per cent strength in a
water-washable base suitable for daytime applica-
tion, and 3 per cent in petrolatum for night
application in conjunction with protective or
occlusive dressings. The latter type preparation
is best suited for the more chronic, dry condi-
tions. Iodochlorhydroxyquin may be used simul-
taneously with, or in areas previously treated by,
other common therapeutic topical agents, with
the possible exception of mercury and sulfur,

702 lodochlorhydroxyquin

Part I

where irritating compounds might be formed due
to liberation of small amounts of free iodine. It
may be used in conjunction with the usual types
of wet dressings. lodochlorhydroxyquin stains
the skin and clothing yellow. It is used in den-
tistry for infected alveolar pockets.

Because of its chemical similarity to chiniofon,
iodochlorhydroxyquin was considered likely to be
effective in amebic dysentery; tests showed it to
be effective in monkeys (Anderson and Koch,
Proc. S. Exp. Biol. Med., 1931, 28, 828). David
et al. (J.A.M.A., 1933, 100, 1658) found that,
while it is slightly more toxic than chiniofon, it
is so much stronger that its therapeutic index —
that is, the ratio between the efficient dose and
toxic dose — is much higher than that of chiniofon.
It was employed in 46 cases of human amebic
dysentery with 82 per cent of apparently per-
manent cures. No unpleasant symptoms were
observed in any case. D'Antoni {Intemat. Clin.,
1942, 1, 100) rated it as the drug of fourth
choice, advising tha't it be used after chiniofon,
diodoquin and carbarsone had failed to eradicate
the parasite, or in cases in which the other drugs
were contraindicated. He found that it was effec-
tive about 80 per cent of the time. It seemed to
be more toxic than diodoquin and chiniofon but
less so than carbarsone. Iodochlorhydroxyquin
can be used by ambulatory cases and, like diodo-
quin, it has the advantage in the treatment of
children that the tablets can be chewed. For
adults, 250 mg. (approximately 4 grains) is pre-
scribed three times daily after meals for 10 days;
this course may be repeated after a rest period of
7 to 10 days. In particularly severe infestations,
twice this dose has been employed in robust in-
dividuals. For children, the dose is 20 mg. (ap-
proximately Yi grain) for each 15 pounds of body
weight three times daily after meals. There are
essentially no contraindications to the drug, al-
though caution is required in the presence of liver
disease. In about 40 per cent of patients diarrhea
appears on the second or third day of treatment
but can be controlled after one or two days by
kaolin suspended in aluminum hydroxide gel or
by camphorated opium tincture. Aqueous suspen-
sions may be used as a retention enema. Manson-
Bahr {Brit. M. J., 1941, 2, 255) was not im-
pressed with its value, but Faust (J.A.M.A., 1946,
132, 965) feels that its clinical usefulness has
been insufficiently emphasized.

Against trichomonas vaginitis, it has been used
effectively (Zener, Am. J. Surg., 1939, 44, 416)
by daily insufflation of about 2 Gm. of a powder
composed of 25 per cent iodochlorohydroxyquin,
10 per cent boric acid, 20 per cent zinc stearate,
42.5 per cent lactose and 2.5 per cent lactic acid,
which formulation is officially recognized as Com-
pound Iodochlorhydroxyquin Powder. A similar
effect was obtained by nightly insertion for 1 or
2 weeks of vaginal suppositories containing 250
mg. of the drug with 25 mg. of lactic acid and
100 mg. of boric acid.

Dose. — The usual dose of iodochlorhydroxy-
quin is 250 mg. (approximately 4 grains) 3 times
a day by mouth for 10 days, with a range of dose
of 250 to 500 mg. The maximum safe dose is
500 mg., and the total dose in 24 hours should
not exceed 1 Gm.

Storage. — Preserve "in tight, light-resistant
containers." N.F.

IODOCHLORHYDROXYQUIN
TABLETS. N.F.

"Iodochlorhydroxyquin Tablets contain not
less than 92.5 per cent and not more than 107.5
per cent of the labeled amount of iodochlor-
hydroxyquin (C9H5CIINO)." N.F.

Usual Size. — 250 mg. (approximately 4
grains).

COMPOUND IODOCHLOR-
HYDROXYQUIN POWDER. U.S.P.

Vioform Insufflate (Ciba).

Mix 25 Gm. of lactic acid with 100 Gm. of
boric acid, then mix with 425 Gm. of lactose,
250 Gm. of iodochlorhydroxyquin, and 200 Gm.
of zinc stearate. U.S.P.

This powder is employed by intravaginal in-
sufflation in the treatment of trichomonas
vaginitis; about 2 Gm. is applied in this manner
daily (Zener, Am. J. Surg., 1939, 44, 416).

IODOFORM. N.F.

Triiodomethane, [Iodoformum]

"Iodoform, previously dried over sulfuric acid
for 4 hours, contains not less than 99 per cent of
CHI3." N.F.

Forrayl Triiodide. Iodof orraium. Fr. Iodoforme ; Formene
tri-iode. Ger. Jodoform; Formyltrijodid. It. Jodoformio.
Sp. Yodoformo.

Iodoform, discovered by Serullas about 1828,
was introduced as a remedy, about 1837, by
R. M. Glover of London, and Bouchardat, of
Paris, and was admitted into the U.S.P. of 1870.

Various methods for the manufacture of iodo-
form by processes that depend upon the inter-
action of iodine, alcohol, or acetone in the pres-
ence of an alkali or alkaline carbonate have been
described. It is now made by electrolysis. An
alkaline solution of sodium iodide is electrolyzed
in the presence of alcohol; from the iodine which
is liberated at the anode, iodoform is obtained
by the following reaction:

CH3.CH2OH + 5I2 + H2O -» CHI3 + CO2 + 7HI

Description. — "Iodoform occurs as a fine
greenish yellow powder, or lustrous crystals. It
has a peculiar, very penetrating, persistent odor.
Iodoform is slightly volatile even at ordinary
temperatures, and distils slowly with steam. One
Gm. of Iodoform dissolves in about 60 ml. of
alcohol, in about 80 ml. of glycerin, in about 10
ml. of chloroform, in about 7.5 ml. of ether, and
in about 34 ml. of olive oil. One Gm. dissolves in
about 16 ml. of boiling alcohol. Iodoform is
practically insoluble in water to which, however,
it imparts its odor and taste. Iodoform melts to
a brown liquid at about 115°, and decomposes at
a higher temperature, emitting vapors of iodine."
N.F.

Standards and Tests. — Loss on drying. — Not
over 1 per cent, when dried over sulfuric acid for
4 hours. Residue on ignition. — Not over 0.2 per
cent. Coloring matter, acids, and alkalies. — -On
shaking 2 Gm. of iodoform with 5 ml. of distilled
water for 1 minute and then filtering, the filtrate

Part I

lodophthalein Sodium 703

is colorless and free from bitter taste, and is
neutral to litmus paper. N.F.

Assay. — About 200 mg. of iodoform, previ-
ously dried over sulfuric acid for 4 hours, is dis-
solved in alcohol and the solution allowed to
stand overnight in contact with 30 ml. of 0.1 N
silver nitrate and nitric acid. The excess of silver
nitrate remaining after the silver iodide has pre-
cipitated is titrated with 0.1 N ammonium
thiocyanate, using ferric ammonium sulfate T.S.
as indicator. Each ml. of 0.1 N silver nitrate
represents 13.12 mg. of CHI3. N.F.

Uses. — When applied to a mucous membrane,
iodoform exercises a marked anesthetic action.
Although it is itself practically devoid of anti-
bacterial properties, when brought in contact with
bodily secretions it gradually liberates iodine,
which is actively antiseptic (Chargeff, Biochem.
Ztschr., 1929, 225, 69). The experiments of
Gosselin indicate that it is especially inimical to
the tubercle bacillus. When swallowed, iodoform
is partially decomposed in the intestines and ab-
sorbed, appearing in the urine partly as an iodide
or an iodate and partly as an unidentified organic
compound; some of it appears to pass through
the alimentary canal unabsorbed. From raw sur-
faces it is sometimes readily absorbed in the
form of its breakdown products.

Iodoform is used chiefly by topical application.
It has long been used as an antiseptic dressing
in suppurating wounds, gauze impregnated with
iodoform being inserted as packing to prevent
premature granulation tissue formation and to
prevent closure of the wound orifice so that
exudate will drain adequately. The anesthetic
effect of iodoform has been utilized in treatment
of laryngeal tuberculosis and in internal hemor-
rhoids; in the latter condition suppositories con-
taining 300 to 600 mg. (approximately 5 to 10
grains) are prescribed. It may be applied also to
mucosal inflammations in the sigmoid colon, to-
gether with bismuth subcarbonate in a mixture of
equal parts of cod liver oil and cottonseed oil,
given by retention enema. The B.P. formerly
recognized Ointment of Iodoform for the Eye,
containing 4 per cent of the chemical. It was
formerly quite commonly injected, as a 5 per
cent solution in olive oil, into cavities of tubercu-
lous osteomyelitis or lymphadenitis. Scotti (/.
Trop. Med. Hyg., 1937, 40, 174) used iodoform
in amebic dysentery in keratinized capsules, be-
ginning with doses of about 60 mg. daily and
gradually increasing the amount, if no unpleasant
symptoms occurred, up to 200 mg. a day. The
earlier use of iodoform as a substitute for the
iodides in syphilis has been abandoned.

One of the principal obstacles to its employ-
ment is the odor, which, to some patients, is
unbearable. Some of the methods for hiding the
odor involve the use of agents, such as tannin,
which cause decomposition of the iodoform and
lessen its efficacy. Probably the best masking
agents to use are volatile oils, such as of anise,
peppermint, fennel, bergamot, almond, etc. On
the other hand, its odor is useful in masking fetid
secretions, as in ileocolostomies, etc. Narat
(J.A.M.A., 1946, 130, 238) suggested that steri-
lized sawdust containing 10 per cent iodoform,
enclosed in small gauze sacks, be placed locally

for this purpose. A 2 to 4 per cent ointment is
used on the eyelids. For insufflation, the powdered
drug should be diluted with talcum to produce
a more dense powder and to decrease the con-
centration of the drug, [v]

Toxicology. — When introduced into the cir-
culation of lower animals iodoform exerts a cer-
tain degree of narcotic effect from which after
moderate doses the animal completely recovers
after some hours. With larger amounts the nar-
cosis is followed by convulsions and rapid pulse
and after death fatty degeneration is observed in
heart, liver and kidney.

The free use of iodoform locally has led to a
number of cases of poisoning, not a few ending
fatally (Shaw, Lancet, 1933, 2, 250). In the
milder cases the principal symptoms are general
malaise and depression, faintness, headache, loss
of appetite, and a persistent iodoform taste in
the mouth. It may cause dermatitis. In some cases
there is a slight temporary increase of tempera-
ture. Mental depression or excitement is espe-
cially noticed. Finally the pulse becomes accel-
erated, soft, and feeble; in some cases the pulse
is very rapid — from 150 to 180 — while the tem-
perature remains normal or is only slightly ele-
vated. In severe cases the manifestations of
iodoform poisoning resemble somewhat those of
meningitis ; they are headache, somnolence (deep-
ening into stupor), contracted, motionless pupils,
abnormal quiet or restlessness ending in active
delirium, with, however, a normal temperature
and an exceedingly rapid pulse. In such cases
death almost always follows; sometimes the
symptoms may develop abruptly even after the
dressing has been removed. It was claimed by
Samter and Retzlaff (Therap. Gaz., 1889) that
potassium bromide is an antidote in iodoform
poisoning.

Langenstein attributed a fatal outcome to local
application of 4 Gm. of iodoform powder. Ordi-
narily not more than 2 Gm. (approximately 30
grains) should be employed at a time as a wound
dressing. Verneuil sometimes injected as much as
5 Gm. (approximately 75 grains) of iodoform
at a time.

Dose, internally, 30 to 200 mg. (approximately
Yi to 3 grains).

Storage. — Preserve "in tight, light-resistant
containers, and avoid excessive heat." N.F.

IODOPHTHALEIN SODIUM.

U.S.P. (B.P.)

Soluble lodophthalein, Tetraiodophenolphthalein Sodium,

Tetraiodophthalein Sodium, Tetiothalein Sodium,

[Iodophthaleinum Sodicum]

NoO

COONa 3H20

"lodophthalein Sodium contains not less than
85 per cent of tetraiodophenolphthalein. The

704 lodophthalein Sodium

Part I

separated tetraiodophenolphthalein contains not
less than 60 per cent and not more than 63 per
cent of iodine (I)." U.S.P.

The B.P. title of this substance is lodophthalein,
and it is required that not less than 87.0 per cent
of tetraiodophenolphthalein be present; the iodine
content of the latter is between 60.0 per cent and
63.0 per cent.

B.P. lodophthalein; Iodophthaleinum. Iodeikon; Kera-
phen (Picker); Shadocol (Davies, Rose); Stipolac (Bur-
roughs Wellcome); T.I.P.P.S. (National Synthetics). Na-
trium Iodophtaleinicum. Fr. Tetraiodophtaleinate de so-
dium; Foriod; Iodtetragnost; Tetraiode. Sp. Yodoftaleina
Sodica.

Tetraiodophenolphthalein, the parent substance
of this compound, may be prepared by adding an
aqueous solution of iodine and potassium iodide
to a solution of phenolphthalein in sodium hy-
droxide. Upon acidification with hydrochloric acid,
tetraiodophenolphthalein precipitates. After filtra-
tion and washing, the precipitate is further puri-
fied by dissolving it' in sodium hydroxide and re-
precipitating it with hydrochloric acid. After a
second filtration and washing the disodium deriva-
tive is prepared by dissolving the precipitate in
sodium hydroxide, from which solution it may be
crystallized.

lodophthalein sodium should not be confused
with phenoltetraiodophthalein sodium, which was
recognized in N.N.R. 1951 under the title Phen-
tetiothalein Sodium and was formerly marketed
under the name Iso-Iodeikon (Mallinckrodt). The
two compounds are isomeric; in phenoltetra-
iodophthalein sodium the four iodine atoms sub-
stitute into the phthalic acid nucleus while in
iodophthalein sodium two atoms of iodine substi-
tute into each of the two phenol residues. Phen-
tetiothalein sodium may be prepared by the
interaction of tetraiodophthalic acid and phenol,
followed by conversion of the reaction product
into a disodium salt.

Description. — "Iodophthalein Sodium is a
pale blue-violet, odorless, crystalline powder, hav-
ing a saline and astringent taste. On exposure to
air it absorbs carbon dioxide and gradually decom-
poses with the liberation of the free iodophthalein.
One Gm. of Iodophthalein Sodium dissolves in
about 7 ml. of water. It is slightly soluble in
alcohol." U.S.P.

Standards and Tests. — Identification. — (1)
A cream-colored precipitate forms on adding
diluted hydrochloric acid to a 1 in 50 solution of
iodophthalein sodium. (2) When 100 mg. of iodo-
phthalein sodium is ignited with 500 mg. of
monohydrated sodium carbonate, the mixture
leached with hot water, and filtered, the filtrate
responds to tests for iodides. (3) Iodophthalein
sodium responds to the flame test for sodium.
Free phthalein. — A clear, deep blue liquid is pro-
duced when 1 Gm. of iodophthalein sodium is
dissolved in 50 ml. of recently boiled and cooled
water; on standing, this solution may absorb
carbon dioxide and develop a precipitate of free
iodophthalein. U.S.P.

Assay. — For tetraiodophenolphthalein. — A so-
lution of 500 mg. of iodophthalein sodium in 50
ml. of distilled water is acidified with diluted
hydrochloric acid and the resulting precipitate of

tetraiodophenolphthalein separated on a tared
filtering crucible, washed, dried at 105° for 2
hours, and weighed. For iodine. — About 200 mg.
of tetraiodophenolphthalein obtained in the pre-
ceding assay is heated with a mixture of sodium
hydroxide T.S. and a potassium permanganate
solution, after which the oxidized iodine is re-
duced to iodide with sodium bisulfite in acid solu-
tion. After adding a dilute permanganate solution
to liberate just enough elemental iodine to pro-
duce a faint yellow color, the solution is titrated
with 0.05 N silver nitrate until the iodide concen-
tration is reduced to such a low level as to fail to
produce a blue color with starch indicator, even
though some elemental iodine is present. Each ml.
of 0.05 N silver nitrate represents 6.346 mg. of
iodine (I). U.S.P.

The B.P. assay for iodophthalein is the same
as that of the U.S.P., but the assay for iodine is
similar to that applied by the B.P. to chiniofon.

Incompatibilities. — Iodophthalein sodium
slowly absorbs carbon dioxide from the air, with
formation of insoluble tetraiodophenolphthalein;
other acid-reacting compounds have the same
effect.

Uses. — Iodophthalein sodium, like iodoalphi-
onic acid and iopanoic acid, is used for roent-
genologic examination of the gall bladder. Fol-
lowing oral or intravenous administration it is
concentrated to a sufficient degree in the normal
gall bladder to provide a cholecystogram. Because
it is not completely absorbed from the intestinal
tract, faint residual shadows may be visualized
after the dye has been ingested. Iodophthalein
sodium has also been used as a test of excretory
function of the liver, its action depending upon
the fact that when the liver is normal the com-
pound is eliminated from the blood chiefly
through the liver. Delario (/. Lab. Clin. Med.,
January, 1931) found that after intravenous in-
jection into dogs from 60 to 70 per cent of the
substance was excreted by the fiver, the remainder
being eliminated in part through the kidneys and
in part through intestinal glands. San Julian and
Mejias (Rev. din. espan., 1951, 40, 232) obtained
better results by oral administration than by in-
jection of the compound; also, cholecystograms
were successful more frequently with iodo-
phthalein sodium than when iodoalphionic acid
was used.

Antibacterial Actiox. — Nickel (J. Phar-
macol., 1929, 27, 359) found that iodophthalein
sodium has a marked bacteriostatic effect on
gram-positive cocci, and suggested use of the
compound to prevent streptococcal infections of
the gall bladder. It has been used successfully in
the treatment of typhoid carriers (see Enright,
JAM. A., 1941, 116, 220).

Toxicology. — In a considerable number of
patients there are unpleasant symptoms, such as
dizziness, nausea, and lowering of blood pressure,
following intravenous injection; oral ingestion
may cause diarrhea. These reactions indicate the
need for caution in use of the compound. Hsieh
(Ann. Int. Med., 1927, 1, 96) found that doses of
less than 250 mg. per Kg. caused slight, but not
dangerous, changes in the fiver; with larger quan-
tities there was marked fatty degeneration not

Part I

lodopyracet Injection 705

only in the liver but also in the kidney and heart.
Dick and Wallace (Brit. J. Surg., 1928, 15, 360)
considered it especially dangerous in cases of
obstructive jaundice and reported two fatalities;
their doses were larger than are commonly con-
sidered to be safe. In the presence of jaundice a
satisfactory shadow of the gall bladder is often
not obtained. Caution is indicated in patients
with myocardial damage or uremia.

Dose. — The usual dose of iodophthalein so-
dium is 3 Gm. (about 45 grains) intravenously,
with a range of 2 to 4 Gm. The maximum safe
dose is usually 4 Gm., which quantity should
seldom be exceeded in 24 hours. The dose must
be varied somewhat according to the size of the
patient. No food should be permitted for several
hours before or after injection; water may be
taken freely. For a patient weighing between 115
and 160 pounds (52 to 73 Kg.) a solution con-
taining 3 Gm. in 24 ml. or 3.5 Gm. in 28 ml. of
freshly distilled water is prepared, the solution
being sterilized by heating the container in boil-
ing water for 20 minutes; patients weighing less
than 115 pounds should receive proportionately
less of the compound but those weighing more
than 160 pounds should generally not be given
more than 3.5 Gm. All solutions must be freshly
prepared immediately before use. The intravenous
dose should be divided into two equal portions
given 30 minutes apart. Extravasation into tissues
must be avoided as necrosis may result. The
densest shadow usually forms about 4 hours after
the injection. A fatty meal is then given and a
second roentgenogram is taken 1 hour after the
meal; a third roentgenogram may be taken 3
hours after the meal.

The oral dose is 4 Gm., dissolved in 30 ml. of
distilled water and added to 120 to 240 ml. of
grape juice, ingested with and after the evening
meal, which should be free of fat; the solution of
the compound should be not more than 48 hours
old. Gelatin capsules, each containing 500 mg. of
iodophthalein sodium, may be taken in place of
the solution. Roentgenograms are taken the fol-
lowing morning.

Phentetiothalein sodium (see above) is used
like iodophthalein sodium but is better suited for
intravenous injection than the latter drug because
the dosage is smaller and it is better tolerated.
The dose is calculated on the basis of 40 mg. per
Kg. of body weight, with a maximum dose of 2.5
Gm. The compound is dissolved in 30 ml. of
freshly distilled water, filtered through fine paper,
and sterilized for 15 minutes in a boiling water
bath. It is injected intravenously by gravity with
about 150 ml. of Ringer's solution in not less than
15 minutes. Best results are obtained if the in-
jection is made in the morning with the stomach
empty, omitting breakfast and lunch, roentgeno-
grams being taken 4, 8, and 24 hours after injec-
tion. It may also be injected between 5 and 9
P.M., in which case the evening meal and break-
fast are omitted, films being taken in the morning.
To determine liver function, blood is collected
half an hour and again preferably one hour after
injection; the serum is slightly alkalinized with
5 per cent sodium hydroxide solution and the
color compared with standards (Cole et al.,

J.A.M.A., 1928, 90, 111). If the compound is to
be used only for gallbladder visualization it may
be administered orally; 4 Gm. is given in capsules,
or dissolved in distilled water and taken with
grape juice during and after the evening meal,
which should be free of fat. Because phenetetio-
thalein sodium is not absorbed rapidly into the
blood by this method, it is not possible to per-
form the liver function test following oral
administration.

Storage. — Preserve "Iodophthalein Sodium in
tight containers." U.S.P.

IODOPYRACET INJECTION.
U.S.P. (LP.)

Diodone Injection, [Injectio Iodopyraceti]

N-CH2C00"

N+H{CH2CH20H)2

"lodopyracet Injection is a sterile solution of
the diethanolamine salt of 3,5-diiodo-4-pyridone-
N-acetic acid [C2H5l2NOCH2COONH2(CH2-
CH20H)2] in water for injection. It contains,
in each 100 ml., not less than 34 Gm. and not
more than 36 Gm. of the salt. The separated
3,5-diiodo-4-pyridone-N-acetic acid, when dried
at 105° for 1 hour, contains not less than 61.5
per cent and not more than 63.5 per cent of
iodine (I)." U.S.P.

Three concentrations are recognized by the
B.P., which requires Injection of Diodone (35
per cent) to contain not less than 16.6 per cent
w/v and not more than 18.4 per cent w/v of I,
Injection of Diodone (50 per cent) to contain not
less than 23.7 per cent w/v and not more than
26.3 per cent w/v of I, and Injection of Dio-
done (70 per cent) to contain not less than 33.2
per cent w/v and not more than 36.8 per cent w/v
of I. It is sterilized by bacteriological filtration
and distributed in ampuls, or the filled ampuls
are sterilized by heating in an autoclave, avoiding
contact of the injection with metal.

B.P. Injection of Diodone; Injectio Diodoni. Diodrast
( Winthr op-S teams) .

The 3,5-diiodo-4-pyridone-N-acetic acid com-
ponent of iodopyracet may be prepared by inter-
action of 3,5-diiodo-4-pyridone and monochloro-
acetic acid (Dohrn and Diedrich, Ann. Chem.,
1932, 494, 284). Several methods may be utilized
for the synthesis of 3,5-diiodo-4-pyridone. These
include (1) heating diiodochelidamic acid (3,5-
diiodo-4-hydroxypyridone-2,6-dicarboxylic acid,
which is also a starting compound in the syn-
thesis of iodoxyl) with acetic anhydride, followed
by saponification of the product; (2) iodination
of 4-pyridone; (3) iodination of 4-aminopyridine
followed by diazotization of the product. Because
of the poor solubilty of 3,5-diiodo-4-pyridone-N-
acetic acid, water-soluble salts of it have been
prepared. Iodopyracet injection contains the
diethanolamine salt, which may be prepared by
the reaction of the acid with diethanolamine (U. S.
Patent 1,993,039).

706 lodopyracet Injection

Part I

An isomeric compound of the acid component
of iodopyracet, the 3,5-diiodo-2-pyridone-N-acetic
acid, has been prepared by Sugii et al. (J. Pharm.
Soc. Japan, 1930, 50, 727; 1931. 51, 416. or
see Chem. Abs., 1930, 24, 5326; 1931, 25, 4549)
starting with pyridine, sodamide and xylene. The
sodium salt was used as a contrast medium in
pyelography.

Description. — "Iodopyracet Injection occurs
as a clear, nearly colorless liquid. It is neutral to
litmus. Its specific gravity is about 1.19." U.S.P.
The B.P. gives the weight per ml. of the several
injections as follows: 35 per cent solution. 1.175
to 1.205, at 20°; 50 per cent solution, 1.255 to
1.285, at 20° ; 70 per cent solution. 1.355 to 1.390,
at 30°. The pH range of the solutions is between
6.0 and 8.0.

Standards and Tests. — Identification. — (1)
The free acid, liberated from the injection by
addition of diluted hydrochloric acid, when dried
at 105° for 1 hour, melts between 245° and 249\
(2) The diethanolamine in the filtrate and wash-
ings from the preceding test is in part converted
to diethanolamine trinitrophenolate; when re-
crystallized from alcohol and dried in a desiccator
over sulfuric acid under vacuum the crystals melt
between 108° and 110°. Residue on ignition. —
Xot over 5 mg. from 5 ml. of injection. Inorganic
iodides. — To a portion of the filtrate used in
identification test (2) add chloroform and ferric
chloride T.S.; no color should appear in the
chloroform layer. Pyrogen. — The injection meets
the requirements of the Pyrogen Test. Other re-
quirements.— The injection meets the require-
ments for Injections. U.S.P.

Assay. — For iodopyracet. — A 5-ml. portion of
injection is diluted to 50 ml. with distilled water
and in a one-tenth aliquot of this solution the
iodopyracet is precipitated as the silver salt of
3,5-diiodo-4-pyridone-X-acetic acid which is dried
at 105° for 1 hour, and weighed. The weight
multiplied by 0.9961 gives the weight of iodo-
pyracet in 1 ml. of injection. Iodine assay of the
3 p-diiodo-4-pyridone-X-acetic acid. — About 200
mg. of the dried 3,5-diiodo-4-pyridone-X-acetic
acid obtained in identification test (1) is heated
with a mixture of sodium hydroxide T.S. and a
solution of potassium permanganate. The solution
is acidified and the halogen reduced to iodide with
sodium bisulfite. Sufficient of a dilute solution of
potassium permanganate is added to liberate
enough iodine to produce a faint yellow color,
starch T.S. is added, and the solution titrated
with 0.05 N silver nitrate until the iodide ion con-
centration is depleted to the point of discharging
the blue color of the starch-iodine-iodide complex.
Each ml. of 0.05 N silver nitrate represents
6.346 mg. of I. US.P. The B.P. employs the
assay procedure directed by that compendium for
Chiniofon.

Uses. — Iodopyracet injection is used for intra-
venous urography, venography, angiography, angio-
cardiography, cholangiography, bronchography,
and as a contrast medium in the visualization by
roentgen rays of accessible, normal or abnormal
body cavities such as sinus tracts, the renal pelves,
ureters, etc. This and similar, water-soluble or-
ganic iodine compounds (see Iodohippurate So-

dium, Methiodal Sodium, Sodium Acetrizoate,
and Sodium Iodomethamate) have low toxicity
and are excreted rapidly by the kidneys after
parenteral injection. Other organic iodine com-
pounds (see Iodoalphionic Acid, Iopanoic Acid,
and Iodophthalein Sodium) are used for roent-
genographs visualization of the gall bladder.

Urography. — For excretory urography, the
procedure is briefly as follows: A day or two
before the examination the patient is tested for
sensitivity to the drug by the instillation of a
little of the solution into the conjunctival sac
Asher and Harris. Am. J. Roentgen., 1942, 48,
762) or by injecting 1 ml. intravenously over a
period of one minute (Keats. Bull. Am. Soc. Hosp.
Pharm., May-June. 1951, page 158). In the latter
instance the patient is observed over a 20-minute
period for signs of respiratory* difficulty, sneezing,
itching of the skin or urticaria, nausea or vomiting
and syncope. Oral and skin tests are sometimes
used. It is important to note that not all instances
of hypersensitivity to iodine compounds will be
discovered by such tests. In each instance of fatal
reaction cited by Dotter and Jackson {Radiology,
1950. 54, 52 7), where sensitivity tests had been
performed, results were negative. Food and fluids
are prohibited following the evening meal of the
day before the examination, the fluid restriction
increases the concentration of the drug in the
urinary tract. A cathartic is given the night before
the examination to clear the gastrointestinal tract
of gas and other materials which might cast con-
fusing shadows on the x-ray films; from 30 to 60
ml. of castor oil is preferred. If gas shadows per-
sist on the preliminary films, an injection of
neostigmine methylsulfate or an enema may be
employed. The iodopyracet injection is warmed
to body temperature and 20 ml. (approximately
5 fluidrachms). containing 7 Gm. (approximately
105 grains) of the drug, is injected slowly intra-
venously, usually in an antecubital vein, with
very close and careful observation of the patient.
From 1 to 3 minutes is used to make the injec-
tion and a brief pause after the first 1 or 2 ml.
is advisable. Care should be taken to avoid ex-
travasation of the solution into the tissues around
the vein. An injection of epinephrine hydrochlo-
ride should be immediately available whenever
these injections are given in case a severe reaction
should occur. Just before the injection is made,
pressure is applied to the lower abdomen, by
means of a strap around the body over a block of
wood to obstruct the ureters as they pass over
the brim of the pelvis, to retain the excreted
iodine compound in the renal pelves and upper
ureters and to insure good filling with the contrast
medium at the time the films are exposed. This
pressure may be continued until all the films are
taken; the discomfort may be minimized by care-
ful adjustment of the pressure block to the size
and shape of the patient. A preliminary film is
taken prior to the injection and other exposures
are made at 5-, 15- and 30-minute or other inter-
vals after the injection. When renal function is
normal, good films are obtained 5 to 15 minutes
after the injection; 30 minutes or longer may be
required in instances of impaired renal function.
After removing the pressure and before voiding.

Part I

lodopyracet injection 707

a film of the urinary bladder may be made. For
children the dose should be reduced according to
size and age.

In children or patients without usable veins,
the examination may be carried out with sub-
cutaneous or intramuscular injection (Levant and
Lee, Pennsylvania M. J., 1945, 49, 255). For sub-
cutaneous injection, Nesbit advocated dilution of
the indicated dose of iodopyracet injection with
sterile isotonic sodium chloride solution to a total
volume of 100 ml. and the injection of half of this
diluted solution into the subcutaneous tissue in
each subscapular region. Films are taken at longer
intervals because absorption is slower. Hinman
{Arch. Surg., 1951, 63, 585) confirmed the value
of hyaluronidase to facilitate the absorption, im-
prove the roentgenograms and minimize the dis-
comfort of subcutaneous injection, as originally
reported by Burket and Gyorgy {Pediatrics, 1949,
3, 56). Just before injecting the iodopyracet solu-
tion, 75 units of hyaluronidase are injected into
each site. Intramuscular injection of 10 to 15 ml.
of iodopyracet injection for adults or 5 to 10 ml.
for children into each gluteal region is preferable
because it causes less discomfort and produces
better shadows on the roentgenograms in about
the same time as after intravenous administration.
A local anesthetic may be added to the intra-
muscular or subcutaneous injection.

For retrograde pyelography the 35 per cent
iodopyracet injection should be diluted with sterile
isotonic sodium chloride solution to a concentra-
tion of 10 to 15 per cent and injected slowly and
carefully into the catheter which has been inserted
into the ureteral orifice by means of a cystoscope;
it is best injected by gravity or with a syringe
with a manometer in the circuit. In the adult
about 20 ml. of the diluted solution is required
to fill the renal pelvis. Bilateral retrograde pyelog-
raphy should be performed only when necessary
and then only by expert urologists because this
procedure has caused anuria by reflex splanchnic
stimulation.

Iodopyracet Compound Solution, N.N.R. {Dio-
drast Compound Solution, Winthrop-Stearns)
contains 40.5 per cent of iodopyracet and 9.5 per
cent of the diethylamine salt of 3,5-diiodo-4-
pyridone-N-acetic acid; the iodine content in
organic combination in this solution is about 25
per cent. This solution, containing more iodine,
is used for obese patients or in instances in which
roentgen shadows are indistinct. The uses, meth-
ods of use, dose and toxic effects are the same as
for iodopyracet injection.

Sinus Tracts. — For roentgen visualization of
sinus tracts, fistulae, the paranasal sinuses, the
parotid ducts, the common bile duct by injection
into the draining "T" tube postoperatively, etc.,
the technique is similar to that for retrograde
pyelography.

Venography. — In instances of varicose veins
or other circumstances in which the patency of
venous channels must be determined, iodopyracet
is injected intravenously distal to the site of sus-
pected obstruction. Knowledge of the rate of
venous circulation and experience with the roent-
gen technic is necessary in order to expose the
films at the proper second following the injection.

Imler et al. {Am. J. Roentgen., 1944, 52, 514)
recommended venography in cases of superficial
varicosities before surgical procedures or scleros-
ing injections in patients with a history of throm-
bosis or thrombophlebitis, with severe symptoms
of fatigue, pain on walking or standing, edema,
etc., and with suspected anomalies of major
venous channels. The precautions with the drug
are the same as for intravenous urography. They
noted three instances of thrombosis of the deep
veins of the leg following venography with con-
centrated iodopyracet solutions. Similar injections
are used for the roentgen demonstration of
peripheral arterial lesions and bone tumors. Wag-
ner {J. A.M. A., 1944, 125, 958) reviewed the
complications and indications for arteriography.
Gross {Indiana State M. A. J., 1944, 37, 109)
discussed the value of cerebral arteriography in
differential diagnosis of intracranial lesions. Iodo-
pyracet injection occasionally produces convulsive
seizures, Scott and Seaman, Radiology, 1951, 56,
15), and transient hemiplegia has been reported
by Chusid et al. {J. Neurosurg., 1949, 6, 466).
The dangers of cerebral angiography with iodo-
pyracet injection in hydrocephalic infants have
been reported by Tarlov and Rosenberg {Arch.
Neurol. Psychiat., 1952, 67, 496). Obstruction of
the major dural venous sinuses may be studied by
direct injection of iodopyracet through a catheter
into the superior sagittal sinus (Ray et al.,
Radiology, 1951, 57,477).

Angiocardiography. — For roentgen demonstra-
tion of the chambers of the heart and the great
vessels, a 70 per cent solution of iodopyracet,
marketed as Diodrast Concentrated Solution,
Winthrop-Stearns {Iodopyracet Concentrated So-
lution, N.N.R.). has been employed. Sussman
et al. {Am. J. Dis. Child., 1943, 65, 922) pre-
sented their observations on 80 patients and dis-
cussed the indications and interpretation in con-
genital heart disease. Zinsser and Johnson {Ann.
Int. Med., 1953, 39, 1200) described a technic
for obtaining a characteristic angiocardiographic
pattern in patients with mitral stenosis but with
little or no valvular insufficiency as a means of
selecting patients for commissurotomy. With the
development of surgical procedures for the cor-
rection or alleviation of some of these cardio-
vascular abnormalities this diagnostic procedure
has assumed more practical importance. It re-
quires, however, such accurate timing and team-
work between physician, patient and roentgenolo-
gist that it is employed only in special medical
centers. The dangers and precautions are the same
as for other uses of iodopyracet plus the specific
problems caused by the very rapid intravenous
injection of this concentrated solution in patients
with abnormal cardiovascular systems.

Cholangiography. — Iodopyracet injection has
been used in cases in which it is impossible to
differentiate between hepatocellular damage and
extrahepatic biliary obstruction, and where liver
function tests are equivocal or normal. Keil et al.
{Ann. Int. Med., 1953, 39, 479) made 55 such
examinations by injection of 10 to 15 ml. of
iodopyracet solution into the fundus of the gall
bladder under direct observation during peri-
toneoscopy, the material being introduced through

708 lodopyracet Injection

Part I

a 5-inch, 20-gauge needle thrust through the ab-
dominal wall after aspiration of a quantity of
bile. Cholangiograms were obtained in a few in-
stances by direct injection of a hepatic duct
through the abdominal wall and liver substance,
by Carter and Saypol (J.A.M.A., 1952. 148, 253)
and by Nurick et al. (Brit. J. Surg., 1953, 41, 27),
the latter claiming that it is no more hazardous
than liver biopsy.

Bronchography. — Many attempts have been
made to prepare a water-soluble organic iodine
preparation of suitable viscosity for bronchog-
raphy, in order to avoid the known hazards and
disadvantages of iodized oil (q.v.) instillation. Suc-
cess was achieved by Morales and Heiwinkel
(Acta Radiol., 1948, 30, 257), who incorporated
sodium carboxymethylcellulose to increase the
viscosity of iodopyracet. this preparation now
being marketed under the trade-marked name
Umbradil Viscous B. Use of a similar prepara-
tion, known as Ioduron B, was reported by Fischer
(Schweiz. med. Wchnschr., 1948. 78, 1025).
Norris and Stauffer (Ann. Otol. Rhin. Laryng.,
1951, 60, 802) found that by adding appropriate
amounts of iodopyracet to Ioduron B it is pos-
sible to obtain a water-soluble contrast medium
of whatever viscosity is desired for bronchog-
raphy in any particular study. Roentgen study
indicates that the iodopyracet is usually absorbed
within four hours, being excreted via the kidney,
while the sodium carboxymethylcellulose is re-
moved by cough and other mechanisms of bron-
chial drainage. Of primary advantage is the rapid
elimination in instances of obscure pulmonary
disease in which serial roentgen studies are re-
quired and in localization of foreign bodies which
are to be removed later by bronchoscopy under
fluoroscopic guidance. A similar preparation is
claimed by Peck et al. (Surg. Gyn. Obst., 1951,
92, 685) to be safer and more efficient than is
iodized oil. Flipse et al. (Arch Otolaryng., 1953,
57, 188) found no systemic toxicity from the use
of this medium in 58 patients, of whom 38 had
tuberculosis.

The inherent inaccuracy of nerve-blocking pro-
cedures for relief of pain may be reduced by
roentgen localization of the needle, using iodo-
pyracet as a contrast medium before injecting
local anesthetic agents, in the experience of Alex-
ander and Lovell (J.A.M.A., 1952, 148, 885).
Landes (ibid., 1952, 149, 1053) cautioned that
perineural fibrosis may follow this procedure.

Iodopyracet injection has been used in studies
of kidney function with the clearance technic, i.e.,
comparison of the amount present in the urine
with the concentration in the blood (Newman
et al, Bull. Joints Hopkins Hosp., 1949. 84, 135).

Toxicology. — Local reactions at the site of
injection are infrequent and usually mild. Sys-
temic reactions are more frequent but rarely
serious providing the precautions and contraindi-
cations have been observed and the patient has
been tested for sensitivity. Flushing of the skin
and a sense of warmth is most frequent. Less
often transient nausea, vomiting, erythematous
eruptions, urticaria, dyspnea, lacrimation. sali-
vation, coughing paroxysms, choking sensations
and cyanosis develop. These seldom persist more

than 1 hour. A fall in blood pressure is produced
by therapeutic doses in animals for about 2 hours
and this has been observed in man. The drug is
contraindicated in patients with severe fiver dis-
ease, nephritis and severe uremia, active tubercu-
losis or hyperthyroidism, extreme debility or ad-
vanced age. It should be avoided in patients in
whom a sharp drop in blood pressure might be
deleterious. Epinephrine injection should be avail-
able to treat an acute and severe reaction. Neither
intravenous nor retrograde pyelography should be
repeated very often. [YJ

Dose. — The usual dose is 20 ml. intravenously
(slowly, over a period of 3 minutes), intramuscu-
larly or. diluted with sterile isotonic sodium chlo-
ride solution to 100 ml., subcutaneously divided
between two injection sites. In children the usual
dose intramuscularly or intravenously is 15 ml.
The range of dose intravenously is 20 to 50 ml.,
and intramuscularly 10 to 20 ml. For angiocardiog-
raphy, as much as 50 ml. of the 70 per cent solu-
tion is injected rapidly (v.s.).

Storage. — Preserve "in single-dose contain-
ers, preferably of Type I glass." U.S.P.

Usual Sizes.— 10. 20. or 30 ml. of a 35 per
cent solution. A concentrated solution (70 per
cent) in 20 and 50 ml. ampuls is also available.

IOPANOIC ACID.

Iodopanoic Acid

U.S.P.

COOH
I
HgCHCHgCHj

"Iopanoic Acid contains an amount of iodine
equivalent to not less than 97 per cent and not
more than 101 per cent of C11H12I3NO2, calcu-
lated on the dried basis." U.S.P.

Telepaque (IVinthrop-Stearns).

Iopanoic acid, used as a radiopaque substance,
is P-(3-amino-2,4,6-triiodophenyl)-a-ethylpropi-
onic acid. It may be prepared by reacting m-
nitrobenzaldehyde with propionic anhydride and
sodium propionate to give a-ethyl-w-nitrocin-
namic acid, reducing this with Raney nickel to
3- (w-aminobenzyl) butyric acid, and treating the
last with iodine monochloride to give the triiodo
derivative, which is iopanoic acid. For details of
synthesis see British Patent 655,096 (1951).

Description. — "Iopanoic Acid is a cream-
colored powder. It is tasteless or nearly so, and
has a faint, characteristic odor. It is affected by
light. Iopanoic Acid is insoluble in water. It is
soluble in alcohol, in chloroform, and in ether.
It is soluble in solutions of alkali hydroxides and
carbonates. Iopanoic Acid melts between 152°
and 158°, with decomposition." U.S.P.

Standards and Tests. — Identification. — On
heating iopanoic acid with sodium carbonate, then
extracting with hot water, the solution thus ob-
tained responds to tests for iodide. Loss on dry-

Part I

lopanoic Acid Tablets 709

ing. — Not over 1 per cent, when dried at 100°
for 1 hour. Residue on ignition. — Not over 0.1
per cent. Free iodine. — On shaking iopanoic acid
with a mixture of water and chloroform the latter
shows no violet color. Halide ions. — 200 mg. con-
tains no more halide than corresponds to 0.05
ml. of 0.02 N hydrochloric acid. Heavy metals. —
The limit is 20 parts per million. U.S.P.

Assay. — Iopanoic acid is assayed by the
method employed for and explained under Iophen-
dylate Injection. U.S.P.

Uses. — Iopanoic acid is a water-insoluble or-
ganic iodine compound administered orally as a
radiopaque medium for roentgenologic examina-
tion of the gall bladder. Following ingestion it is
absorbed rapidly, is eliminated in the bile and
begins to concentrate in the gall bladder within
four hours. Maximal concentration occurs 10 to
12 hours after ingestion, persisting until about
16 hours. During this period it produces dense
shadows in the cholecystogram, often permitting
visualization of the extrahepatic ducts. Although
it is chiefly eliminated by the intestinal tract,
there is some renal excretion.

The patient is instructed to take the drug
orally following a light fat-free meal the evening
before the x-ray examination, and is permitted to
take nothing else by mouth until the roentgeno-
grams have been made the next morning, except
for normal quantities of water until retiring. Ac-
cumulated gas may be removed shortly before
examination by means of a saline or sodium
bicarbonate enema. Immediately following roent-
genography the patient is given a high-fat meal
and additional films are taken one to three hours
later to determine the ability of the gall bladder
to contract. Films taken 10 minutes after the
fatty meal are most likely to provide visualiza-
tion of the extrahepatic ducts.

Undesirable effects following ingestion of
iopanoic acid are uncommon. Nausea, vomiting,
diarrhea, and burning on urination occur occa-
sionally. Dunne et at. (Cleveland Clinic Quart.,
1951, 18, 98) compared the side effects and the
gall bladder visualization obtained in a series of
232 unselected cases, half of whom received
iopanoic acid as a contrast medium and half
of whom were given iodoalphionic acid (q.v.).
There was somewhat less nausea following ad-
ministration of iopanoic acid and the incidence of
diarrhea and of dysuria was much lower; side
effects were noted in approximately one-third as
many patients with iopanoic acid as with
iodoalphionic acid and there were only one-fourth
as many side effects described as severe. A higher
incidence of dense gall bladder shadows was ob-
tained with a 3 Gm. dose of iopanoic acid than
with a 4.5 Gm. dose of iodoalphionic acid, sug-
gesting that a smaller dose of iopanoic acid
may prove to be satisfactory. That such is the
case has been demonstrated by Scott and Simril
(/. Missouri M. A., 1951, 48, 866), who stated
that a dose of 2 Gm. is adequate for patients
weighing less than 150 lbs.

Iopanoic acid produced about 35 per cent
greater opacification of the gall bladder than did
iodoalphionic acid following identical doses of 3
Gm., in the experience of Morgan and Stewart

(Radiology, 1952, 58, 231). Almost twice as
many of their patients required a second ex-
amination with a double dose of iodoalphionic
acid as with iopanoic acid in order to obtain satis-
factory visualization. Increased density of the
gall bladder shadow corresponds closely to the
difference in iodine content between the two
preparations. Similar reports of fewer side effects
and greater density on the cholecystogram have
been published by others (Christensen and
Sosman, Am. J. Roentgen., 1951, 66, 764; Abel
et al., Pcrmanente Foundation M. Bull., 1952, 10,
95). Gall bladder contraction following a high-fat
meal is demonstrated in a higher percentage of
patients when iopanoic acid is used than with
iodoalphionic acid, according to Spencer (Gastro-
enterology, 1952, 21, 535), suggesting that the
latter dye may be more irritant and cause spasm
in the bile duct system.

Visualization of the bile ducts occurs often
enough following the ingestion of iopanoic acid
to make this a useful procedure. Shehadi (Am. J.
Roentgen., 1952, 68, 355) believes this may re-
place surgical or transabdominal cholangiography,
as described under iodoalphionic acid (q.v.). A
double dose of the dye may be necessary for
such visualization, especially in obese patients.
Satisfactory post-cholecystectomy cholangiog-
raphy, including visualization of cystic duct
remnants, has been achieved by Twiss et al. (Am.
J. Med. Sc, 1954, 227, 372) by a modification of
the double dose technic. Presumptive evidence of
organic obstruction of the ampulla of Vater or of
the common bile duct sphincter may be obtained.

Administration of iopanoic acid is contrain-
dicated in acute nephritis or uremia and it
should not be given when gastrointestinal tract
disorders prevent its absorption. Pseudoalbu-
minuria may follow its administration (Seedorf
et al, J.A.M.A., 1953, 152, 1332). The com-
pound has a low toxicity (Hopp and Archer, Fed.
Proc, 1951, 10, 310).

Dose. — The usual dose is 3 Gm., orally, given
10 to 12 hours prior to the time roentgen ex-
amination is scheduled, with a range of 2 to 6
Gm. For oral cholangiography a dose of 5 to 6
Gm. is recommended. The maximum safe dose is
usually 6 Gm.

Storage. — Preserve "in tight, light-resistant
containers." U.S.P.

IOPANOIC ACID TABLETS. U.S.P.

"Iopanoic Acid Tablets contain not less than
95 per cent and not more than 105 per cent of
the labeled amount of C11H12I3NO2." U.S.P.

Assay. — The assay for tablets of iopanoic acid
is quite different from that for the bulk sub-
stance. A portion of powdered tablets, equivalent
to about 1 Gm. of iopanoic acid, is treated with
petroleum benzin to remove lubricants; the
iopanoic acid in the residue is dissolved in
neutralized alcohol, and the solution thus ob-
tained titrated with 0.1 iV sodium hydroxide in
the presence of thymol blue indicator. Each ml.
of 0.1 N sodium hydroxide represents 57.10 mg.
of C11H12I3NO2. U.S.P.

Usual Size. — 500 mg.

710 lophendylate Injection

Part I

IOPHENDYLATE INJECTION. U.S.P.

Ethyl Iodophenylundecylate Injection

CH3
CH-CH2(CH2)6CH2C00C2H5

"lophendylate Injection is a sterile mixture of
isomers of ethyl iodophenylundecylate, in uni-
form, but unknown, proportions. It contains not
less than 95 per cent of C19H29IO2." U.S.P.

Ethyl 10-(/>-Iodophenyl)undecylate. Pantopaque (Lafayette) .

This radiopaque medium may be prepared by
treating ethyl 10-phenylhendecanoate with iodine
monochloride (for details see U. S. Patent
2,348,231, granted in 1944).

Description. — "lophendylate Injection is a
colorless to pale yellow, viscous liquid, the color
darkening on long exposure to air. It is odorless
or possesses a faintly ethereal odor. lophendylate
Injection is very slightly soluble in water. It is
freely soluble in alcohol, in benzene, in chloro-
form, and in ether. The specific gravity of lophen-
dylate Injection is between 1.245 and 1.260."
U.S.P.

Standards and Tests. — Identification. — (1)
/»-Iodobenzoic acid obtained by oxidation of
iophendylate injection melts between 268° and
272°. (2) The saponification number of the in-
jection is not less than 395 and not more than
420. Refractive index. — Between 1.5230 and
1.5260. Other requirements. — The injection meets
the requirements under Injections. Residue on
ignition. — Not over 1.0 per cent. Free acids. — The
addition, with vigorous shaking, of 0.3 ml. of
0.1 N sodium hydroxide to an alcohol solution
of 1 ml. of the injection produces a red color
with phenolphthalein T.S. Free iodine. — No blue
color is produced in the aqueous layer of a mix-
ture of 3 ml. of iophendylate injection and a
solution of potassium iodide containing starch
T.S. U.S. P.

Assay. — About 200 mg. of iophendylate injec-
tion is weighed into a tared gelatin capsule and
transferred, along with some lactose, potassium
nitrate and sodium peroxide, to a Parr bomb,
which is fired. Under the oxidative conditions of
the combustion, the iodine of iophendylate is
oxidized to iodate. Any iodide that may be
formed in the combustion is oxidized to iodate by
treating a solution of the alkaline fusion mixture
with bromine T.S. Excess bromine is expelled
from the solution by boiling it after acidifying
with phosphoric acid; some phenol is added to
react with any bromine that may remain in the
solution. Finally potassium iodide is added, which
reacts with iodate to liberate six atoms of iodine
for each atom of iodine represented in iophendy-
late, and the solution is titrated with 0.1 N
sodium thiosulfate, using starch as indicator. A
blank test is performed on the reagents. Each ml.
of 0.1 N sodium thiosulfate represents 6.939 mg.
of C19H29IO2. U.S.P.

Uses. — This iodized fatty acid is absorbable
from tissue and tissue spaces and its low viscosity

recommends it for use as a contrast medium
especially in the subarachnoid space of the spinal
meninges. In myelography, it remains as a dis-
crete fluid mass when handled properly, thus pro-
viding a good shadow on the roentgen film. It is
usually well tolerated by spinal tissues (Stein-
hausen et al., Radiology, 1944, 43, 230).

Aspiration of as much of the medium as pos-
sible following roentgen examination is recom-
mended; opaque material will usually disappear
within 2 months (Ramsey et al., ibid., 236;
Wyatt and Spurring, Surgery, 1944, 16, 561).
The rate of absorption is about 1 ml. per year
but varies with the condition of the tissues.
Peacher and Robertson (/. Neurosurg., 1945, 2,
220) observed only slight reaction of the tissues
to iophendylate. Hinkel {Am. J. Roentgen., 1945,
54, 230) observed during a myelography rapid
passage of iophendylate into the inferior vena
cava following a cough, with trivial subjective
and objective manifestations. Myelography with
Pantopaque is widely used for demonstration of
tumors or herniation of the intervertebral disc
or other lesions compressing the spinal cord
(Soule et al., ibid., 53, 319; Ford and Key,
/. Bone Joint Surg., 1950, 32-A, 257).

Reports on several thousand human cases in
which from 2 to 6 ml. have been employed
intraspinally indicate that it is generally well
tolerated. The incidence of side effects is only
slightly greater than that following lumbar punc-
ture without the injection of any medication;
backache and slight and transient elevation of
temperature may be observed in 10 to 30 per
cent of cases. To avoid extravasation outside the
meninges, it should not be injected sooner than
10 days after a previous intrathecal puncture.
Meningeal reactions, however, have been ob-
served; Tarlov (J. A.M. A., 1945, 129, 1014) de-
scribed such a case and advocated that use of
iophendylate should be restricted to those cases
in which such study is required for a diagnosis
and preferably in instances in which the presence
of a lesion which will require surgical removal is
almost certain. It should be injected immediately
before the roentgen examination under fluoro-
scopic observation, and aspirated and rinsed out
of the spinal canal immediately after the ex-
amination. If surgery is performed, any residual
material should be carefully removed. Erickson
and van Baaren {ibid., 1953, 153, 636) described
a case which terminated fatally 15 months follow-
ing the myelography, due to exudative and ad-
hesive arachnoiditis obstructing the fourth
ventricle of the brain. Passage of the radiopaque
medium to the intracranial subarachnoid space
should be carefully avoided.

An unofficial, aqueous emulsion, Emulsion
Pantopaque 50% V/V (Lafayette), is recognized
in N.N.R. This contains 0.6 per cent of the sur-
face-active compound oleyl methyl taurine
(Chalecke et al., Radiology, 1947, 49, 131). It
may be used as a roentgen contrast medium for
visualization of the biliary tree, sinus and fistulous
tracts, ducts, certain body cavities, empyema
cavities, etc. (George et al., ibid., 137). It has a
low viscosity and surface tension and is miscible
with normal and abnormal tissue fluids. It ad-

Part I

Ipecac 711

heres well to mucous membrane surfaces. In
large cavities, slow absorption may interfere
with subsequent roentgen examinations. This ma-
terial does not give a shadow of sufficient density
for bronchography.

Dose. — The usual dose by intrathecal or special
injection as a roentgen contrast medium is 6 ml.,
with a range of 0.5 to 12 ml. The maximum safe
dose will rarely exceed 20 ml.

Storage. — Preserve "in single-dose containers,
preferably of Type I glass." U.S.P.

Usual Size. — 3 ml. The 50 per cent v/v emul-
sion is supplied in 10-ml. ampuls.

IPECAC. U.S.P. (B.P.) (LP.)

[Ipecacuanha]

"Ipecac consists of the dried rhizome and roots
of Cephaelis Ipecacuanha (Brotero) A. Richard,
known in commerce as Rio or Brazilian Ipecac,
or of Sephaelis acuminata Karsten, known in
commerce as Cartagena, Nicaragua, or Panama
Ipecac (Fam. Rubiacece). Ipecac yields not less
than 2 per cent of the ether-soluble alkaloids of
Ipecac." U.S.P. The B.P. definition for Ipe-
cacuanha is substantially the same; not less than
2.0 per cent of the total alkaloids, calculated as
emetine, is required. The LP. requires Ipe-
cacuanha Root to contain not less than 2.0 per
cent of total alkaloids, calculated as emetine, of
which not less than 60 per cent consists of non-
phenolic alkaloids, calculated as emetine. Both
the B.P. and the LP. recognize also a standard-
ized powder of ipecac, containing 2.0 per cent of
total alkaloids (see the monograph on Prepared
Ipecacuanha).

B.P. Ipecacuanha. LP. Ipecacuanha Root; Ipecacuanhae
Radix. Bras. Poaya. Fr. Ipecacuanha officinal; Racine
d'ipecacuanha. Ger. Brechwurzel ; Ruhrwurzel. It. Ipe-
cacuana ; Radice Brasiliana. Sp. Raiz de ipecacuana ;
Ipecacuana.

Ipecac was used as a medicinal agent by the
South American Indians before the advent of the
white man. Its introduction into European medi-
cine was chiefly owing to the success which Dr.
Adrien Helvetius of Paris had in treating dysen-
tery with the drug. His results were so striking
that they attracted the attention of Louis XIV,
who in 1682 offered him public honors and a large
gift of money in exchange for his secret.

The natives of Brazil apparently applied the
term "ipecacuanha" to a number of roots pos-
sessing in common emetic properties, and it was
not until Gomez collected some authentic plants
himself that its real botanical source was known.
These were described by Brotero in 1803, under
the name of Callicocca Ipecacuanha.

There exists considerable difference of opinion
as to which of the generic terms should be defi-
nitely adopted as the standardized generic name
of the true ipecac species. Chief among those
listed in the literature as synonyms are the fol-
lowing: Uragoga, L. 1731; Psychotria, L. 1759;
Evea, Aublet 1775; Tapogomea, Aublet 1775;
Cephaelis, Swartz 1788; and Callicocca, Schreber
1789. According to the rule of priority in start-
ing nomenclature with 1753, Uragoga would be
correct as the proper designation of the Ipecac
genus and Uragoga Ipecacuanha Baillon {Nat.

Hist. PL, London, 1881) the proper designation
of the species; but Cephaelis of Swartz is alone
listed in the Nomina Conservanda of the last In-
ternational Congress of Botanists, evidently be-
cause it had received the greatest publicity and
use and is, accordingly, recognized in the U.S.P.
and B.P.

Cephaelis Ipecacuanha is a low, straggling
shrub indigenous to Brazil but also found grow-
ing in Colombia where it flourishes in deep, moist
humous soils of forests. Its underground portion
consists of a somewhat branched root system,
made up of a smooth rhizome bearing two kinds
of roots, smooth and annulated, also a sub-
merged portion of the stem which has frequently
been gathered with the roots as the drug of com-
merce. This stem arches upward becoming green
and angular above ground and attaining a length
of a foot or less. It bears a few opposite,
petiolate, stipulate, obovate and entire leaves and
heads of small, white flowers, the corollas of
which are funnel-shaped. The fruits occur as
clusters of dark purple berries, each containing
two plano-convex seeds.

The U.S.P., B.P., and LP. recognize two sorts
of ipecac. The Rio, or Brazilian, Ipecac is from
the Cephaelis Ipecacuanha. It grows in moist,
dense and shady woods in Brazil and Bolivia. It is
said to be most abundant within the limits of the
eighth and twenty-second degrees of south lati-
tude. Cartagena Ipecac (also called Nicaragua,
Savanilla and Panama Ipecac) is from the C.
acuminata. It grows in the moist forests of
United States of Colombia. The roots are
gathered from January to late March by the
natives who seize all the stems of a clump, loosen
them from the soil and then, by thrusting a
pointed stick under the roots, tear up the whole
mass. The roots are then freed from adhering soil
and packed in bags or bales of hide in which they
are stored until purchased by traders ; Rio ipecac
comes chiefly from the interior provinces of
Mato Grosso and Minas Geraes and is shipped to
the U. S. A. mainly from Rio de Janeiro, Bahia
and Pernambuco. Cartagena ipecac is exported to
this country from Cartagena and Savanilla,
Colombia, and from Corinto, Nicaragua. It differs
from the Rio variety in being thicker, and in
showing less pronounced annulations. There are
two varieties of Cartagena ipecac, viz., the
grayish-brown and the reddish-brown. The latter
has, within recent years, been coming largely
from Nicaragua under the name of Nicaragua
Ipecac, and is characterized by its root being
beset with numerous transverse ridges bearing,
frequently, light-colored abrasions. During 1952,
importations of ipecac amounted to 54,559
pounds, from Brazil, Nicaragua, Panama, Colom-
bia, and the Canal Zone.

Attempts were made by the British, in 1866
and 1872, to cultivate ipecac in India from root
cuttings sent from Brazil, but without com-
mercial success. It is now cultivated on a small
scale at Mungpoo in the Darjeeling district of
Bengal. For pharmacognostic studies on Indian
Ipecac, see Bal and Datta, Indian Jour. Pharm.,
1946, 8, 76. In 1886, it was found that ipecac
flourished in the Straits Settlements. The Johore,

712 Ipecac

Part I

or Indian, Ipecac is now produced on a com-
mercial scale in the State of Selangor, near Singa-
pore.

Description. — "Unground Rio Ipecac occurs
as a mixture of segments of the roots and
rhizomes, the latter with one or more attached
roots. The roots are in cylindrical pieces, mostly
curved and sharply flexuous. occasionally
branched, from 3 to 15 cm. in length and from
1 to 4 mm. in diameter, reddish brown to dark
brown, either smooth or closely annulated, the
latter with thickened, incomplete rings and
usually exhibiting transverse fissures with vertical
sides. The bark of the smooth root is thin, ap-
proximately one-ninth of the diameter of the
root, that of the annulated root approximately
two-thirds of the entire diameter. The fracture
of the bark is short, easily separable from the
tough, fibrous wood. The rhizomes are cylindrical,
attaining a length of 10 cm. and a thickness of 2
mm., finely longitudinally wrinkled, with a few
elliptical scars and a distinct pith approximately
one-sixth of the entire diameter of the rhizome.
The odor is distinctive; the dust is sternutatory.
The taste is bitter, nauseous and acrid." U.S.P.
For histology see U.S.P. XV.

"Unground Cartagena Ipecac. — As compared
with Rio Ipecac. Cartagena Ipecac is up to 6.5
mm. in diameter; externally grayish, grayish
brown or reddish brown, the reddish brown
variety frequently beset with numerous transverse
ridges bearing light-colored abrasions; its annula-
tions are less numerous; its simple starch grains
are, on the average, larger in the xylem rays of
the wood.

"Powdered Ipecac is pale brown, weak yellow
or light olive-gray. The elements of identification
are: the cork cells; the starch grains simple or
2- to 8-compound. the simple grains up to 15 n
in diameter (Rio Ipecac) and up to 22 n in diam-
eter (Cartagena Ipecac); raphides of calcium
oxalate up to 80 u in length and fragments of
the tracheids and vessels with simple and
bordered pits. A few more or less elongated
rectangular stone cells with the thick and pitted
lignified walls from the overground stem of
ipecac may be present." U.S.P.

It is quite common to find in commerce mix-
tures of Rio and Cartagena ipecac. These are
usually distinguished from each other by the
larger size of the starch grains in the medullary
rays of the wood of the Cartagena variety but
Hartwich (Apoth.-Ztg., 26, 57), pointed out that
the size of the starch grains is not sufficient to
differentiate these varieties and states that there
is a greater difference in the cells of the woody
portion of the root.

Standards and Tests. — Overground stems. —
Not over 5 per cent. Foreign organic matter. —
Not over 2 per cent. U.S.P. The B.P. and I.P.
limit ash to 5.0 per cent, and acid-insoluble ash
to 2.0 per cent.

Assay. — A 10-Gm. portion of ipecac, in fine
powder, is macerated with peroxide-free ether in
the presence of ammonia T.S. A one-half aliquot
of the ether solution is extracted with approxi-
mately 1 A' sulfuric acid, from which latter the

alkaloids are transferred to peroxide-free ether
after alkalinization with ammonia T.S. Most of
the ether is evaporated, exactly 10 ml. of 0.1 N
sulfuric acid is added, the remaining ether vola-
tilized and the excess of acid titrated with 0.1 N
sodium hydroxide, using methyl red T.S. as indi-
cator. Each ml. of 0.1 N sulfuric acid represents
24.0 mg. of the ether-soluble alkaloids of ipecac.
U.S.P.

The B.P. and I.P. assays for total alkaloids
differ from that of the U.S.P. in many details
but are based on the conventional methods of
alkaloidal assay. The I.P. assay for non-phenolic
alkaloids is performed by alkalinizing with
sodium hydroxide the titrated liquid left from the
assay for total alkaloids and extracting with
ether. The solvent is evaporated, the residue dis-
solved in an excess of 0.1 N sulfuric acid and the
excess of acid titrated with 0.1 N sodium hydrox-
ide, using methyl red as indicator.

Constituents. — The alkaloid "emetine" found
in ipecac by Pelletier. in 1817, was shown by
Paul and Cownley (Am. J. Pharm., 1895, p. 256,
and 1901. p. 87) to consist of three alkaloids,
emetine, cephaeline, and psychotrine. These, to-
gether with O-methylpsychotrine and emetamine,
isolated by Pyman (/. Chem. S., 1917, 111, 428),
constitute the principal ipecac alkaloids. Those
reported by Hesse (Pharm. J., 1914, 93, 425),
ipecamine and hydro-ipecamine, are of minor im-
portance. There is also present ipecacuanhin
(ipecacuanhic acid), a glycoside which shows
little pharmacologic action. The belief of Huerre
(/. pharm. chim., 1920. 20, 425) that it is of
therapeutic importance seems improbable.

For chemical structure of emetine see under
Emetine Hydrochloride. From the studies of
Carr and Pyman it would appear that cephaeline
differs from emetine in the substitution of a
hydroxyl for a methoxyl group. Therefore,
cephaeline is a phenol but emetine is not (Proc.
Chem. S., 1913, 29, 226). They assigned to psy-
chotrine the formula C2SH36X2O4. Emetamine.
C29H36X2O4. differs from emetine in containing
four less hydrogen atoms, corresponding to the
presence of two additional double bonds.

Pyman (Trans. Chem. Soc, 1917, 111, 438)
showed that psychotrine can be converted either
into O-methylpsychotrine or into cephaeline. which
yields emetine upon methylation. A stereo-
isomeride of emetine, called iso-emetine, was
prepared by Pyman from methylpsychotrine by
reduction.

Browne (/. A. Ph. A., 1917, 6, 1043) investi-
gated kryptonine (emetoidine) , an alkaloid previ-
ously reported by Lloyd. It is a red base of very
bitter taste, possesses emetic action and when
injected intravenously it lowers the blood pres-
sure similarly to emetine. For paramecia and
rabbits it is less toxic than emetine.

The medicinal virtues of ipecac reside chiefly,
if not solely, in the alkaloids emetine and
cephaeline. The other alkaloids play a relatively
unimportant part in any of the therapeutic effects.
Because of the difference in the actions of these
two alkaloids the relative proportions present is
a matter of some interest. From the researches of

Part I

Ipecac 713

Paul and Cownley, of Lowin, and of Caesar and
Loretz, it is well established that Rio ipecac
yields from 1.4 to 1.9 per cent of emetine and
from 0.5 to 0.6 per cent of cephaeline. Cartagena
ipecac has a higher proportion of cephaeline, aver-
aging from 1.2 to 1.4 per cent, and about the
same proportion of emetine.

Emetine and cephaeline are reported by Friese
(Pharm. Zentr., 1935, 76, 233) to occur in a
number of other South American species of the
Rubiacece, this author finding them in the roots
of Remijia amazonica Schumn., Ferdinandusa
elliptica Schumn. var. Belemnensis Ducke, To-
coyena longiflora Aubl., Caperona decorticans
Spruce, Bothriospora corytnbosa Hook., and eme-
tine in the stem bark of Hillia illustris (Veil.)
Schumn. _

Substitutes and Adulterants. — The chief
adulterant of ipecac is the aerial stem of the
same plant. The submerged portion of the stem
from which roots emanate, and which might be
called the rhizome, is claimed by Viehoever and
Ewing (/. A. Ph. A., 1921, p. 766) to contain the
ether-soluble alkaloids of ipecac in substantial
amounts. The rhizome, which is now recognized
in the official description, must not be confused
with an aerial continuation of it, the overground
stems, which is comparatively low in alkaloidal
content. The latter may be distinguished from the
rhizome by its thinner bark, numerous chloro-
plasts, by opposite leaf scars at its nodes, and
by the stone cells in the pericycle.

Formerly several roots — some of them not
even closely related to ipecac — appeared in the
markets as false ipecac. Most of them are now
rare in commerce. Among the most important of
these were the following:

Undulated Ipecac. — This is the root of Rich-
ardia scabra Linne (Fam. Rubiacea), indigenous
to Brazil. It occurs in somewhat tortuous pieces
which differ from ipecac in being less completely
and regularly annulated and in possessing a
porous wood and a bark that is often violet-
colored within.

Greater Striated Ipecac. — The root of Psy-
chotria emetica, L. (Fam. Rubiacece) closely re-
sembles the Cartagena ipecac from which it can
be distinguished by its violet-colored bark and
total absence of starch, as viewed in transverse
sections under a microscope.

Trinidad Ipecac. — The rhizomes and roots of
Asclepias curassavica, L. (Fam. Asclepiadacece)
have been offered as a substitute in Europe.
This spurious article is entirely devoid of ipecac
alkaloids, has a yellowish-brown external color,
a white interior and a bitter taste.

Lesser Striated Ipecac (also called Black Stri-
ated Ipecac or False Ipecac) (Holmes). — This
was formerly attributed to an unidentified species
of Richardsonia but Maheu and Chartier (Pharm.
J., 1927, 119, 630) after careful study assign it
to Manettia ignita Schum. (Fam. Rubiacece).
They found emetine in it. It occurs in very short
fragments, 2 or 3 cm. long, and 2 or 3 mm. in
thickness; some nearly cylindrical, others nar-
rowly fusiform; others again formed of roundish
or pyriform segments, somewhat thicker than the

preceding, placed end to end. The color is gener-
ally gray-brown, darker than that of greater
striated ipecac. The longitudinal stria? are fine,
and regular on the transverse section. The cortical
portion is starchy and often dark violet in color,
and its consistence firmer than in the larger
kind; the wood is yellowish, and porous.

White Ipecac is obtained from Ionidium Ipe-
cacuanha St. Hil. (Hybanthus Ipecacuanha (L.)
Baill) (Fam. Violaceai), indigenous to Brazil.
The root is much branched, free from annula-
tions and of a grayish-white or light brownish-
yellow color. The bark is very thin and the wood
is light yellow and porous. It is distinguished by
the presence of stone cells and freedom from
starch. It contains inulin but no emetine. Ac-
cording to Pelletier, it has, however, emetic
properties.

In addition to the above the following adul-
terants have occasionally been found as admix-
tures of the drug: (1) The roots of Heteropteris
pauciflora (Fam. Malpighiacece) which are devoid
of starch and possess rosette aggregates of cal-
cium oxalate and stone cells; (2) numerous other
foreign roots. Kraemer (Proc. A. Ph. A., 1900,
p. 214) published a note on a so-called ipecac
which proved to be derived from Polygala angu-
lata DC.

Uses. — Ipecac is in large doses emetic, in
smaller doses, diaphoretic and expectorant, and
in still smaller doses, stimulant to the stomach,
exciting appetite and facilitating digestion. In
quantities not quite sufficient to cause vomiting,
it produces nausea, and frequently acts on the
bowels. As an emetic it is mild, but tolerably
certain, and free from corrosive or narcotic
properties.

Action. — The researches of Waters and Koch
(/. Pharmacol., 1917, 10, 73) have shown that
psychotrine is practically non-toxic and probably
plays no part in the action of ipecac. Cephaeline
and emetine are similar in their effects although
differing in degree. Emetine is a more active
amebicide but is less irritant and emetic, and
also less toxic, than cephaeline. Eggleston and
Hatcher (/. Pharmacol., 1923, 21, 1) found that
both alkaloids have a direct stimulant action upon
the vomiting center in the medulla. In their opin-
ion the emetic effect is due not only to this
action but in part to the local irritant effect upon
the gastric mucosa. Because of the promptness
with which emesis occurs it is scarcely possible
for enough of the active principles to be absorbed
from the stomach to produce direct systemic
effects. When injected subcutaneously or intra-
venously in large dose, however, the alkaloids act
as depressants to the motor side of the spinal
cord and probably also to the respiratory center.
It would appear that they have some special
predilection for the lungs, for after toxic doses
alternating areas of pallor and intense hyperemia
have been found in the pulmonary tissue. The
toxicology of ipecac was re-evaluated by Radom-
ski et al. (J. Pharmacol. 1952, 104, 421).

Amebiasis. — Originally introduced as a remedy
for dysentery, ipecac for centuries was alter-
nately lauded as a specific and condemned as

714 Ipecac

Part I

useless in this disease. In 1911 Vedder (see
J. A.M. A., 1914, 62, 501) showed that a 1 to
10,000 infusion of ipecac destroyed the viability
of the EndamebcB, and that the alkaloid emetine
in a 1 to 100,000 solution had the same effect.
He also showed that the drug had no bactericidal
power. Since this research, reasons for the diver-
gence of opinion as to the usefulness of ipecac
are apparent. There are two types of dysentery,
one due to a specific ameba and the other caused
by a bacillus. In the latter form of the disease
the drug is useless but it is of real value in the
amebic type of dysentery. It has, however, been
supplanted by its alkaloid emetine for this
purpose (see Emetine Hydrochloride). Simon
(J.A.M.A., 1918, 71, 2042) maintained that the
whole drug administered by mouth gave better
results than subcutaneous injection of the alka-
loid in chronic cases where the ameba has become
encysted. For this purpose, the dried powder in
salol-coated pills was preferred. The dose was 3
to 4.5 Gm. giveiy at bedtime daily until the
patient received a total dose of 30 Gm. The pa-
tient was kept at bed rest and given opium tinc-
ture to decrease the nausea and vomiting. The
latter was frequently severe enough to demand
cessation of the treatment.

Expectorant. — As an emetic ipecac is rarely
used merely for the purpose of evacuating the
stomach. Some clinicians believed that it has a
direct influence on hepatic secretion, but it is
more probable that its effects on the liver are due
simply to its emetic action. By virtue of their
nauseating effect small doses of ipecac tend to
increase various secretions of the body. Thus it
is widely used as a diaphoretic, especially in com-
bination with opium (see Ipecac and Opium Pow-
der), in the early stages of acute coryza and
other mild infections (see Tomb, South African
M. J., 1945, Nov. 24, p. 429). In the same way
it acts as an expectorant, and in the early stages
of acute bronchitis ipecac syrup has been widely
used. It is beneficial in croup. Perry and Boyd
(/. Pharmacol., 1941, 73, 65) reported marked
increase of bronchial secretions in rabbits fol-
lowing administration of large doses of ipecac.
In humans, Alstead (Lancet, 1939, 2, 932) found
no increase in the volume of sputum in cases of
chronic bronchitis. Ipecac has been used by some
in the treatment of paroxysmal auricular tachy-
cardia. The arrhythmia is abolished through vagal
impulses induced by stimulation of the medulla,
and through induction of nausea and vomiting.
Many years ago Trousseau claimed that ipecac
possessed valuable hemostatic powers, especially
useful in hemoptysis, but this use of it failed to
receive general recognition. The treatment was
revived by Flandin (Presse mid., 1913) and
other French clinicians, [v]

The usual dose is not listed by the U.S. P.
since the whole powder is rarely used in practice
unless as an emergency emetic in which case 1
to 4 Gm. (approximately 15 to 60 grains) is
given with a glass of lukewarm water. The syrup
and the fluidextract are more commonly used. As
a nauseating expectorant or diaphoretic, 30 to
120 mg. (approximately y* to 2 grains) is appro-
priate.

PREPARED IPECACUANHA.
B.P. (LP.)

Ipecacuanha Praeparata

The B.P. recognizes under this title a finely
powdered root which is adjusted to contain 2.0
per cent (limits 1.90 to 2.10) of the total alka-
loids of ipecacuanha, calculated as emetine. The
LP. recognizes the same preparation under the
title Standardized Powdered Ipecacuanha Root
(Pulvis Ipecacuanhae Radicis Standardisatus). It
should be kept in a well-closed container.

This is intended as a means of administering a
standardized form of the whole drug. The dose
is from 30 to 120 mg. (approximately l/2 to 2
grains); or as an emetic, 1 to 2 Gm. (approxi-
mately 15 to 30 grains).

Off. Prep. — Powder of Ipecacuanha and
Opium; Tablets of Acetylsalicylic Acid with
Ipecacuanha and Opium; Tablets of Ipecacuanha
and Opium, B.P.

IPECAC FLUIDEXTRACT.
U.S.P. (B.P.)

[Fluidextractum Ipecacuanhae]

"Ipecac Fluidextract yields, from each 100 ml.,
not less than 1.8 Gm. and not more than 2.2 Gm.
of the ether-soluble alkaloids of ipecac." U.S.P.
The B.P. Liquid Extract of Ipecacuanha is re-
quired to contain 2.0 per cent w/v of the total
alkaloids of ipecac, calculated as emetine (limits,
1.90 to 2.10).

B.P. Liquid Extract of Ipecacuanha; Extractum Ipe-
cacuanhae Liquidum. _ Extractum Ipecacuanhae Fluidum.
Fr. Extrait fluide d'ipecacuanha. Ger. Brechwurzelfluidex-
trakt. It. Estratto fluido d'ipecacuana. Sp. Extracto Fluido
de Ipecacuana.

Prepare the fluidextract by exhausting ipecac
by percolation with a menstruum of 3 volumes of
alcohol and 1 volume of water, macerating for 72
hours and percolating slowly. Reduce the perco-
late, by evaporation at a temperature not over
60°, to 1000 ml. Add 2000 ml. of water and allow
the mixture to stand overnight; filter it and
evaporate the filtrate to a volume of 565 ml. Add
35 ml. of hydrochloric acid and 300 ml. of alcohol,
mix well, and filter. Assay a portion of this liquid
and adjust the remainder of it, by adding a mix-
ture of 30 volumes of alcohol, 3.5 volumes of
hydrochloric acid, and 66.5 volumes of water, to
contain 2.0 Gm. of ether-soluble alkaloids of ipe-
cac in each 100 ml. of fluidextract. U.S.P.

In the preparation of the fluidextract the pre-
cipitation with water is for the purpose of re-
moving resinous matter which, if present, would
produce a cloudy syrup; the hydrochloric acid
insures stability of the alkaloids.

The B.P. Liquid Extract of Ipecacuanha is pre-
pared from finely powdered ipecac by percolation.
The menstruum is 80 per cent alcohol. A portion
of the percolate is reserved. The remainder is
concentrated in a vacuum below 60° and this
residue is dissolved in the reserved portion. This
liquid is assayed for alkaloidal content and ad-
justed to the proper strength. After the liquid
extract is allowed to stand it is filtered.

Assay. — A 10-ml. portion of fluidextract is ab-
sorbed on paper or asbestos and dried at a tem-

Part I

Ipecac and Opium Powder 715

perature not over 60°; this material is assayed
in the manner described under Ipecac. Alterna-
tively the extraction of alkaloids from the fluid-
extract may be made in a liquid-liquid automatic
extractor. U.S.P.

The B.P. assay, performed on 5 ml. of liquid,
begins with an extraction of non-alkaloidal matter
with chloroform, in the presence of dilute sulfuric
acid; the chloroform solution, after washing to
recover any alkaloid which may have been ex-
tracted by it, is discarded. The acid liquid is
alkalinized with ammonia and the liberated alka-
loids extracted with chloroform ; the chloroform is
evaporated and the alkaloids in the residue esti-
mated by solution in excess 0.1 N sulfuric acid
followed by titration with 0.1 N sodium hydroxide
using methyl red as indicator.

Alcohol Content. — From 28 to 33 per cent,
by volume, of C2H5OH. U.S.P.

Ipecac fluidextract is a limpid, dark reddish-
brown, transparent liquid, of a bitterish, slightly
acrid taste, but without the nauseous flavor of the
root. It is a convenient preparation for the in-
clusion of ipecac in expectorant and diaphoretic
mixtures.

Dose, as emetic, 0.5 to 1 ml. (approximately
8 to 15 minims); as an expectorant, 0.06 to 0.12
ml. (approximately 1 to 2 minims). @

Storage. — Preserve "in tight, light-resistant
containers, and avoid exposure to excessive heat."
U.S.P.

Off. Prep. — Ipecac Syrup, U.S. P.; Ipecac
Tincture, B.P.; Rhubarb and Soda Mixture, N.F.

IPECAC SYRUP. U.S.P.

[Syrupus Ipecacuanhae]

Syrupus Ipecacuanhae Gallicus.

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